Use of the Physician Orders for Scope of Treatment Program in Indiana Nursing Homes

OBJECTIVES: To assess the use of the Indiana Physician Orders for Scope of Treatment (POST) form to record nursing home (NH) resident treatment preferences and associated practices. DESIGN: Survey. SETTING: Indiana NHs. PARTICIPANTS: Staff responsible for advance care planning in 535 NHs. MEASUREMENTS: Survey about use of the Indiana POST, related policies, and educational activities. METHODS: NHs were contacted by telephone or email. Nonresponders were sent a brief postcard survey. RESULTS: Ninety-one percent (n=486) of Indiana NHs participated, and 79% had experience with POST. Of the 65% of NHs that complete POST with residents, 46% reported that half or more residents had a POST form. POST was most often completed at the time of admission (68%). Only 52% of participants were aware of an existing facility policy regarding use of POST; 80% reported general staff education on POST. In the 172 NHs not using POST, reasons for not using it included unfamiliarity with the tool (23%) and lack of facility policies (21%). CONCLUSION: Almost 3 years after a grassroots campaign to introduce the voluntary Indiana POST program, a majority of NHs were using POST to support resident care. Areas for improvement include creating policies on POST for all NHs, training staff on POST conversations, and considering processes that may enhance the POST conversation, such as finding an optimal time to engage in conversations about treatment preferences other than a potentially rushed admission process

Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke

Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible

Preparing Einstein Students to Practice in Twenty-first Century Medicine

The current trend in medical education is to introduce clinical teaching early in the medical school curriculum to help students understand the relevance of the basic sciences to clinical practice. The Introduction to Clinical Medicine (ICM) Program for students in the first two years at the Albert Einstein College of Medicine (AECOM) is comprised of three, required, integrated courses providing skills training in both medical interviewing and physical examination, training in diagnostic reasoning skills, and opportunities to discuss broad themes in medicine and the doctor-patient relationship. Competency evaluation of students’ clinical skills is an essential part of the ICM Program. Innovative strategies for weaving themes related to cultural competency have been incorporated into the ICM program to address the wide spectrum of cultural issues affecting medical care and the doctor/patient relationship, including diversity, spirituality, complementary and alternative medical practices, and end-of-life care. A total of 300 medical school faculty members teach in the various ICM courses. Much effort goes into keeping the faculty current, happy, and rewarded for their dedication and hard work in teaching the students. The ICM Program continues to strive for excellence as we prepare AECOM students to face the demands of medical practice in the twenty-first centur

INNOVATIVE MEDICAL EDUCATION Preparing Einstein Students to Practice Twenty-first Century Medicine

ABSTRACT The current trend in medical education is to introduce clinical teaching early in the medical school curriculum to help students understand the relevance of the basic sciences to clinical practice. The Introduction to Clinical Medicine (ICM) Program for students in the first two years at the Albert Einstein College of Medicine (AECOM) is comprised of three, required, integrated courses providing skills training in both medical interviewing and physical examination, training in diagnostic reasoning skills, and opportunities to discuss broad themes in medicine and the doctor-patient relationship. Competency evaluation of students' clinical skills is an essential part of the ICM Program. Innovative strategies for weaving themes related to cultural competency have been incorporated into the ICM program to address the wide spectrum of cultural issues affecting medical care and the doctor/patient relationship, including diversity, spirituality, complementary and alternative medical practices, and end-of-life care. A total of 300 medical school faculty members teach in the various ICM courses. Much effort goes into keeping the faculty current, happy, and rewarded for their dedication and hard work in teaching the students. The ICM Program continues to strive for excellence as we prepare AECOM students to face the demands of medical practice in the twenty-first century

Short-Term Medical Costs of a VHA Health Information Exchange: A CHEERS-Compliant Article.

