PubMed Health⌕ Search

Biomedical subjects

A M Kramer

Publications and source records attributed to A M Kramer.

At least 37 records · Page 2Linked to original sources
PubMed1994

Measuring and assuring the quality of home health care.

The growth in home health care in the United States since 1970, and the exponential increase in the provision of Medicare-covered home health services over the past 5 years, underscores the critical need to assess the effectiveness of home health care in our society. This article presents conceptual and applied topics and approaches involved in assessing effectiveness through measuring the outcomes of home health care. Definitions are provided for a number of terms that relate to quality of care, outcome measures, risk adjustment, and quality assurance (QA) in home health care. The goal is to provide an overview of a potential systemwide approach to outcome-based QA that has its basis in a partnership between the home health industry and payers or regulators.

Data Collection↗
PubMed1994

Outcome studies of hip fractures. A functional viewpoint.

As the success rate for repair of hip fractures continues to increase, emphasis is shifting to outcomes beyond the simple fracture repair to include restoration of function. The orthopaedist's role is critical in understanding, assessing, and determining patient prognosis with respect to functional outcome. Multiple factors are predictive of outcome following hip fracture; these factors may facilitate the orthopaedist's decision making in providing care that will maximize restoration relative to a patient's premorbid ability to walk and live independently. This review of past research summarizes our current knowledge of hip-fracture outcomes and prognostic indicators.

Age Factors↗
PubMed1992

Geriatric care approaches in health maintenance organizations.

The objective of this project was to describe geriatric care provided under Medicare-risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi-problem patients, (3) treating multi-problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long-term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare-risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority.

Geriatric Assessment↗
PubMed1992

Grip strength and fatigue in junior college tennis players.

Change in grip strength over 30 trials was documented in two samples of junior college tennis players to assess possible fatigue. Eight men and eight women performed 30 maximum-grip strength tests with 25-sec. rests between trials. Significant positive correlations (.38 and .53 for men and women) were observed between grip strength and trials. In practical terms, grip strength did not change over 30 trials in these tennis players. The data suggested that the repetitive gripping patterns used by these players in tennis play resulted in consistent maximum-grip strengths across 30 trials.

Adult↗
PubMed1991

Phase II clinical trial of 4'-O-tetrahydropyranyl-adriamycin (THP-adriamycin) in recurrent squamous cell carcinoma of the head and neck.

Fourteen patients previously treated with surgery, radiotherapy, and/or chemotherapy for primary squamous cell carcinoma of the head and neck were treated with 4'-O-tetrahydropyranyl-Adriamycin (THP-adriamycin) for locally or distantly recurrent disease. The starting dose was 60 mg/m2 by i.v. infusion, with courses repeated every 3 to 4 weeks. A total of 34 courses of treatment were delivered (median, 2; range, 1-6). All patients were evaluable for response and toxicity. There were no responses. Severe (grade 3 or 4) neutropenia occurred in 11 patients. Thrombocytopenia, anemia, and gastrointestinal toxicity were modest, and no hepatic, renal, or cardiac toxicity was observed. The lack of response in association with severe neutropenia and moderate other toxicities using this dose and schedule of THP-Adriamycin should be taken into consideration prior to the pursuit of further study of this compound in a similar patient population.

Adult↗
PubMed1990

Prevention of second primary tumors with isotretinoin in squamous-cell carcinoma of the head and neck.

