290 research outputs found
Utah\u27s Black Hole of Tax Incentives
In Utah, a state job-creation program gives out millions of dollars a year to private companies. Over the course of a semester, our team looked through hundreds of pages of court documents, EPA violations and workplace safety violations to uncover what kinds of companies the Utah state government pays to expand there. We also analyzed employment data to show, for the first time, which companies create the jobs they are supposed to and which do not.http://mcgillmathis.com/projects/capstone/index.htm
Patient reported outcome measures of quality of end-of-life care: a systematic review
End-of-life (EoL) care is increasingly used as a generic term in preference to palliative care or terminal care, particularly with reference to individuals with chronic disease, who are resident in community and long-term care (LTC) settings. This review evaluates studies based on patient reported outcome measures (PROMS) of quality of EoL care across all health-care settings. From 1041 citations, 12 studies were extracted by searches conducted in EBSCO, Scopus, Web of Science, PubMed, Cochrane, Open Grey and Google Scholar databases. At present, the evidence base for EoL care is founded on cancer care. This review highlights the paucity of studies that evaluate quality of EoL care for patients with chronic disease outside the established cancer-acute care paradigm, particularly in LTC. This review highlights the absence of any PROMs for the estimated 60% of patients in LTC with cognitive impairment. Patient-reported outcomes (PROs) are critical to understanding how EoL care services and practices affect patients’ health and EoL experience. PROMs describe the quality of care from the patient's perspective and add balance to existing clinical or proxy-derived knowledge on the quality of care and services provided
Conservative Management of Paediatric Clavicle Fractures
Paediatric clavicle fractures have traditionally been treated nonoperatively. Recent studies have recommended operative management for displaced midshaft fractures. We conducted a retrospective review of all clavicle fractures in children aged one to sixteen over a two-year period. We classified fractures and evaluated followup and clinical outcome. We identified 190 fractures. There were 135 boys and 55 girls. 65% of fractures were displaced and 35% undisplaced. Mean radiographic and clinical followup was 35 days and 44 days, respectively. Clavicle fractures in children heal with nonoperative management. Radiographs of clavicle fractures in children are unnecessary in the absence of clinical symptoms
Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression
Short but accurate cognitive screening instruments are required in busy clinical practice. Although widely-used, the diagnostic accuracy of the standardised Mini-Mental State Examination (SMMSE) in different dementia subtypes remains poorly characterised. We compared the SMMSE to the Quick Mild Cognitive Impairment (Qmci) screen in patients (n = 3020) pooled from three memory clinic databases in Canada including those with mild cognitive impairment (MCI) and Alzheimer’s, vascular, mixed, frontotemporal, Lewy Body and Parkinson’s dementia, with and without co-morbid depression. Caregivers (n = 875) without cognitive symptoms were included as normal controls. The median age of patients was 77 (Interquartile = ±9) years. Both instruments accurately differentiated cognitive impairment (MCI or dementia) from controls. The SMMSE most accurately differentiated Alzheimer’s (AUC 0.94) and Lewy Body dementia (AUC 0.94) and least accurately identified MCI (AUC 0.73), vascular (AUC 0.74), and Parkinson’s dementia (AUC 0.81). The Qmci had statistically similar or greater accuracy in distinguishing all dementia subtypes but particularly MCI (AUC 0.85). Co-morbid depression affected accuracy in those with MCI. The SMMSE and Qmci have good-excellent accuracy in established dementia. The SMMSE is less suitable in MCI, vascular and Parkinson’s dementia, where alternatives including the Qmci screen may be used. The influence of co-morbid depression on scores merits further investigation
Validity of the Japanese version of the quick mild cognitive impairment screen
