Public Health Commons^™

Elders With Serious Mental Illness: Lost Opportunities And New Policy Options, Darlene O'Connor, Faith Little, Richard Mcmanus

Richard H. McManus

This article reviews key federal Medicaid policies affecting older adults with serious, long-term mental illness: (a) the Medicaid exclusion of coverage for Institutions for Mental Diseases, (b) the Preadmission Screening and Resident Review Process, and (c) the Medicaid Home and Community Based Services waiver policy. Documenting the incentives and restrictions in these policies provides an historical context for understanding the current gaps in treatment for elders with mental illness. New federal options under the Deficit Reduction Act may provide opportunities for reducing the institutional bias for older adults with mental illness and for improving mental health services for elders under …

Increase In The Proportion Of Patients Hospitalized With Acute Myocardial Infarction With Do-Not-Resuscitate Orders Already In Place Between 2001 And 2007: A Nonconcurrent Prospective Study, Jane Saczynski, Ezra Gabbay, David Mcmanus, Richard Mcmanus, Joel Gore, Jerry Gurwitz, Darleen Lessard, Robert Goldberg

Richard H. McManus

BACKGROUND AND OBJECTIVE: Shared decision making and advance planning in end-of-life decisions have become increasingly important aspects of the management of seriously ill patients. Here, we describe the use and timing of do-not-resuscitate (DNR) orders in patients hospitalized with acute myocardial infarction (AMI). STUDY DESIGN AND SETTING: The nonconcurrent prospective study population consisted of 4182 patients hospitalized with AMI in central Massachusetts in four annual periods between 2001 and 2007. RESULTS: One-quarter (25%) of patients had a DNR order written either prior to or during hospitalization. The frequency of DNR orders remained constant (24% in 2001; 26% in 2007). Among …

Transitions, Risks, And Actions In Coronary Events--Center For Outcomes Research And Education (Trace-Core): Design And Rationale, Molly Waring, Richard Mcmanus, Jane Saczynski, Milena Anatchkova, David Mcmanus, Randolph Devereaux, Robert Goldberg, Jeroan Allison, Catarina Kiefe

Richard H. McManus

Background: Cardiovascular disease continues to cause significant morbidity, mortality, and impaired quality of life, with unrealized health gains from the underuse of available evidence. The Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) aims to advance the science of acute coronary syndromes by examining the determinants and outcomes of the quality of transition from hospital to community and by quantifying the impact of potentially modifiable characteristics associated with decreased quality of life, rehospitalization, and mortality. Methods and Results: TRACE-CORE comprises a longitudinal multiracial cohort of patients hospitalized with acute coronary syndromes, 2 research projects, …

Elders With Serious Mental Illness: Lost Opportunities And New Policy Options, Darlene O'Connor, Faith Little, Richard Mcmanus

Richard H. McManus

This article reviews key federal Medicaid policies affecting older adults with serious, long-term mental illness: (a) the Medicaid exclusion of coverage for Institutions for Mental Diseases, (b) the Preadmission Screening and Resident Review Process, and (c) the Medicaid Home and Community Based Services waiver policy. Documenting the incentives and restrictions in these policies provides an historical context for understanding the current gaps in treatment for elders with mental illness. New federal options under the Deficit Reduction Act may provide opportunities for reducing the institutional bias for older adults with mental illness and for improving mental health services for elders under …

Increase In The Proportion Of Patients Hospitalized With Acute Myocardial Infarction With Do-Not-Resuscitate Orders Already In Place Between 2001 And 2007: A Nonconcurrent Prospective Study, Jane Saczynski, Ezra Gabbay, David Mcmanus, Richard Mcmanus, Joel Gore, Jerry Gurwitz, Darleen Lessard, Robert Goldberg

Richard H. McManus

BACKGROUND AND OBJECTIVE: Shared decision making and advance planning in end-of-life decisions have become increasingly important aspects of the management of seriously ill patients. Here, we describe the use and timing of do-not-resuscitate (DNR) orders in patients hospitalized with acute myocardial infarction (AMI). STUDY DESIGN AND SETTING: The nonconcurrent prospective study population consisted of 4182 patients hospitalized with AMI in central Massachusetts in four annual periods between 2001 and 2007. RESULTS: One-quarter (25%) of patients had a DNR order written either prior to or during hospitalization. The frequency of DNR orders remained constant (24% in 2001; 26% in 2007). Among …

