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Biomedical subjects

E H Bradley

Publications and source records attributed to E H Bradley.

At least 19 recordsLinked to original sources
PubMed2006

The impact of late career job loss on myocardial infarction and stroke: a 10 year follow up using the health and retirement survey.

BACKGROUND: Involuntary job loss is a major life event associated with social, economic, behavioural, and health outcomes, for which older workers are at elevated risk. OBJECTIVE: To assess the 10 year risk of myocardial infarction (MI) and stroke associated with involuntary job loss among workers over 50 years of age. METHODS: Analysing data from the nationally representative US Health and Retirement Survey (HRS), Cox proportional hazards analysis was used to estimate whether workers who suffered involuntary job loss were at higher risk for subsequent MI and stroke than individuals who continued to work. The sample included 4301 individuals who were employed at the 1992 study baseline. RESULTS: Over the 10 year study frame, 582 individuals (13.5% of the sample) experienced involuntary job loss. After controlling for established predictors of the outcomes, displaced workers had a more than twofold increase in the risk of subsequent MI (hazard ratio (HR) = 2.48; 95% confidence interval (CI) = 1.49 to 4.14) and stroke (HR = 2.43; 95% CI = 1.18 to 4.98) relative to working persons. CONCLUSION: Results suggest that the true costs of late career unemployment exceed financial deprivation, and include substantial health consequences. Physicians who treat individuals who lose jobs as they near retirement should consider the loss of employment a potential risk factor for adverse vascular health changes. Policy makers and programme planners should also be aware of the risks of job loss, so that programmatic interventions can be designed and implemented to ease the multiple burdens of joblessness.

Age Factors↗
PubMed2004

Data feedback efforts in quality improvement: lessons learned from US hospitals.

BACKGROUND: Data feedback is a fundamental component of quality improvement efforts, but previous studies provide mixed results on its effectiveness. This study illustrates the diversity of hospital based efforts at data feedback and highlights successful strategies and common pitfalls in designing and implementing data feedback to support performance improvement. METHODS: Open ended interviews with 45 clinical and administrative staff in eight US hospitals in 2000 concerning their perceptions about the effectiveness of data feedback in supporting performance improvement efforts were analysed. The hospitals were chosen to represent a range of sizes, geographical regions, and beta blocker improvement rates over a 3 year period. Data were organized and analyzed in NUD-IST 4 using the constant comparative method of qualitative data analysis. RESULTS: Although the data feedback efforts at the hospitals were diverse, the interviews suggested that seven key themes may be important: (1) data must be perceived by physicians as valid to motivate change; (2) it takes time to develop the credibility of data within a hospital; (3) the source and timeliness of data are critical to perceived validity; (4) benchmarking improves the meaningfulness of data feedback; (5) physician leaders can enhance the effectiveness of data feedback; (6) data feedback that profiles an individual physician's practices can be effective but may be perceived as punitive; (7) data feedback must persist to sustain improved performance. Embedded in several themes was the view that the effectiveness of data feedback depends not only on the quality and timeliness of the data, but also on the organizational context in which such efforts are implemented. CONCLUSIONS: Data feedback is a complex and textured concept. Data feedback strategies that might be most effective are suggested, as well as potential pitfalls in using data to promote performance improvement.

Adrenergic beta-Antagonists↗
PubMed2001

Functional disability and health care expenditures for older persons.

BACKGROUND: The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons. METHODS: Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables. RESULTS: The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures. CONCLUSIONS: Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short- and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden.

Aged↗
PubMed2001

Documentation of discussions about prognosis with terminally ill patients.

PURPOSE: Previous studies have suggested the importance of communicating with patients about prognosis at the end of life, yet the prevalence, content, and consequences of such communication have not been fully investigated. The purposes of this study were to estimate the proportion of terminally ill inpatients with documented discussions about prognosis, describe the nature and correlates of such discussions, and assess the association between documented discussions about prognosis and subsequent advance care planning. SUBJECTS AND METHODS: Inpatients (n = 232) at least 65 years old who had brain, pancreas, liver, gall bladder, or inoperable lung cancer were randomly selected from six randomly chosen community hospitals in Connecticut. The presence and content of discussions about prognosis, advanced care planning efforts, and sociodemographic and clinical factors were ascertained by comprehensive review of medical records using a standardized abstraction form. RESULTS: Discussions about prognosis were documented in the medical records of 89 (38%) patients. Physicians and patients were both present during the discussion in 46 (52%) of these cases. Time until expected death was infrequently documented. Having a documented discussion about prognosis was associated with documented discussions of life-sustaining treatments (adjusted odds ratio [OR] = 5.8; 95% confidence interval [CI]: 2.8 to 12.0) and having a do-not-resuscitate order (adjusted OR = 2.2; 95% CI: 1.1 to 4.2). CONCLUSIONS: Among terminally ill patients with cancer, discussions about prognosis as documented in medical charts are infrequent and limited in scope. In some cases, such documented discussions may be important catalysts for subsequent discussions of patient and family preferences regarding treatment and future care.

