2012 May 17

Transitions in Care for Older Adults with and without Dementia.

May 172012

Transitions in Care for Older Adults with and without Dementia.

J Am Geriatr Soc. 2012 May;60(5):813-20

Authors: Callahan CM, Arling G, Tu W, Rosenman MB, Counsell SR, Stump TE, Hendrie HC

Abstract
OBJECTIVES: To describe transitions in care of persons with dementia with attention to nursing facility transitions.
DESIGN: Prospective cohort.
SETTING: Public health system.
PARTICIPANTS: Four thousand one hundred ninety-seven community-dwelling older adults.
MEASUREMENTS: Participants' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS) from 2001 to 2008 with a mean follow-up of 5.2 years from the time of enrollment.
RESULTS: Older adults with prevalent (n = 524) or incident (n = 999) dementia had greater Medicare (44.7% vs 44.8% vs 11.4%, P < .001) and Medicaid (21.0% vs 16.8% vs 1.4%, P < .001) nursing facility use, greater hospital (76.2% vs 86.0% vs 51.2%, P < .001) and home health (55.7% vs 65.2% vs 27.3%, P < .001) use, more transitions in care per person-year of follow-up (2.6 vs 2.7 vs 1.4, P < .001), and more mean total transitions (11.2 vs 9.2 vs 3.8, P < .001) than those who were never diagnosed (n = 2,674). For the 1,523 participants with dementia, 74.5% of transitions to nursing facilities were transfers from hospitals. For transitions from nursing facilities, the conditional probability was 41.0% for a return home without home health care, 10.7% for home health care, and 39.8% for a hospital transfer. Of participants with dementia with a rehospitalization within 30 days, 45% had been discharged to nursing facilities from the index hospitalization. At time of death, 46% of participants with dementia were at home, 35% were in the hospital, and 19% were in a nursing facility.
CONCLUSION: Individuals with dementia live and frequently die in community settings. Nursing facilities are part of a dynamic network of care characterized by frequent transitions.

PMID: 22587849 [PubMed - in process]

Link to Article at PubMed

Are geriatricians more efficient than other physicians at managing inpatient care for elderly patients?

J Am Geriatr Soc Start a Discussion »

May 172012

Are geriatricians more efficient than other physicians at managing inpatient care for elderly patients?

J Am Geriatr Soc. 2012 May;60(5):869-76

Authors: Sorbero ME, Saul MI, Liu H, Resnick NM

Abstract
OBJECTIVES: To compare outcomes and measures of efficiency for hospitalized elderly adults managed by geriatricians with those managed by other physicians.
DESIGN: Secondary data analysis using a system that integrates clinical and financial information for inpatient and outpatient services delivered throughout the University of Pittsburgh Medical Center (UPMC). Propensity scores were developed based on participant sociodemographic and clinical characteristics and used to match participants based on the attending physician's specialty (geriatrician, n = 701; nongeriatrician, n = 11,549). Multivariate analyses using generalized estimating equations methods were performed.
SETTING: Two UPMC hospitals in Pittsburgh, Pennsylvania.
PARTICIPANTS: Patients aged 65 and older admitted in 2002 in a medical diagnosis-related group (DRG).
MEASUREMENTS: Outcomes (inpatient mortality, 30-day mortality, readmission) and efficiency measures (length of stay, total costs, and surplus, which is the difference between hospital costs and payment received for an admission).
RESULTS: Elderly adults managed by geriatricians were significantly older (P < .001) and more likely to be male (P < .001) and had more diagnoses (P < .001). Propensity scores successfully balanced characteristics managed by the two groups. Patients of geriatricians had shorter length of stay (P < .001), lower costs per admission (P < .001), and greater surplus (P < .001) with no differences in outcomes. In multivariate analyses, there were not significant differences in outcomes, but patients of geriatricians had significantly shorter length of stay and lower costs per admission and generated more surplus for the hospitals.
CONCLUSION: Geriatricians were more efficient than other physicians in managing hospitalized elderly adults with medical DRGs frequently managed by geriatricians. This efficiency did not compromise patient outcomes.

PMID: 22587852 [PubMed - in process]

Link to Article at PubMed

Combination therapy in type 2 diabetes mellitus: adding linagliptin to a stable regimen of metformin and a sulfonylurea.

Expert Opin Pharmacother Start a Discussion »

May 172012

Combination therapy in type 2 diabetes mellitus: adding linagliptin to a stable regimen of metformin and a sulfonylurea.

Expert Opin Pharmacother. 2012 May 16;

Authors: Aronson R

Abstract
Linagliptin, the most recently approved drug of the dipeptidyl peptidase-4 (DPP-4) inhibitor class, is an oral agent used to improve glycemic control in type 2 diabetes mellitus (T2DM). By inhibiting the DPP-4 enzyme, these drugs slow the inactivation of the endogenous incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), in turn reducing blood glucose levels in a glucose-dependent manner. As well as significantly reducing glycosylated hemoglobin, the class has a good safety profile, with a low incidence of hypoglycemia, and is not associated with weight gain. From a practical point of view, they also have simple regimens, generally with once-daily oral administration, and can be used as monotherapy or in combination with other anti-diabetic drugs. Owens and colleagues have reported a 6-month study of linagliptin add-on therapy in patients who were receiving a stable regimen of metformin and a sulfonylurea, but needed additional glycemic control. Linagliptin was associated with significant improvement in glycemic control and was well-tolerated by patients, indicating that it provides a valuable option for a large number of patients with T2DM, especially for those who would prefer to add an oral therapy to a current regimen.