Transitions, Risks, And Actions In Coronary Events--Center For Outcomes Research And Education (Trace-Core): Design And Rationale, Molly Waring, Richard Mcmanus, Jane Saczynski, Milena Anatchkova, David Mcmanus, Randolph Devereaux, Robert Goldberg, Jeroan Allison, Catarina Kiefe

Richard H. McManus

Background: Cardiovascular disease continues to cause significant morbidity, mortality, and impaired quality of life, with unrealized health gains from the underuse of available evidence. The Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) aims to advance the science of acute coronary syndromes by examining the determinants and outcomes of the quality of transition from hospital to community and by quantifying the impact of potentially modifiable characteristics associated with decreased quality of life, rehospitalization, and mortality. Methods and Results: TRACE-CORE comprises a longitudinal multiracial cohort of patients hospitalized with acute coronary syndromes, 2 research projects, …

A Double-Blind, Randomized, Placebo Controlled Trial Of Ramelteon For The Treatment Of Insomnia And Mood Stability In Patients With Euthymic Bipolar Disorder, Edward Norris

Edward R Norris MD, FAPA, FAPM

The study was a single-site, double-blind, randomized, placebo-controlled, parallel group study to evaluate the efficacy of adjunctive ramelteon in the treatment of insomnia and mood stability in patients with euthymic bipolar disorder for up to 24 weeks of maintenance treatment. Participants with euthymic bipolar disorder and sleep disturbances were randomized to receive adjunctive ramelteon or placebo in addition to their reular psychiatric medications for up to 24 weeks or until they experienced a relapse (defined as a depressed or manic event).

Treating Methicillin-Resistant Staphylococcus Aureus With The Drug Vancomycin In A Home Infusion Therapy Setting, Joshua Webb, Alberto Coustasse, Dennis Emmett

Dennis Emmett

The basic purpose of this paper is to examine the effects the home infusion therapy has on the cost, duration of, and effectiveness of treatment between those individuals under 60 and those 60 and over. The results show that those 60 and over had a slightly higher cost/day. The older age group had slightly smaller treatment duration, then the younger group. The number of adverse effects was small. The results suggest that home infusion therapy appears to be a viable alternative to hospitalization.

Treating Methicillin-Resistant Staphylococcus Aureus With The Drug Vancomycin In A Home Infusion Therapy Setting, Joshua L. Webb, Alberto Coustasse, Dennis Emmett

Alberto Coustasse, DrPH, MD, MBA, MPH

The basic purpose of this paper is to examine the effects the home infusion therapy has on the cost, duration of, and effectiveness of treatment between those individuals under 60 and those 60 and over. The results show that those 60 and over had a slightly higher cost/day. The older age group had slightly smaller treatment duration, then the younger group. The number of adverse effects was small. The results suggest that home infusion therapy appears to be a viable alternative to hospitalization.

Judy Savageau And Terri Anderson On Strategies For Strategic Planning To Improve Evaluation, Judith A. Savageau, Teresa Anderson

Judith A. Savageau

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.

Judy Savageau On The Irb Process In Human Subject Research, Judith A. Savageau

Judith A. Savageau

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.

Judy Savageau And Laura Sefton On Creating Standard Operating Procedures For Evaluation Projects, Judith A. Savageau, Laura A. Sefton

Judith A. Savageau

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.

Judy Savageau And Linda Cabral On Using Journal Clubs To Promote Best Practices In Evaluation, Judith A. Savageau, Linda M. Cabral

Judith A. Savageau

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.

Michelle Landry And Judy Savageau On No Need To Reinvent The Wheel: Project Management Tools For Your Evaluation Projects, Michelle R. Landry, Judith A. Savageau

Judith A. Savageau

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness.