Advance Directives↗
PubMed2001

Goals for the care of frail older adults: do caregivers and clinicians agree?

PURPOSE: Establishing shared treatment goals for patients may improve the quality of care by facilitating achievement of appropriate and desired outcomes. The purpose of this study was to describe types of family caregiver and physician treatment goals for frail elderly patients who had a high prevalence of cognitive impairment, and to ascertain the level of agreement between family caregivers and physicians on principal treatment goals. SUBJECTS AND METHODS: We surveyed family caregivers and physicians for 200 consecutive older adults who were initially evaluated at the outpatient geriatric assessment center of a major teaching hospital. Treatment goals for patients were measured after a comprehensive geriatric assessment. RESULTS: Goals commonly chosen as most important by family caregivers and physicians pertained to day-to-day functioning (61 [31%] family caregivers, 81 [41%] physicians), behavior and emotional health (56 [28%] family caregivers, 50 [25%] physicians), and safety (40 [20%] family caregivers, 29 [15%] physicians). Although a substantial proportion of family caregiver and physician pairs shared at least one goal (157 [79%] of 200), agreement on presence or absence of individual categories of goals was poor (kappas from -0.19 to 0.28), and agreement on the most important goal was also poor (kappa 0.20). CONCLUSIONS: Agreement on treatment goals between family caregivers and physicians for patients at the study site was low. These results suggest that encounters between family caregiver and physician may need improvement. Further research is needed to assess whether lack of agreement is found in other settings, persists over time, and affects achievement of goals and optimal health outcomes.

Activities of Daily Living↗
PubMed2001

Factors associated with home versus institutional death among cancer patients in Connecticut.

OBJECTIVE: To assess the relationships between home death and a set of demographic, disease-related, and health-resource factors among individuals who died of cancer. DESIGN: Prospective cohort study. SETTING: All adult deaths from cancer in Connecticut during 1994. PARTICIPANTS: Six thousand eight hundred and thirteen individuals who met all of the following criteria: died of a cancer-related cause in 1994, had previously been diagnosed with cancer in Connecticut, and were age 18 and older at the time of death. MEASUREMENT: Site of death. RESULTS: Twenty-nine percent of the study sample died at home, 42% died in a hospital, 17% died in a nursing home, and 11% died in an inpatient hospice facility. Multivariate analysis indicated that demographic characteristics (being married, female, white, and residing in a higher income area), disease-related factors (type of cancer, longer survival postdiagnosis), and health-resource factors (greater availability of hospice providers, less availability of hospital beds) were associated with dying at home rather than in a hospital or inpatient hospice. CONCLUSIONS: The implications of this study for clinical practice and health planning are considerable. The findings identify groups (men, unmarried individuals, and those living in lower income areas) at higher risk for institutionalized death-groups that may be targeted for possible interventions to promote home death when home death is preferred by patients and their families. Further, the findings suggest that site of death is influenced by available health-system resources. Thus, if home death is to be supported, the relative availability of hospital beds and hospice providers may be an effective policy tool for promoting home death.

Aged↗
PubMed2001

The impact of involuntary job loss on subsequent alcohol consumption by older workers: findings from the health and retirement survey.

OBJECTIVE: To estimate the effect of involuntary job loss on subsequent alcohol consumption by older workers in the United States. METHODS: Using longitudinal data from the 1992 and 1994 waves of the Health and Retirement Survey, the authors estimated multivariate models to assess the impact of involuntary job loss on subsequent alcohol use. Two outcomes were investigated: reported daily alcohol consumption and onset of drinking. The analysis sample included 207 workers who experienced involuntary job loss between survey dates and a comparison group of 2,866 continuously employed workers. RESULTS: After baseline alcohol consumption and a variety of socioeconomic and illness-related covariates were controlled, involuntary job loss was not associated (p>.05) with number of daily drinks consumed at follow-up. However, among those who did not consume alcohol at baseline, individuals who suffered involuntary job loss were twice as likely as continuously employed individuals to start drinking by follow-up (OR = 2.01; CI = 1.06-3.80). The majority of those who began drinking at follow-up reported drinking less than 1 drink per day. DISCUSSION: The findings provide evidence of a significant relationship between job loss and subsequent alcohol use among baseline nondrinkers. However, the magnitude of the changes in drinking was quite modest.