Early detection of dementia provides opportunities for interventions that could delay or prevent its progression. We developed the Japanese version of the Quick Mild Cognitive Impairment (Qmci-J) screen, which is a performance-based, easy-to-use, valid and reliable short cognitive screening instrument, and then we examined its validity. Community-dwelling adults aged 65–84 in Niigata prefecture, Japan, were concurrently administered the Qmci-J and the Japanese version of the standardized Mini-Mental State Examination (sMMSE-J). Mild cognitive impairment (MCI) and dementia were categorized using established and age-adjusted sMMSE-J cut-offs. The sample (n = 526) included 52 (9.9%) participants with suspected dementia, 123 (23.4%) with suspected MCI and 351 with likely normal cognition. The Qmci-J showed moderate positive correlation with the sMMSE-J (r = 0.49, p < 0.001) and moderate discrimination for predicting suspected cognitive impairment (MCI/dementia) based on sMMSE-J cut-offs, area under curve: 0.74, (95%CI: 0.70–0.79), improving to 0.76 (95%CI: 0.72 to 0.81) after adjusting for age. At a cut-off of 60/61/100, the Qmci-J had a 73% sensitivity, 68% specificity, 53% positive predictive value, and 83% negative predictive value for cognitive impairment. Normative data are presented, excluding those with any sMMSE-J < 27. Though further research is required, the Qmci-J screen may be a useful screening tool to identify older adults at risk of cognitive impairment
Sleep disturbance in older patients in the emergency department: prevalence, predictors and associated outcomes
Impaired sleep is common in hospital. Despite this, little is known about sleep disturbance among older adults attending Emergency Departments (ED), particularly overnight-boarders, those admitted but housed overnight while awaiting a bed. Consecutive, medically-stable patients aged ≥70, admitted through a university hospital ED were evaluated for overnight sleep quality (Richards Campbell Sleep Questionnaire/RCSQ) and baseline sleep (Pittsburgh Sleep Quality Index/PSQI). Additional variables included frailty, functional and cognitive status, trolley location, time in ED and night-time noise levels. Over four-weeks, 152 patients, mean age 80 (± 6.8) years were included; 61% were male. Most (68%) were ED boarders (n = 104) and 43% were frail. The majority (72%) reported impaired sleep quality at baseline (PSQI ≥ 5) and 13% (20/152) had clinical insomnia. The median time spent in ED for boarders was 23 h (Interquartile ± 13). After adjusting for confounders, median RCSQ scores were significantly poorer for ED boarders compared with non-boarders: 22 (± 45) versus 71 (± 34), respectively, (p = 0.003). There was no significant difference in one-year mortality (p = 0.08) length of stay (LOS) (p = 0.84), 30-day (p = 0.73) or 90-day (p = 0.64) readmission rates between boarders and non-boarders. Sleep disturbance is highly prevalent among older adults admitted through ED. ED boarders experienced significantly poorer sleep, without this impacting upon mortality, LOS or re-admission rates
Selecting a bedside cognitive vital sign to monitor cognition in hospital: feasibility, reliability, and responsiveness of logical memory
Although there is a high prevalence of delirium and cognitive impairment among hospitalised older adults, short, reliable cognitive measures are rarely used to monitor cognition and potentially alert healthcare professionals to early changes that might signal delirium. We evaluated the reliability, responsiveness, and feasibility of logical memory (LM), immediate verbal recall of a short story, compared to brief tests of attention as a bedside “cognitive vital sign” (CVS). Trained nursing staff performed twice-daily cognitive assessments on 84 clinically stable inpatients in two geriatric units over 3–5 consecutive days using LM and short tests of attention and orientation including months of the year backwards. Scores were compared to those of an expert rater. Inter-rater reliability was excellent with correlation coefficients for LM increasing from r = 0.87 on day 1 to r = 0.97 by day 4 (p < 0.0001). A diurnal fluctuation of two points from a total of 30 was deemed acceptable in clinically stable patients. LM scores were statistically similar (p = 0.98) with repeated testing (suggesting no learning effect). All nurses reported that LM was feasible to score routinely. LM is a reliable measure of cognition showing diurnal variation but minimal learning effects. Further study is required to define the properties of an ideal CVS test, though LM may satisfy these
Screening for markers of frailty and perceived risk of adverse outcomes using the Risk Instrument for Screening in the Community (RISC)