PMID: 22587735 [PubMed - as supplied by publisher]

Link to Article at PubMed

Multidrug-resistant Pseudomonas aeruginosa bloodstream infections: risk factors and mortality.

Epidemiol Infect Start a Discussion »

May 172012

Multidrug-resistant Pseudomonas aeruginosa bloodstream infections: risk factors and mortality.

Epidemiol Infect. 2011 Nov;139(11):1740-9

Authors: Tumbarello M, Repetto E, Trecarichi EM, Bernardini C, De Pascale G, Parisini A, Rossi M, Molinari MP, Spanu T, Viscoli C, Cauda R, Bassetti M

Abstract
We retrospectively studied patients diagnosed with P. aeruginosa bloodstream infections (BSIs) in two Italian university hospitals. Risk factors for the isolation of multidrug-resistant (MDR) or non-MDR P. aeruginosa in blood cultures were identified by a case-case-control study, and a cohort study evaluated the clinical outcomes of such infections. We identified 106 patients with P. aeruginosa BSI over the 2-year study period; 40 cases with MDR P. aeruginosa and 66 cases with non-MDR P. aeruginosa were compared to 212 controls. Independent risk factors for the isolation of MDR P. aeruginosa were: presence of central venous catheter (CVC), previous antibiotic therapy, and corticosteroid therapy. Independent risk factors for non-MDR P. aeruginosa were: previous BSI, neutrophil count <500/mm3, urinary catheterization, and presence of CVC. The 21-day mortality rate of all patients was 33·9%. The variables independently associated with 21-day mortality were presentation with septic shock, infection due to MDR P. aeruginosa, and inadequate initial antimicrobial therapy.

PMID: 21226988 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses.

Am J Respir Crit Care Med Start a Discussion »

May 172012

Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses.

Am J Respir Crit Care Med. 2012 Apr 1;185(7):738-43

Authors: Garland A, Roberts D, Graff L

Abstract
RATIONALE: Around-the-clock intensivist presence in intensive care units (ICUs) has been promoted as necessary to optimize outcomes. Little data have addressed how it affects the multiple stakeholders in such care.
OBJECTIVES: To assess effects of around-the-clock intensivist presence on intensivists, patients, families, housestaff, and nurses.
METHODS: This 32-week, crossover pilot trial of two intensivist staffing models, performed in two Canadian ICUs, alternated 8-week blocks of two staffing models: the standard model, where one intensivist worked for 7 days, taking night call from home; and the shift work model, where one intensivist worked 7 day shifts, while other intensivists remained in the ICU at night.
MEASUREMENTS AND MAIN RESULTS: Surveys scaled from 0-100 points assessed outcomes for 24 intensivists (primary outcome: burnout); 119 families (satisfaction); 74 nurses (satisfaction with collaboration and communications, role conflict); and 34 housestaff (autonomy, supervision, and learning opportunities). Outcomes for 501 patients included mortality, length of stay, and resource use. Intensivists doing shift work experienced less burnout (-6.9 points; P = 0.04). Adjusted hospital mortality (odds ratio, 1.22; P = 0.44), ICU length of stay (-6 h; P = 0.46), and family satisfaction (0.9 points; P = 0.79) did not differ between staffing models. Under shift work staffing, nurses reported more role conflict (9 points; P < 0.001), whereas nighttime housestaff reported less autonomy, more supervision, but no difference in learning opportunities.
CONCLUSIONS: Shiftwork staffing was better for intensivists and most were receptive once they had experienced it. Although there were no evident negative outcomes for patients or families, further evaluation is needed to clarify how around-the-clock intensivist staffing influences the various stakeholders in ICU care, given power considerations in this study. Clinical trial registered with www.clinicaltrials.gov (NCT 01146691).

PMID: 22246176 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Apolipoprotein M – a new biomarker in sepsis.

Crit Care Start a Discussion »

May 172012

Apolipoprotein M - a new biomarker in sepsis.

Crit Care. 2012 May 17;16(3):126

Authors: Christoffersen C, Nielsen LB

Abstract
ABSTRACT: Sepsis is one of the leading causes of mortality in non-cardiac intensive care units, and the need for markers of progression and severity are high. Also, treatment of sepsis is highly debated and potential new targets of treatment are of great interest. In the previous issue of Critical Care Kumaraswamy and colleagues have investigated whether plasma apolipoprotein M (apoM) is affected during different grades of sepsis, septic shock and systemic inflammatory response syndrome. Interestingly, plasma apoM was significantly decreased in all groups of patients with a relationship to severity of disease. This identifies apoM as a potential new biomarker in sepsis. It also underscores the possibility that altered high-density lipoprotein in sepsis patients can affect the course of disease. Thus, since apoM is the carrier of Sphingosine-1-P (S1P), a molecule with great influence on vascular barrier function, the study presented raises the interest and relevance for further studies of apoM and S1P in relation to sepsis and inflammation.

PMID: 22587809 [PubMed - as supplied by publisher]

Link to Article at PubMed

May 2012
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