Adverse Drug Events Post-Hospital Discharge In Older Patients: Types, Severity, And Involvement Of Beers Criteria Medications, Abir O. Kanaan, Jennifer L. Donovan, Nerissa P. Duchin, Terry S. Field, Jennifer Tjia, Sarah L. Cutrona, Shawn J. Gagne, Lawrence D. Garber, Peggy Preusse, Leslie R. Harrold, Jerry H. Gurwitz

Lawrence D. Garber

Objective: To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period post-hospitalization in older adults.

Design: Clinical pharmacists reviewed the ambulatory records of 1000 consecutive discharges.

Setting: A large multispecialty group practice closely aligned with a Massachusetts-based health plan.

Participants: Hospitalized patients aged 65 years and older who were discharged to home.

Measurements: Possible drug-related incidents occurring during the 45-day period post-hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further …

Adverse Drug Events Post-Hospital Discharge In Older Patients: Types, Severity, And Involvement Of Beers Criteria Medications, Abir O. Kanaan, Jennifer L. Donovan, Nerissa P. Duchin, Terry S. Field, Jennifer Tjia, Sarah L. Cutrona, Shawn J. Gagne, Lawrence D. Garber, Peggy Preusse, Leslie R. Harrold, Jerry H. Gurwitz

Jennifer Tjia

Objective: To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period post-hospitalization in older adults.

Design: Clinical pharmacists reviewed the ambulatory records of 1000 consecutive discharges.

Setting: A large multispecialty group practice closely aligned with a Massachusetts-based health plan.

Participants: Hospitalized patients aged 65 years and older who were discharged to home.

Measurements: Possible drug-related incidents occurring during the 45-day period post-hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further …

Reducing Rehospitalizations Through Automated Alerts To Primary Care Providers And Staff When Older Patients Are Discharged From The Hospital: A Randomized Trial, Jerry H. Gurwitz, Terry S. Field, Jessica Ogarek, Jennifer Tjia, Sarah L. Cutrona, Leslie R. Harrold, Jennifer L. Donovan, Abir O. Kanaan, Shawn J. Gagne, Peggy Preusse, Lawrence D. Garber

Jennifer Tjia

Background: Inadequate continuity of care places older patients at very high risk during transitions from the hospital to ambulatory setting.

Methods: We conducted a randomized controlled trial of an HIT-based transitional care intervention in patients aged 65 and older discharged from hospital to home. All patients were senior plan members of a Massachusetts-based health plan, and cared for by a multispecialty medical group using the EpicCare Ambulatory Medical Record. In addition to notifying providers about the patient’s recent transition, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and …

Understanding Antipsychotic Drug Use In The Nursing Home Setting, Celeste A. Lemay, Alice F. Bonner, Christina Compher, Terry S. Field, Jonathan Freedlander, Susan Joslin, Kathleen M. Mazor, Jennifer Tjia, Jerry H. Gurwitz

Jennifer Tjia

Introduction: The increasing prevalence of antipsychotic medication use in residents of nursing homes (NH) in the absence of psychiatric diagnoses is concerning. To address these concerns, it is essential to explore how these medications are being prescribed and managed in the NH setting. Our objectives were to understand the decision-making process that influences prescribing and factors that trigger administration of antipsychotic medications to residents with dementia in NHs and to explore why residents remain on antipsychotic medications over an extended period of time.

Methods: Interviews with prescribers, caregivers, and family members, on-site observations in study facilities, and review of NH …

Intervention To Reduce Adverse Outcomes Among Older Adults Discharged From Skilled Nursing Facilities To Home, Terry S. Field, Jessica Ogarek, Abir O. Kanaan, Jennifer L. Donovan, Peggy Preusse, Devi Sundaresan, Shawn J. Gagne, Lawrence D. Garber, Jennifer Tjia, Sarah L. Cutrona, Jerry H. Gurwitz

Jennifer Tjia

Background: Older adults may be at risk for adverse outcomes after discharge from skilled nursing facilities (SNF), but little research has focused on this transition.

Objective: To assess the impact of an alert system on the rates of adverse outcomes among older adults discharged from SNFs to home.