BACKGROUND: Patients with head-and-neck cancers who are free of disease after local therapy remain at high risk for both recurrent and second primary tumors. Retinoids have proved efficacious in the treatment of premalignant oral lesions and are promising agents for the prevention of epithelial carcinogenesis. METHODS: We prospectively studied 103 patients who were disease-free after primary treatment for squamous-cell cancers of the larynx, pharynx, or oral cavity. After completion of surgery or radiotherapy (or both), these patients were randomly assigned to receive either isotretinoin (13-cis-retinoic acid) (50 to 100 mg per square meter of body-surface area per day) or placebo, to be taken daily for 12 months. RESULTS: There were no significant differences between the two groups in the number of local, regional, or distant recurrences of the primary cancers. However, the isotretinoin group had significantly fewer second primary tumors. After a median follow-up of 32 months, only 2 patients (4 percent) in the isotretinoin group had second primary tumors, as compared with 12 (24 percent) in the placebo group (P = 0.005). Multiple second primary tumors occurred in four patients, all of whom were in the placebo group. Of the 14 second cancers, 13 (93 percent) occurred in the head and neck, esophagus, or lung. CONCLUSIONS: Daily treatment with high doses of isotretinoin is effective in preventing second primary tumors in patients who have been treated for squamous-cell carcinoma of the head and neck, although it does not prevent recurrences of the original tumor.

Adult↗
PubMed1990

The increased needs of patients in nursing homes and patients receiving home health care.

To evaluate the effects of Medicare's prospective payment system and Medicaid's preadmission regulations on long-term care, we constructed clinical profiles in 1982 and 1986 of about 500 randomly selected patients from each of three types of facilities: nursing homes with relatively high proportions of Medicare patients (high-Medicare nursing homes; n = 23), traditional nursing homes (n = 19), and home health agencies (n = 18). Data were obtained directly from the care givers on the medical problems, problems requiring skilled nursing, and functional problems of these representative patients from 12 states. For Medicare patients in high-Medicare nursing homes, the prevalence of medical problems and problems requiring skilled nursing increased substantially, whereas the prevalence of functional problems remained relatively unchanged. For example, from 1982 to 1986 there was a marked increase in the frequency of tube feedings (21 to 29 percent), oxygen use (6 to 14 percent), urinary tract infection (7 to 13 percent), and diastolic hypertension (1 to 10 percent), but not difficulty in eating (48 to 51 percent) or speaking (28 to 29 percent). In contrast, in traditional nursing homes there was an increase in the prevalence of functional disability, but virtually no change in that of problems requiring medical and skilled nursing care. In home health care the functional care needs of Medicare patients increased significantly, and there was a slight increase in the prevalence of problems requiring medical and skilled nursing care. We conclude that from 1982 to 1986 the needs of patients in long-term care increased substantially. This trend appears to result from Medicare's prospective payment system, which encourages earlier hospital discharge to long-term care settings, and from Medicaid's policy of de-institutionalization. Meeting this greater need for care will be costly. We require a better system of reimbursing for long-term care and ensuring its quality.

Deinstitutionalization↗
PubMed1990

Quality of long-term care in nursing homes and swing-bed hospitals.

By 1989, more than 1,100 hospitals in rural communities throughout the United States were using hospital beds as swing beds to provide both long-term and acute care. In this study, the quality of long-term care in swing-bed hospitals was compared with the quality of nursing home care, using patient outcomes along with both process and structural measures of quality. Several methodological and conceptual points on measuring and analyzing the quality of long-term care are discussed in this article. Data were analyzed on approximately 2,000 patients in four different primary data samples, three of which were longitudinal involving multiple follow-up points. An analysis of changes in patient status over time, hospitalization rates, rates of discharge to independent living, services provided, and certain structural indicators showed that (1) relative to nursing home care, swing-bed care is more effective in enhancing functional outcomes and discharge to independent living and in reducing hospitalization for long-term care patients, and (2) nursing home care appears more desirable than swing-bed care for long-stay, chronic care patients with no rehabilitation potential. Swing-bed hospitals have gravitated largely to admitting postacute long-term care patients. They do not typically compete directly with community nursing homes for chronic care patients. The greater effectiveness of swing-bed care for patients with near-acute long-term care needs suggests that this approach should be considered in urban communities and that we should scrutinize our current tendency to place in traditional nursing homes many patients who have at least some rehabilitation potential.

Activities of Daily Living↗
PubMed1990

Assessing and assuring the quality of home health care: a conceptual framework.

