Biomedical subjects

J Karuza

Publications and source records attributed to J Karuza.

At least 19 recordsLinked to original sources

PubMed2001

Antibiotic use, hospital admissions, and mortality before and after implementing guidelines for nursing home-acquired pneumonia.

OBJECTIVES: To compare two strategies for implementing guidelines for nursing home-acquired pneumonia (NHAP) and to measure outcomes associated with treatment in accordance with the guidelines. DESIGN: Randomized controlled trial. SETTING: Ten skilled nursing facilities (SNFs) from a single metropolitan area. PARTICIPANTS: Patients with an episode of pneumonia acquired more than 3 days after admission to SNF (N = 350): 226 preintervention episodes of pneumonia and 116 postintervention episodes. INTERVENTIONS: Multi-faceted education intervention including small-group consensus process limited to physicians and a similar intervention that included physicians and nurses within randomly selected SNFs. MEASUREMENTS: Antibiotic use at diagnosis compared with the guidelines, hospital admission, severity of pneumonia, and 30-day mortality. RESULTS: Data were complete for 344 episodes of NHAP. For the preintervention group (n = 226), 62.2% (79/127) of the episodes were treated with parenteral antibiotics (PA) when PA were recommended by the guidelines and 57.6% (57/99) of episodes were treated with oral antibiotics (OA) when OA were indicated by the guidelines. Postintervention, treatment with PA and OA according to the guidelines was not significantly different between the two groups of randomized SNFs. A multivariate analysis comparing PA use pre- and postintervention for all SNFs, adjusted for variation in the frequency and severity of pneumonia, found significantly more of the postintervention episodes were treated with PA in accordance with the guidelines (P < .02). A preintervention significant difference in 30-day mortality observed between episodes with indications for PA (37.8% (48/127)) and episodes with indications for OA (6.1% (6/99)) (P < .001) was not present postintervention (11.5% (6/52); (23.8% (15/64); P = .06). There was no significant difference in 30-day mortality preintervention and postintervention for episodes with guideline indications for OA (P = .35) or for PA (P = .05) (P = .16 for multivariate analysis). The difference in PA use was not associated with significant differences in hospital admissions for episodes on NHAP. CONCLUSION: The increase in the use of PA provides evidence that care within SNFs can be significantly changed using standard quality improvement techniques. Use of the guidelines did not significantly affect mortality. The addition of a practical severity of NHAP model or a change in reimbursement structure may enhance the guidelines' impact on hospitalization for NHAP. The financial benefits available with use of the guidelines will be limited unless the guidelines contribute to a reduction in rates of hospitalization.

Administration, Oral↗

PubMed1997

Medical practice with nursing home residents: results from the National Physician Professional Activities Census.

OBJECTIVE: The study describes the prevalence of medical nursing home practice. Further, it examines the extent to which physician characteristics and local county health care resources predict nursing home involvement. This information is relevant to evaluating and devising strategies that address the future provision of medical care in institutionalized long-term care. DESIGN: A cross-sectional survey. SETTING: A national sample of all licensed practicing physicians was obtained from a special Professional Activities (PPA) survey conducted by the American Medical Association (AMA) in 1991. PARTICIPANTS: Respondents were 21,578 physicians involved in direct patient care. MEASURES: The typical number of hours spent weekly caring for nursing home patients was obtained from the PPA survey, and physician demographics were obtained from the AMA Masterfile. County health care resources were obtained from the National Institutes of Health Area Resources File. RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients. In all disciplines, a majority of physicians with a nursing home practice spent less than 2 hours per week with patients. Logistic regressions indicted that family practitioners and internists were most likely to have a nursing home practice, but general practitioners were most likely to spend more time in practice. Only 15% of specialists reported having a nursing home practice. Prevalence of practice was greatest among solo practitioners and physicians in partnerships and least among academic and hospital-based physicians and physicians in group practice or employed by the government. Most county of practice resources were not associated or were modestly associated with nursing home practice, but having a nursing home practice became much more likely as the number of nursing home residents increased and hospital beds decreased. A pattern was found for nursing home practice to be slightly less likely as the county's per capita income and the proportion of proprietary nursing facilities increased. CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.

Aged↗

PubMed1997

Delivery of vaccines to adults: correlations with physician knowledge and patient variables.