Aged↗
PubMed2000

Health effects of involuntary job loss among older workers: findings from the health and retirement survey.

OBJECTIVES: To estimate the health consequences of involuntary job loss among older workers in the United States. METHODS: Using longitudinal data from the 1992 and 1994 waves of the Health and Retirement Survey, multivariate regression models were estimated to assess the impact of involuntary job loss on both physical functioning and mental health. Our analysis sample included 209 workers who experienced involuntary job loss between survey dates and a comparison group of 2,907 continuously employed workers. RESULTS: The effects of late-life involuntary job loss on both follow-up physical functioning and mental health were negative and statistically significant (p < .05), even after baseline health status and sociodemographic factors were controlled for. Among displaced workers, reemployment was positively associated with both follow-up physical functioning and mental health, whereas the duration of joblessness was not significantly associated with either outcome. DISCUSSION: The findings provide evidence of a causal relationship between job loss and morbidity among older workers. This relationship is reflected in both poorer physical functioning and mental health for workers who experience involuntary job loss. In addition to the economic consequences of worker displacement, there may be important health consequences of job loss, especially among older workers.

Activities of Daily Living↗
PubMed2000

Goals in geriatric assessment: are we measuring the right outcomes?

Previous evaluative studies of outpatient geriatric assessment have focused on a limited set of outcomes related to functioning, health services utilization, and costs. The purpose of this study was to identify important goals for care as described by patients and family caregivers being cared for in this setting. Using a cross-section of 226 consecutive sets of patients and their primary family caregivers, physicians, and case managers, goals of care for individual patients were coded from open-ended interview responses. The most common categories of goals expressed by family caregivers were obtaining education and referrals (57.5%) and improving social and family relationships (53.0%). The process of establishing and meeting such goals should be explicitly included in the design of future evaluations of outpatient geriatric assessment.

Activities of Daily Living↗
PubMed2000

Attitudes about care at the end of life among clinicians: a quick, reliable, and valid assessment instrument.

Several initiatives to improve care at the end of life involve educational programs to influence clinicians' attitudes about care for patients with terminal illnesses. The objective of this research was to develop and test a short and easily administered instrument for measuring physicians' and nurses' attitudes towards care at the end of life. The instrument was tested using a cross-sectional study of 50 clinicians (25 physicians and 25 nurses) from general medicine, cardiology, oncology, and geriatric medicine. Both reliability and validity were assessed, and the instrument was found to have acceptable test-retest reliability and construct validity. Such an assessment instrument may be useful in evaluating the impact of initiatives to modify attitudes towards terminal care and in improving the quality of care at the end of life.

Adult↗
PubMed2000

The role of gender in MPH graduates' salaries.

Several studies have demonstrated that workforce roles and salaries differ substantially between men and women in administrative positions within the health care industry. Recent studies of graduates with masters of business administration (MBA) and masters of health administration (MHA) degrees have indicated that women tend to experience lower salaries, given like responsibilities. However, the impact of gender on salary has been less studied among masters of public health (MPH) graduates in the health care field. Our objective was to assess the impact of gender on salary among MPH degree graduates. Using a cross-sectional survey of all graduates from the MPH program at Yale University between 1991-1997 (n = 201, response rate = 51%), we ascertained graduates' reported salary in the first job post-graduation and reported salary in their current position. Bivariate and multivariate analyses were used to assess the unadjusted and adjusted associations between gender and salary. Salaries in both the first job post-graduation and in the current job differed significantly by gender, with women earning less than men (p-values < .05). Moreover, these differences persisted after controlling for a set of human capital measures including pre-MPH work experience, age at graduation, years since graduation, area of specialization within the MPH degree, and type of work site (governmental or nonprofit versus for-profit). Unlike studies of MBA and MHA graduates, however, this study did not find evidence that the gender-related salary gap widened as the years since graduation increased, although the sample size did not allow comprehensive testing of this trend.

Adult↗
PubMed2000

Referral of terminally ill patients for hospice: frequency and correlates.

BACKGROUND: Despite the central role of hospice in end-of-life care, little is known about the proportion of terminally ill patients referred for hospice and the physician factors associated with hospice referral. METHODS: Cross-sectional data from a self-administered survey of 231 physicians were used to estimate the proportion of terminally ill patients who were referred for hospice and to assess the independent effects of physician factors on hospice referral. RESULTS: On average, physicians reported referring about 55% of their terminally ill patients for hospice; 26.7% of the physicians referred less than one quarter of their terminally ill patients. Physician specialty, board certification, and physicians' knowledge level about hospice were independently associated with the proportions of terminally ill patients referred for hospice. CONCLUSION: Many terminally ill patients are not referred for hospice care and physician factors influence the use of hospice significantly. The study suggests effective factors and groups to target with interventions to enhance the appropriate use of hospice.