Increased use of home care services, and the provision of more sophisticated care to acutely ill patients, have prompted concern about quality assurance in home settings. A conceptual framework is proposed to assess home health-care quality based on two premises: outcome, process, and structural measures, first, are required to evaluate quality accurately; classification of patients into quality indicator groups (QUIGs), second, permits specification and use of more practical and valid quality measures. The framework may prove useful because measures are related directly to patient conditions, services rendered, and treatment objectives. Further reliability and validity testing of the QUIGs and a system of operational quality measures are currently underway.

Activities of Daily Living↗
PubMed1987

Changing patterns of disease on an inpatient medical service: 1961-1962 to 1981-1982.

To assess changes in disease on an internal medicine teaching service, the records of 292 patients admitted to University Hospital, Denver, Colorado, in the academic years 1961-1962 or 1981-1982 were reviewed. It was hypothesized that patients admitted more recently would be older, more chronically and catastrophically ill, and more likely to have multiple illnesses than patients of an earlier era. Over time, length of stay and mortality rates decreased and acuteness of illness increased, whereas age, chronicity, and co-morbidity remained constant. Changes in the prevalence of some common diseases reflected evolving medical and social influences on hospital use. Modern medical residents are exposed to more patients for a shorter time. They see more acute illness but less of the ongoing process of diagnosis and treatment. Awareness of such changes can help educators design residency programs that better prepare internists for practice.

Acute Disease↗
PubMed1986

The physician and resource allocation.

Even though there is substantial pressure on physicians to significantly reduce the amount of public monies spent on geriatric health care, it is improper for physicians to let financial concerns take precedence over their obligations to care for the patients who seek their services and assistance. The doctor/patient relationship demands that the physician be faithful to the cause of meeting the needs of patients. This faith is kept by taking all necessary steps to respect and promote the autonomy of patients. This is best done by adhering to a commitment of pursuing a process of communication with patients that leads to the attainment of informed consent or refusal from patients. Two consequences likely to follow are protection of many patients from protracted, miserable deaths because of less use of invasive medical procedures, and subsequent financial savings from this lower degree of use.

Age Factors↗
PubMed1985

Academic affiliation with a nursing home. Impact on patient outcome.

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.

Aged↗
PubMed1985

Nursing home case-mix differences between Medicare and non-Medicare and between hospital-based and freestanding patients.

Case-mix differences between Medicare and non-Medicare nursing home patients and between hospital-based and freestanding nursing home patients were assessed for a sample of 756 patients from 26 nursing homes in six states in 1983. Significant differences were found between Medicare and non-Medicare patients and between hospital-based and freestanding nursing home patients. Thus, two attributes, the percentage of Medicare patient days and whether a nursing home is hospital-based or freestanding, probably should be taken into consideration as facility-level case-mix indicators in determining Medicare reimbursement until a more refined approach to case-mix reimbursement can be developed. Hospital-based/freestanding case-mix differences also suggest that Medicaid reimbursement should recognize potential differences in cost structure between these two types of facilities.

Activities of Daily Living↗
PubMed1985

Cost-effectiveness implications based on a comparison of nursing home and home health case mix.

Case-mix differences between 653 home health care patients and 650 nursing home patients, and between 455 Medicare home health patients and 447 Medicare nursing home patients were assessed using random samples selected from 20 home health agencies and 46 nursing homes in 12 states in 1982 and 1983. Home health patients were younger, had shorter lengths of stay, and were less functionally disabled than nursing home patients. Traditional long-term care problems requiring personal care were more common among nursing home patients, whereas problems requiring skilled nursing services were more prevalent among home health patients. Considering Medicare patients only, nursing home patients were much more likely to be dependent in activities of daily living (ADLs) than home health patients. Medicare nursing home and home health patients were relatively similar in terms of long-term care problems, and differences in medical problems were less pronounced than between all nursing home and all home health patients. From the standpoint of cost-effectiveness, it would appear that home health care might provide a substitute for acute care hospital use at the end of a hospital stay, and appears to be a more viable option in the care of patients who are not severely disabled and do not have profound functional problems. The Medicare skilled nursing facility, however, is likely to continue to have a crucial role in posthospital care as the treatment modality of choice for individuals who require both highly skilled care and functional assistance.

Activities of Daily Living↗