Our objective was to explore reasons why vaccines are not provided to adult patients receiving primary health care. The study setting was a primary health care clinic in a urban hospital staffed primarily by residents and teaching faculty. The patients were identified as all continuity care patients with a scheduled visit to the clinic during the 4-week study period in April 1995. The providers were all primary care providers for the patients during the study period. The providers were given two surveys before the study: one to assess their knowledge of published preventive health care guidelines and one to assess their perspective of the guidelines. During the study period, the charts of the patients were reviewed for the services they had received. An assessment was placed in each patient's chart for the provider's completion during the visit. The assessment enabled the provider to explain why services had not been provided. The results showed that influenza, pneumococcal, and diphtheria-tetanus vaccines were provided at varying rates. Each vaccine had a different profile as to noncompliance with guidelines. Lack of provider knowledge of the guideline was most apparent with pneumococcal vaccine. Providers' ambivalence regarding the scientific basis and/or clinical importance was most apparent with influenza vaccine. Patient refusal was a prominent cause with influenza vaccine in the elderly. Patient appointment behavior (opportunity for care and compliance) also seemed to play an important role. We conclude that explanations for nondelivery of vaccines to adults seem to be multiple. Lack of physician knowledge and physician perception of the guidelines provide some explanations. Patient-related factors including refusal, decreased opportunity for care, and noncompliance also play important roles in why vaccinations are not provided. Improvement in the rates at which immunizations to adults are provided will require interventions in multiple areas.

Adult↗

PubMed1996

Assessment of delivery of preventive health services.

Our objective was to design and evaluate an instrument to assess the performance of a clinic in the delivery of preventive health services to a general medical clinic population. The patients were identified prospectively; data were obtained retrospectively with review of the charts. The study was conducted in a primary care clinic staffed primarily by internal medicine residents in an urban academic medical center. Patients who were receiving continuity care in the clinic and who were scheduled for an appointment during the 4-week study period were eligible for inclusion. Patients were identified by the appointment schedule. Charts were reviewed for the delivery of preventive health services. Data were abstracted utilizing a standard instrument. We found that the rate at which services were provided varied considerably by service and over time. The techniques used provided some insight into methods for the evaluation of the delivery of preventive services. It should be possible to assess a clinic's performance over a range of services over its entire population over time. An understanding of this more global performance may provide a better tool for managers and researchers addressing these issues. There may be legitimate reasons for services not being provided. These issues are complex and require sensitive, detailed investigation.

Delivery of Health Care↗

PubMed1995

Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process.

BACKGROUND: A dissemination intervention to facilitate adoption of a preventive practice guideline (influenza vaccination for older adults) in group practices was developed and evaluated. The intervention, small-group consensus process, started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment (ie, "buy in") to adopt the guideline. METHODS: Thirteen group practices and their primary care physicians (mean size, 5) were assigned randomly to intervention or control arms. In each group practice, physicians in the intervention arm met for 1 hour. Control physicians participated in an unrelated discussion (non-steroidal drug use). Guideline adoption was determined by changes in physicians' vaccination rates that were obtained through prechart and postchart reviews of 51 physicians. Prequestionnaires and postquestionnaires measured influenza knowledge and prevention attitudes. RESULTS: Using analysis of covariance, the small-group consensus process was found to increase physician vaccination rates by 34% compared with the control arm (F (1,48) = 19.49). All intervention arm physicians increased vaccination rates from before to after compared with 54% of control arm physicians. Attitudes and knowledge did not change and were unrelated to increased vaccination rates. CONCLUSIONS: A case is made for the small-group consensus process as an effective utilization-focused dissemination method. Interventions based on group dynamics and sensitive to local practice contexts can be useful in facilitating adoption of guidelines by physicians in group practices.

Decision Making↗

PubMed1995

The small group consensus process for changing physician practices: influenza vaccination.

OBJECTIVE: To evaluate the effectiveness of a small group consensus process in enhancing compliance with guidelines for influenza vaccination among older HMO members. DESIGN: A controlled study of the practice of primary care physicians, with pre/post comparisons and a 2-year follow-up. SETTING: An 84,000 member prepaid staff model HMO group practice. PARTICIPANTS: Primary care clinicians (N = 36) practicing in a staff model HMO. INTERVENTION: A small-group process, including opinion leader, feedback, and group decision making. MAIN OUTCOME MEASURE: Percentage of patients in a given physician-panel who received influenza immunization. RESULTS: Improvement in vaccination rate from 60.8% to 72.35% (with further increases over 2 successive years), in the intervention group as compared with improvement in the control from 60.7% to 65.93%. CONCLUSION: In this model, the small group consensus process resulted in an alteration in physician practice pattern, yielding a significant improvement in immunization rates above the already-established level of 60%.

Aged↗

PubMed1995

Academics and the nursing home.

Several characteristics of the nursing home justify its new found status as an academic site, including a heterogenous patient population, a rich and varied milieu for teaching, opportunities for faculty development, and more importantly, the nursing home's new found position in the health care continuum. Mandates from a number of professional and accrediting bodies pertaining to primary care training experiences further highlight the nursing home's role in medical education. In addition to education, research in the nursing home has become increasingly recognized and valued. The incorporation of nursing facilities into the academic mainstream will impact positively not only in patient care and age-related clinical investigation but also on the breadth and quality of training for the primary care physician of the future.