Connecticut↗
PubMed1999

Goal-setting in clinical medicine.

The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning.

Aged↗
PubMed1999

Public information and private search: evaluating the Patient Self-Determination Act.

Despite substantial regulatory efforts to improve consumer information regarding health and health care, little is known about the impact of such efforts on consumer behavior. This article examines the effect of federal legislation to enhance consumer information regarding the use of life-sustaining technology in end-of-life medical treatment decision making. Using a unique set of data abstracted from the medical records of six hundred elderly patients in nursing homes, the study finds a substantial impact of the law in promoting improved documentation of patient wishes for end-of-life medical care. Further, the data reveal that the effect of the law varies among identifiable subgroups. Consistent with the theory of search, the article demonstrates that the effects of regulatory efforts that promote the public provision of consumer information are greatest among individuals for whom information is most beneficial but for whom private search is costly. Implications for health policy are discussed.

Advance Directives↗
PubMed1998

A taxonomy for goal setting in the care of persons with dementia.

OBJECTIVE: Develop a taxonomy for understanding and classifying goals in the care of persons with dementia. DESIGN: Qualitative study using open-ended interviews with key informants and the constant comparative method of qualitative data analysis. SETTING: The geriatric assessment center at a large academic medical center in Connecticut. PARTICIPANTS: Key informant interviews with 36 subjects: consecutive patients receiving geriatric assessment at the center and their primary family caregivers, case managers, and physicians of patients. MEASUREMENTS AND MAIN RESULTS: Goals, or desired outcomes, for the patient's care as described by patients, primary family caregivers, case managers, and physicians were the main measurements. Participant interviews were conducted until the point of theoretical saturation, i.e., until further interviews no longer provided new concepts. All participants articulated at least one goal. Specific goals were characterized by a limited number of goal attributes resulting in a taxonomy, or consistent classification system, for reported goals. These attributes include domain (or content), specificity, time frame, and level of challenge. CONCLUSIONS: The findings suggested that patients, primary family caregivers, and clinicians can articulate goals of care and may bring differing perspectives to the goal-setting process. The research identified a taxonomy that may facilitate negotiation of goals by revealing important, and perhaps overlooked, aspects of goals and the goal-setting process.

Activities of Daily Living↗
PubMed1998

Discussions about end-of-life care in nursing homes.

OBJECTIVE: To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the resident's wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions. DESIGN: Retrospective cohort study of residents admitted to nursing homes before and after the PSDA. SETTING: Six large (at least 120 licensed chronic care beds), randomly selected nursing homes in Connecticut. PARTICIPANTS: Six hundred randomly selected nursing home residents admitted during 1990 and 1994 to one of the six study nursing homes. MEASUREMENTS: Documented discussions concerning future treatment wishes were abstracted from residents' nursing home medical records. Participants in the discussion, as well as the timing (i.e., date) and content of the documented discussions were recorded. Sociodemographic and health status factors were also obtained from the medical record. RESULTS: A large majority of residents (71.5%) had no discussion of future treatment wishes documented in their medical record. However, the percentage of residents with documented discussions had increased since the implementation of the PSDA (36.7% post-PSDA vs 20.3% pre-PSDA). Of those in the post-PSDA cohort who had had discussions, 90% had only one discussion within the first year of admission, and more than half (58.1%) of those who had discussions discussed only life-support systems (cardiopulmonary resuscitation, artificial nutrition and hydration, and ventilation) rather than broader preferences for future treatment, including proxy decision-making. CONCLUSIONS: Despite the increased prevalence of discussions about future treatment wishes since the enactment of the PSDA, no discussions were documented for most residents. For those with documented discussions, such conversations occurred rarely and were narrow in scope, suggesting that residents' and families' roles in medical decision-making in nursing homes may be limited.

Advance Care Planning↗
PubMed1998

Monitoring clinical quality in Medicaid managed care.

With the recent exponential growth in managed-care plan enrollment by Medicaid beneficiaries, a variety of quality monitoring systems have emerged. This paper argues that existing quality monitoring systems, originally designed for use by employers in the private sector, are a useful starting point for quality monitoring in the Medicaid program, but that substantial enhancements are needed to provide adequate quality assurance for Medicaid beneficiaries. This paper describes the development of a range of indicators for monitoring the clinical aspect of the quality of care for Medicaid beneficiaries and offers a framework for adapting existing monitoring systems to the needs of the Medicaid population. This work is part of a larger collaborative effort by the Connecticut Department of Public Health and the Department of Epidemiology and Public Health of Yale University School of Medicine to develop a blueprint for state government's role in quality assessment and performance management for managed care.

Adult↗