Methods: Within a multispecialty group practice, we tracked 30-day re-hospitalizations after SNF discharges during an intervention that provided discharge alerts to primary care physicians. We compared them to discharges from the pre-intervention period matched on age, gender and SNF. For the first 100 intervention discharges and their matches, we performed chart reviews …

Barriers And Facilitators To Addressing Perinatal Depression In Obstetric Settings, Nancy Byatt, Kathleen Biebel, Liz Friedman, Gifty Debordes-Jackson, Jeroan J. Allison, Douglas M. Ziedonis

Kathleen Biebel

Background: Perinatal depression is common and can cause suffering for mother, fetus/child and family. The perinatal period is an ideal time to detect and treat depression due to regular contact between mothers and health professionals. Despite the opportune time and setting, depression is under-diagnosed and under-treated in the obstetric setting. Caring and committed providers are frustrated and confused, and mothers do not feel heard or understood by their providers.

Objectives: (1) Identify postpartum women’s perspective on how perinatal depression is addressed in obstetric settings; (2) Identify strategies for improvement of the delivery of depression care in OB/Gyn settings; and, (3) …

Rates Of Insurance For Injured Patients Before And After Health Care Reform In Massachusetts: Another Case Of Double Jeopardy?, Heena P. Santry, Courtney E. Collins, Jason T. Wiseman, Julie M. Flahive, Charles M. Psoinos, Zeling Chau, Shimul A. Shah, Catarina I. Kiefe

Catarina I. Kiefe

Background: As a result of healthcare reform (HCR), insurance rates among Massachusetts (MA) residents increased from 86.6% (2006) to 94.4% (2010) and conferred a 7.6% higher probability of being insured compared to neighboring states. The effect of an individual mandate on insurance rates among trauma patients is unknown.

Methods: This was retrospective analysis of adult (18-64yrs) trauma patients from MA and surrounding states (NH, RI, CT, NY, VT) treated at our level 1 trauma center in central MA before (2004-2005) and after (2009-2010) MA-HCR. We estimated changes in insurance rates across time-periods and state-residence.

Results: Before MA-HCR, 76.7% (1647/2,148) of …

Reducing Rehospitalizations Through Automated Alerts To Primary Care Providers And Staff When Older Patients Are Discharged From The Hospital: A Randomized Trial, Jerry H. Gurwitz, Terry S. Field, Jessica Ogarek, Jennifer Tjia, Sarah L. Cutrona, Leslie R. Harrold, Jennifer L. Donovan, Abir O. Kanaan, Shawn J. Gagne, Peggy Preusse, Lawrence D. Garber

Abir O. Kanaan

Background: Inadequate continuity of care places older patients at very high risk during transitions from the hospital to ambulatory setting.

Methods: We conducted a randomized controlled trial of an HIT-based transitional care intervention in patients aged 65 and older discharged from hospital to home. All patients were senior plan members of a Massachusetts-based health plan, and cared for by a multispecialty medical group using the EpicCare Ambulatory Medical Record. In addition to notifying providers about the patient’s recent transition, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and …

Can Kawasaki Disease Be Managed?, Alberto Coustasse, Julius Larry, Doohee Lee

Doohee Lee

Kawasaki Disease (KD) is the leading cause of acquired cardiovascular disease among children, but management of KD has received relatively little attention. In the US alone, about 5500 cases were estimated in 2009. KD is most common among Asian and Pacific Islander children but can affect all ethnicities and races. Timely and accurate diagnosis remains critical, but difficult: the etiology of KD is unknown, and no accurate diagnostic laboratory test has been developed. Continuing medical education can help physicians, clinicians, and nurse practitioners accurately diagnose and treat KD. A registry specific to KD or a surveillance system may be necessary …

Can Kawasaki Disease Be Managed?, Alberto Coustasse, Julius Larry, Doohee Lee

Alberto Coustasse, DrPH, MD, MBA, MPH

Kawasaki Disease (KD) is the leading cause of acquired cardiovascular disease among children, but management of KD has received relatively little attention. In the US alone, about 5500 cases were estimated in 2009. KD is most common among Asian and Pacific Islander children but can affect all ethnicities and races. Timely and accurate diagnosis remains critical, but difficult: the etiology of KD is unknown, and no accurate diagnostic laboratory test has been developed. Continuing medical education can help physicians, clinicians, and nurse practitioners accurately diagnose and treat KD. A registry specific to KD or a surveillance system may be necessary …

Managed Care, Hospice Use, Site Of Death, And Medical Expenditures In The Last Year Of Life, Ezekiel Emanuel, Arlene Ash, Wei Yu, Gail Gazelle, Norman Levinsky, Olga Saynina, Mark Mcclellan, Mark Moskowitz

wei yu

BACKGROUND: We examined deaths of Medicare beneficiaries in Massachusetts and California to evaluate the effect of managed care on the use of hospice and site of death and to determine how hospice affects the expenditures for the last year of life.