Academic Medical Centers↗

PubMed1994

Physician staffing patterns correlates of nursing home care: an initial inquiry and consideration of policy implications.

BACKGROUND: To determine, post-OBRA 1987, medical organization in nursing facilities (ie, medical director and staff profile, closing of medical staff, use of physician contract); structural correlates of medical organization; and links between medical organization, especially closed staffing, and medical care. METHOD: Mail survey of New York state nursing facility administrators (63% response). Survey consisted of open and closed end items that focused on facility and staff demographics, medical organization, and markers of medical care delivery, ie, physicians' daily presence, average response time to emergency calls, cross coverage for acute conditions and emergencies, attendance at care conferences, and offering of in-services. RESULTS: On average, facilities had 8.6 attending physicians, 32 residents per physician, 70% of residents cared for by non-staff physicians, no daily physician presence (60%), and no cross coverage. Most medical directors were from family (42%) or internal (55%) medicine, had a tenure of 7.5 years, did not have a certificate of added qualification in geriatrics (73%), and attended residents (66%). Forty-three percent of facilities had closed medical staffs, and 12% had physician contracts. Closed staffs were more likely in facilities that were larger, had more Medicaid residents, used physician extenders, and had more residents per nurse. Facilities with closed medical staffs had fewer physicians more residents per physician, and reported medical care practice patterns that would be associated with quality of care. These effects were independent of nursing and facility characteristics. Physician contract was unrelated to care. CONCLUSIONS: Medical organization and practice patterns emerge as important factors in considerations of nursing home quality. Results argue that, as in acute settings, limiting practice privileges in nursing homes may be a useful organizational strategy to improve quality of care.

Delivery of Health Care↗

PubMed1994

Resident training in nursing home care: survey of successful educational strategies.

OBJECTIVE: To identify educational strategies for resident training in nursing home care deemed successful by a large number of programs. DESIGN: A mail survey with three follow-up mailings. PARTICIPANTS: Directors of accredited internal medicine and family practice residency programs. MEASUREMENTS: Open- and closed-ended questionnaire eliciting curricular content, instructional strategies, and evaluation techniques from programs offering a nursing home experience. Identification of barriers to implementation of a nursing home curriculum and recommendations for success were requested. MAIN RESULTS: Of the 814 surveys mailed, 537 were returned for a response rate of 66%. Nursing home experiences were required in 86% of family practice residency programs but in only 25% of internal medicine programs. Most geriatric medicine curricular content areas were taught in the nursing home; however, relatively little emphasis was given to rehabilitation, organization, and financing of health care, and coordination of care between acute and chronic settings. Direct patient care, bedside rounds, and lectures were the most common instructional strategies reported. Evaluation approaches included faculty observations, resident attendance, and chart reviews with written and skill-based examinations infrequent. Availability of faculty and conflict with other rotations were identified as the principal barriers to implementation of nursing home rotations. An organized nursing home curriculum supervised by enthusiastic faculty using a longitudinal rotation format with resident involvement in an interdisciplinary team was recommended. CONCLUSIONS: Educational strategies exist for successful implementation of a residency nursing home curriculum. Greater priority must be given to training residents in nursing home care and developing nursing home faculty to substantially increase the number and quality of physicians who practice in this setting.

Accreditation↗

PubMed1992

Methicillin-resistant Staphylococcus aureus: a questionnaire survey of 75 long-term care facilities in western New York.