BACKGROUND: Functional decline and frailty are common in community dwelling older adults, increasing the risk of adverse outcomes. Given this, we investigated the prevalence of frailty-associated risk factors and their distribution according to the severity of perceived risk in a cohort of community dwelling older adults, using the Risk Instrument for Screening in the Community (RISC). METHODS: A cohort of 803 community dwelling older adults were scored for frailty by their public health nurse (PHN) using the Clinical Frailty Scale (CFS) and for risk of three adverse outcomes: i) institutionalisation, ii) hospitalisation and iii) death, within the next year, from one (lowest) to five (highest) using the RISC. Prior to scoring, PHNs stated whether they regarded patients as frail. RESULTS: The median age of patients was 80 years (interquartile range 10), of whom 64% were female and 47.4% were living alone. The median Abbreviated Mental Test Score (AMTS) was 10 (0) and Barthel Index was 18/20 (6). PHNs regarded 42% of patients as frail, while the CFS categorized 54% (scoring ≥5) as frail. Dividing patients into low-risk (score one or two), medium-risk (score three) and high-risk (score four or five) using the RISC showed that 4.3% were considered high risk of institutionalization, 14.5% for hospitalization, and 2.7% for death, within one year of the assessment. There were significant differences in median CFS (4/9 versus 6/9 versus 6/9, p < 0.001), Barthel Index (18/20 versus 11/20 versus 14/20, p < 0.001) and mean AMTS scores (9.51 versus 7.57 versus 7.00, p < 0.001) between those considered low, medium and high risk of institutionalisation respectively. Differences were also statistically significant for hospitalisation and death. Age, gender and living alone were inconsistently associated with perceived risk. Frailty most closely correlated with functional impairment, r = −0.80, p < 0.001. CONCLUSION: The majority of patients in this community sample were perceived to be low risk for adverse outcomes. Frailty, cognitive impairment and functional status were markers of perceived risk. Age, gender and social isolation were not and may not be useful indicators when triaging community dwellers. The RISC now requires validation against adverse outcomes
Economic (gross cost) analysis of systematically implementing a programme of advance care planning in three Irish nursing homes.
Background: Although advance care planning (ACP) and the use of advanced care directives (ACD) and end-of-life care plans are associated with a reduction in inappropriate hospitalisation, there is little evidence supporting the economic benefits of such programmes. We assessed the economic impact (gross savings) of the Let Me Decide (LMD) ACP programme in Ireland, specifically the impact on hospitalisations, bed days and location of resident deaths, before and after systematic implementation of the LMD-ACP combined with a palliative care education programme. Methods: The LMD-ACP was introduced into three long-term care (LTC) facilities in Southern Ireland and outcomes were compared pre and post implementation. In addition, 90 staff were trained in a palliative care educational programme. Economic analysis including probabilistic sensitivity analysis was performed. Results: The uptake of an ACD or end-of-life care post-implementation rose from 25 to 76 %. Post implementation, there were statistically significant decreases in hospitalisation rates from baseline (hospitalisation incidents declined from 27.8 to 14.6 %, z = 3.96, p < 0.001; inpatient hospital days reduced from 0.54 to 0.36 %, z = 8.85, p < 0.001). The percentage of hospital deaths also decreased from 22.9 to 8.4 %, z = 3.22, p = 0.001. However, length of stay (LOS) increased marginally (7–9 days). Economic analysis suggested a cost-reduction related to reduced hospitalisations ranging between €10 and €17.8 million/annum and reduction in ambulance transfers, estimated at €0.4 million/annum if these results were extrapolated nationally. When unit costs and LOS estimates were varied in scenario analyses, the expected cost reduction owing to reduced hospitalisations, ranged from €17.7 to €42.4 million nationally. Conclusions: Implementation of the LMD-ACP (ACD/end-of-life care plans combined with palliative care education) programme resulted in reduced rates of hospitalisation. Despite an increase in LOS, likely reflecting more complex care needs of admitted residents, gross costs were reduced and scenario analysis projected large annual savings if these results were extrapolated to the wider LTC population in Ireland
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