The Virtual Lifetime Electronic Record (VLER) Health program provides the Veterans Health Administration (VHA) a framework whereby VHA providers can access the veterans’ electronic health record information to coordinate healthcare across multiple sites of care. As an early adopter of VLER, the Indianapolis VHA and Regenstrief Institute implemented a regional demonstration program involving bi-directional health information exchange (HIE) between VHA and non-VHA providers.The aim of the study is to determine whether implementation of VLER HIE reduces 1 year VHA medical costs.A cohort evaluation with a concurrent control group compared VHA healthcare costs using propensity score adjustment. A CHEERs compliant checklist was used to conduct the cost evaluation.Patients were enrolled in the VLER program onsite at the Indianapolis VHA in outpatient clinics or through the release-of-information office.VHA cost data (in 2014 dollars) were obtained for both enrolled and nonenrolled (control) patients for 1 year prior to, and 1 year after, the index date of patient enrollment.There were 6104 patients enrolled in VLER and 45,700 patients in the control group. The annual adjusted total cost difference per patient was associated with a higher cost for VLER enrollees $1152 (95$807–1433) (P < 0.01) (in 2014 dollars) than VLER nonenrollees.Short-term evaluation of this demonstration project did not show immediate reductions in healthcare cost as might be expected if HIE decreased redundant medical tests and treatments. Cost reductions from shared health information may be realized with longer time horizons

Does Inclusion of Stroke Severity in a 30-day Mortality Model Change Standardized Mortality Rates at VA Hospitals?

Background—The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospital-level mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration. Methods and Results—A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6%. The RSMR interquartile range without the NIHSS ranged from 5.1% to 5.6%. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1%–5.6%). Among veterans ≥65 years, the RSMR interquartile range without the NIHSS ranged from 9.2% to 10.3%. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4% to 10.0%. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95% confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals. Conclusions—The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality

Evolutionary Signatures in the Formation of Low-Mass Protostars. II. Towards Reconciling Models and Observations

A long-standing problem in low-mass star formation is the "luminosity problem," whereby protostars are underluminous compared to the accretion luminosity expected both from theoretical collapse calculations and arguments based on the minimum accretion rate necessary to form a star within the embedded phase duration. Motivated by this luminosity problem, we present a set of evolutionary models describing the collapse of low-mass, dense cores into protostars, using the Young & Evans (2005) model as our starting point. We calculate the radiative transfer of the collapsing cores throughout the full duration of the collapse in two dimensions. From the resulting spectral energy distributions, we calculate standard observational signatures to directly compare to observations. We incorporate several modifications and additions to the original Young & Evans model in an effort to better match observations with model predictions. We find that scattering, 2-D geometry, mass-loss, and outflow cavities all affect the model predictions, as expected, but none resolve the luminosity problem. A cycle of episodic mass accretion, however, can resolve this problem and bring the model predictions into better agreement with observations. Standard assumptions about the interplay between mass accretion and mass loss in our model give star formation efficiencies consistent with recent observations that compare the core mass function (CMF) and stellar initial mass function (IMF). The combination of outflow cavities and episodic mass accretion reduce the connection between observational Class and physical Stage to the point where neither of the two common observational signatures (bolometric temperature and ratio of bolometric to submillimeter luminosity) can be considered reliable indicators of physical Stage.Comment: 27 pages. Accepted for publication in Ap

Care Trajectories of Veterans in the Twelve Months following Hospitalization for Acute Ischemic Stroke

Background—Recovery after a stroke varies greatly between individuals and is reflected by wide variation in the use of institutional and home care services. This study sought to classify veterans according to their care trajectories in the 12 months after hospitalization for ischemic stroke. Methods and Results—The sample consisted of 3811 veterans hospitalized for ischemic stroke in Veterans Health Administration facilities in 2007. Three outcomes—nursing home care, home care, and mortality—were modeled jointly >12 months using latent class growth analysis. Data on Veterans’ care use and cost came from the Veterans Administration and Medicare. Covariates included stroke severity (National Institutes of Health Stroke Scale), functional status (functional independence measure score), age, marital status, chronic conditions, and prestroke ambulation. Five care trajectories were identified: 49% of Veterans had Rapid Recovery with little or no use of care; 15% had a Steady Recovery with initially high nursing home or home care that tapered off; 9% had Long-Term Home Care; 13% had Long-Term Nursing Home Care; and 14% had an Unstable trajectory with multiple transitions between long-term and acute care settings. Care use was greatest for individuals with more severe strokes, lower functioning at hospital discharge, and older age. Average annual costs were highest for individuals with the Long-Term Nursing Home trajectory ($63 082), closely followed by individuals with the Unstable trajectory ($58 720). Individual with the Rapid Recovery trajectory had the lowest costs ($9271). Conclusions—Care trajectories after stroke were associated with stroke severity and functional dependency and they had a dramatic impact on subsequent costs