OBJECTIVES: To determine the frequency of recognition of methicillin-resistant Staphylococcus aureus (MRSA) as an infection control problem and its prevalence among long-term care facilities, and to evaluate whether certain long-term care facility characteristics such as bed size, ownership, level of infection control activity, and frequency of resident transfers to acute care hospitals are related to the recognition or prevalence of MRSA in this setting. DESIGN: Questionnaire survey. SETTING: Seventy-five long-term care facilities in the 8 counties of western New York. RESULTS: Seventy-five of 81 (92.6%) long-term care facilities returned a completed questionnaire. Seventy-nine percent were considered to have a "limited" level of infection control activity (part-time infection control practitioner who spent less than 10 hours a week on infection control activities). The larger the long-term care facility, the more time was spent on infection control activities (p = .01). Seventy-two percent of the long-term care facilities screened new admissions for MRSA by reviewing culture reports; 69% of the long-term care facilities had a specific infection control policy for MRSA. Sixteen of the 75 (21%) facilities felt they had an infection control problem with MRSA. By univariate analysis, the only characteristic significantly associated with this recognition was use of nurse practitioners or physician assistants by a facility (p < .05). Eighty-one percent of the 75 long-term care facilities had identified one or more patients with MRSA in the year prior to the survey. By univariate analysis, the only characteristics that were significantly associated with the number of residents with MRSA were the monthly average number of residents transferred to acute care facilities (p = .034) and facility bed size (p = .022); there was also a trend toward increasing intensity of infection control activities (p = .085). However, facility bed size and the average number of resident transfers per month to acute care facilities were strongly associated (p = .0002). By stepwise logistic regression analysis, only bed size was an independent predictor of the number of residents with MRSA. Many long-term care facilities had tried to eradicate MRSA; ciprofloxacin was most commonly used to eradicate MRSA. CONCLUSIONS: The vast majority of the 75 long-term care facilities in the 8 counties of western New York have identified patients with MRSA, although only a minority (21%) of them actually believed that an infection control problem existed. Facility size (a surrogate for the monthly average number of resident transfers to acute care facilities) seems to be an important factor in determining the number of residents with MRSA in long-term care facilities in our geographic region. The major longitudinal studies of MRSA in such facilities have so far been done only in Veterans Affairs facilities. Further studies are needed in freestanding long-term care facilities, the largest group of long-term care facilities in the United States, to determine the epidemiology of MRSA in this setting and to develop practical and valid infection control methods for residents with MRSA.

Health Facility Size↗

PubMed1992

Oral status and resident well-being in a skilled nursing facility population.

We studied the relationship between oral status and well-being in dentate and edentulous institutionalized residents through interviews with and dental examinations on 58 men and women. Oral status (measured by oral function, dental problem self report, soft tissue anomalies, and dry mouth) and well-being (measured by affect balance, self-esteem, health status, and nurse's ratings) were similar for dentate and edentulous subjects. Multiple regression analyses indicated oral status was significantly related to well-being. Unexpectedly, the extent of caries and plaque was also positively related to well-being, suggesting complex relationships between oral status markers and well-being in institutional settings.

Aged↗

PubMed1990

Models of helping and coping, responsibility attributions, and well-being in community elderly and their helpers.

The analysis of Brickman et al. (1982), which separates attribution of a problem's cause and solution, was tested in 4 studies. Young and elderly adults' (n = 210) well-being was related only to taking responsibility for solutions. The elderly compared with the young adults assumed less responsibility for problem cause and solution. They also preferred helping and coping models that assume low self-responsibility for solutions (e.g., medical model). This result was replicated with Meals on Wheels clients (n = 51). An intragenerational helping pattern was found in Study 3. Lay helpers (n = 63) helped mainly same-age recipients. Elderly and middle-aged helpers compared with young adults preferred using a medical model. Overall, a cohort bias in model preference was suggested. In Study 4, problem type and recipient age moderated attributions and model choice of young and middle-aged Ss (n = 92). Relevance to the control literature and ethical and clinical implications of a medical-model bias are discussed.

Adaptation, Psychological↗

PubMed1990

A comparison between erythrocyte sedimentation rate (ESR) and selected acute-phase proteins in the elderly.

The erythrocyte sedimentation rate (ESR) and selected acute-phase proteins (APPs) were studied in 101 elderly people (mean age, 72 years) to determine their utility as diagnostic aids in subjects with underlying infections or inflammation. ESR and values for serum immunoglobulin A (IgA), the fourth component of complement (C4), haptoglobin, and alpha-1-antitrypsin (AAT) all correlated with infection or inflammation. C4 was the only test predictive of mortality at six months. Neither ESR nor any of the APPs demonstrated concomitantly high sensitivity, specificity, and positive predictive values. Receiver-operating characteristic curve analysis revealed low true positive to false positive ratios for all of the tests studied. In the elderly, measurement of APPs as a guide to underlying infection or inflammation has limited utility and offers no advantage over the traditional low-cost ESR.

Acute-Phase Proteins↗

PubMed1989

Erythrocyte sedimentation rate and C-reactive protein compared in the elderly.

The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentrations were studied in 101 elderly individuals (mean age 72 y) to determine their utility as diagnostic aids in subjects with underlying infection/inflammation. Whereas ESR and CRP were both significantly increased in patients with infection or inflammation, or both, analysis of variance indicated that those subjects still alive six months later had significantly lower ESR values. Analysis of sensitivity, specificity, and positive predictive values indicated that neither test satisfactorily discriminated between patients with and those without ongoing active or chronic disease. Receiver-operating characteristic curve analysis confirmed the low true-positive/false-positive ratios of both ESR and CRP. In the elderly, neither CRP nor ESR has distinct advantages over the other, and both tests evidently have limited utility.

Aged↗

PubMed1988