METHODS: Medicare data for beneficiaries in Massachusetts (n = 37 933) and California (n = 27 685) who died in 1996 were merged with each state's death certificate files to determine site and cause of death. Expenditure data were Health Care Financing Administration payments and were divided into 30-day periods from the date of death back 12 months.

RESULTS: …

Who Participates In Web-Assisted Tobacco Interventions? The Quit-Primo And National Dental Practice-Based Research Network Hi-Quit Studies, Rajani S. Sadasivam, Rebecca L. Kinney, Kathryn L. Delaughter, Sowmya R. Rao, Jessica Hillman Williams, Heather L. Coley, Midge N. Ray, Gregg H. Gilbert, Jeroan J. Allison, Daniel E. Ford, Thomas K. Houston

Rajani S. Sadasivam

INTRODUCTION: Smoking is the most preventable cause of death. Although effective, Web-assisted tobacco interventions are underutilized and recruitment is challenging. Understanding who participates in Web-assisted tobacco interventions may help in improving recruitment.

OBJECTIVES: To understand characteristics of smokers participating in a Web-assisted tobacco intervention (Decide2Quit.org).

METHODS: In addition to the typical Google advertisements, we expanded Decide2Quit.org recruitment to include referrals from medical and dental providers. We assessed how the expanded recruitment of smokers changed the users' characteristics, including comparison with a population-based sample of smokers from the national Behavioral Risk Factors Surveillance Survey (BRFSS). Using a negative binomial regression, we …

Improved Survival After Heart Failure: A Community-Based Perspective, Samuel W. Joffe, Kristy T. Webster, David D. Mcmanus, Michael S. Kiernan, Darleen M. Lessard, Jorge L. Yarzebski, Chad E. Darling, Joel M. Gore, Robert J. Goldberg

Jorge L. Yarzebski

BACKGROUND: Heart failure is a highly prevalent, morbid, and costly disease with a poor long-term prognosis. Evidence-based therapies utilized over the past 2 decades hold the promise of improved outcomes, yet few contemporary studies have examined survival trends in patients with acute heart failure. The primary objective of this population-based study was to describe trends in short- and long-term survival in patients hospitalized with acute decompensated heart failure (ADHF). A secondary objective was to examine patient characteristics associated with decreased long-term survival.

METHODS AND RESULTS: We reviewed the medical records of 9748 patients hospitalized with ADHF at all 11 medical …

Antipsychotic Use Among Nursing Home Residents, Becky Briesacher, Jennifer Tjia, Terry Field, Daniel Peterson, Jerry Gurwitz

Jennifer Tjia

The prescribing of antipsychotic medications persists at high levels in US nursing homes (NHs) despite extensive data demonstrating marginal clinical benefits and serious adverse effects, including death.1- 2 However, imprecise and outdated data have limited the understanding of the current state of antipsychotic medication prescribing in NHs.3 We analyzed recent and detailed NH prescription data to address: (1) What is the current level of antipsychotic use? (2) Does antipsychotic use in NHs display geographic variation? and (3) Which antipsychotics are most commonly prescribed?

Potentially Inappropriate Use Of Antipsychotics In Community-Dwelling Adults With Dementia More Common In Those With Low Income, Jennifer Tjia

Jennifer Tjia

Comment on: The essential and potentially inappropriate use of antipsychotics across income groups: an analysis of linked administrative data. [Can J Psychiatry. 2012]

Studies To Reduce Unnecessary Medication Use In Frail Older Adults: A Systematic Review, Jennifer Tjia, Sarah Velten, Carole Parsons, Sruthi Valluri, Becky Briesacher

Jennifer Tjia

BACKGROUND: Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge.

OBJECTIVE: To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness.

METHODS: A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative …