Biomedical subjects

James M Naessens

Publications and source records attributed to James M Naessens.

15 recordsLinked to original sources

PubMed2006

Predictors of discharge to an inpatient extended care facility after total hip or knee arthroplasty.

Increased emphasis has been placed on hospital length of stay and discharge planning after total joint arthroplasty (TJA). The purpose of this study was to identify baseline patient characteristics that are predictive of discharge to an inpatient extended care facility (ECF) after TJA. Clinical, demographic, and resource utilization data were analyzed for 7818 consecutive patients who underwent primary or revision TJA at 1 of 3 high-volume TJA centers. A stepwise linear regression model was used to identify predictors of discharge to an ECF. Overall, 29% of patients were discharged to an ECF after TJA. Older age, higher American Society of Anesthesiologists class, Medicare insurance, and female sex were all associated with a higher likelihood of discharge to an ECF. Significant differences in practice patterns were found across hospitals with respect to discharge disposition after TJA. Further study is necessary to determine the appropriate criteria for discharge to an ECF after TJA.

Adult↗

PubMed2006

Nurse-based telephone protocol versus usual care for management of URI and acute sinusitis: a controlled trial.

Two hundred and twelve patients with upper-respiratory-tract infection (URI) or sinusitis were treated using a nurse-based telephone protocol. This study evaluated the clinical outcomes and satisfaction of the patients compared with patients receiving usual care. For patients with URI, the rate of antibiotic administration was lower in the nurse-based telephone-treatment group (28% vs. 34%; P = .46), and for those with sinusitis, a greater proportion of the telephone treatment group received first-line antibiotics for the infection, compared with the usual care group (81% vs. 53%; P = .01). A guideline-based nurse telephone treatment protocol may decrease inappropriate use of antibiotics for URI and can result in a greater use of first-line antibiotics for patients with sinus infection with similar clinical outcomes.

Anti-Bacterial Agents↗

PubMed2005

Predictors of blood pressure control in patients with diabetes and hypertension seen in primary care clinics.

BACKGROUND: Blood pressure (BP) is not well controlled in the majority of patients with both diabetes and hypertension. This study was designed to identify predictors of BP control in patients with both diabetes and hypertension who are seen in primary care clinics. METHODS: This retrospective study was conducted by identifying a cohort of patients diagnosed with diabetes before January 1, 2000 (inception) who met predefined criteria for hypertension at inception and who received primary care in the ensuing 3-year study period (January 1, 2000, to February 31, 2002). Using the mean of all BP values between January 1, 2002, and December 31, 2002, subjects were divided into two groups: those with controlled BP and those with uncontrolled BP. The distribution of clinical predictors was compared between the two groups. Independent predictors were identified using multivariate logistic regression. RESULTS: Predictors of poor BP control were as follows: 1) isolated systolic hypertension at inception (OR= 0.62, CI = 0.47 to 0.82); 2) uncontrolled BP at inception (OR = 0.71, CI = 0.55 to 0.93); 3) use of oral hypoglycemic drugs versus diet and exercise alone or insulin use (OR = 0.73, CI = 0.56 to 0.95); 4) use of three or more antihypertensive drugs (OR = 0.74, CI = 0.56 to 0.97); and 5) older age (OR = 0.98, CI = 0.97 to 0.99). Predictors of better control were 1) use of nitrates (OR = 1.82, CI = 1.26 to 2.64); 2) history of coronary heart disease (OR = 1.47, CI = 1.08 to 2.00); and 3) at least one annual visit to subspecialist physician (OR = 1.43, CI = 1.09 to 1.88). CONCLUSIONS: Patients with both diabetes and hypertension who are older, have isolated systolic hypertension, use oral hypoglycemic drugs, or use three or more antihypertensive drugs should be targeted for better BP control. The roles of nitrate medication and subspecialist physicians in achieving better BP control needs further study.

Aged↗

PubMed2005

Differences in patient and procedure characteristics and hospital resource use in primary and revision total joint arthroplasty: a multicenter study.

A multicenter retrospective cost-identification cohort study was undertaken to analyze clinical, demographic, and economic data for 4533 consecutive total hip arthroplasty (THA) and 3508 consecutive total knee arthroplasty (TKA) procedures performed during a 3-year period in 1 of 3 hospitals. Statistically significant differences were found between primary and revision procedures with respect to patient age, sex, payer type, mean total operative time, use of allograft, average length of hospital stay, discharge disposition, and hospital costs. Significant differences were also found between different types of revision total joint arthroplasty (TJA) procedures. Our findings could be used to help improve the accuracy of administrative claims data related to primary and revision TJA procedures to identify relevant differences in patient characteristics, procedure characteristics, and hospital resource use.

Aged↗

PubMed2005

Women with diabetes have poorer control of blood pressure than men.

OBJECTIVE: Diabetes is associated with a higher coronary heart disease (CHD) mortality in women compared with men. Less aggressive control of the CHD risk factors in women can contribute to this excess mortality. Because hypertension has a high prevalence in subjects with diabetes, we compared the control of this risk factor between men and women. METHODS: This was a retrospective cohort study comparing blood pressure levels and trends over a 1-year period between men and women with diabetes receiving primary care. Using a chronic disease registry database, subjects with type 1 and type 2 diabetes, aged >or=18, were identified for inclusion. Mean weighted systolic blood pressure (SBP) and diastolic blood pressure (DBP) were calculated for subjects with multiple longitudinal readings. Subjects were classified into four blood pressure control categories based on the mean weighted blood pressure. Comparisons were made between men and women before and after controlling for baseline characteristics. RESULTS: A total of 3181 subjects (46% women) were included in the study. More women than men were in the moderate and severely elevated blood pressure categories (40% and 6% compared with 32% and 5%, respectively, p<0.001). The unadjusted mean SBP was 3 mm Hg higher in women (139 mm Hg in women compared with 136 in men, p<0.001). These differences remained significant after controlling for baseline variables. CONCLUSIONS: In subjects with diabetes receiving medical care, women had poorer control of blood pressure and a significantly higher mean SBP compared with men. These findings might partially explain the excess CHD mortality in women with diabetes.

Adult↗

PubMed2005

Evaluating the performance of an institution using an intensive care unit benchmark.

OBJECTIVES: To describe the performances of selected intensive care units (ICUs) in a single institution using the Acute Physiology and Chronic Health Evaluation (APACHE) III benchmark and to propose interventions that may improve performance. PATIENTS AND METHODS: In this retrospective study, we analyzed APACHE III data from critically ill patients admitted to ICUs at the Mayo Clinic in Rochester, Minn, between October 1994 and December 2003. We retrieved ICU performance measures based on first ICU day APACHE III values. Standardized ratios were defined as ratios of measured to predicted values. The primary performance measure was the standardized mortality ratio, and secondary performance measures were length of stay (LOS) ratios, low-risk monitor ICU admission rates, and ICU readmission rates. We calculated 95% confidence intervals (CIs) for each performance, graded as good, average, or poor. RESULTS: Among 46,381 patients admitted during the study period, 57.5% were in surgical ICUs, 24.8% in a medical ICU, and 17.7% in a surgical-medical ICU. Low-risk monitoring accounted for 37.2% of admissions. Hospital standardized mortality ratios (95% CI) were 0.95 (0.90-0.99), 0.86 (0.81-0.91), and 0.70 (0.66-0.74) for medical, multispecialty, and surgical ICUs, respectively. Hospital LOS ratios (95% CI) were 0.83 (0.81-0.85), 0.91 (0.88-0.93), and 0.99 (0.97-1.00) for medical, multispecialty, and surgical ICUs, respectively. The ICU readmission rate for each ICU was higher than the 6.7% reported in the medical literature. Performances were good in mortality, average to good in LOS, average in low-risk admission, and poor in ICU readmission. CONCLUSIONS: A national benchmarking database can highlight the strengths and weaknesses of ICUs. The performances of ICUs in a single institution may differ; therefore, the performance of each unit should be evaluated individually.

APACHE↗

PubMed2005

Recollection of previous colon cancer screening in Minnesota adults.

Regularly scheduled screening of patients has been shown to be effective for decreasing morbidity and mortality from colorectal cancer. We used a questionnaire to assess patients' ability to accurately recall the date and type of their most recent colorectal cancer screening. The study included 200 consecutive patients whose records indicated they had undergone previous colorectal cancer screening (8 patients were later excluded because they had been screened more than 5 years earlier). Overall, 32.3% of patients could not recall the date of their last colorectal cancer screening, 34.3% recalled the date inaccurately, and 33.3% recalled the date accurately within 1 month. The results suggest that recall alone is not sufficient to determine the date and type of previous colorectal cancer screening, especially if the screening was performed more than a year earlier.

Aged↗

PubMed2004

Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial.

BACKGROUND: Hospitalists are assuming an increasing role in the care of surgical patients, but the impact of this model of care on postoperative outcomes is unknown. OBJECTIVE: To determine the impact of providing a collaborative, hospitalist-led model of care on postoperative outcomes and costs among patients having hip or knee arthroplasty. DESIGN: Randomized, controlled trial. SETTING: Academic medical center. PARTICIPANTS: 526 patients having elective orthopedic surgery who are at elevated risk for postoperative morbidity. MEASUREMENTS: Length of stay, inpatient postoperative medical complications, health care provider satisfaction, and inpatient costs. INTERVENTIONS: A comanagement medical Hospitalist-Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation. RESULTS: More patients in the hospitalist group were discharged from the hospital with no complications (61.6% vs. 49.8%; difference, 11.8 percentage points [95% CI, 2.8 to 20.7 percentage points]). Fewer minor complications were observed among hospitalist patients (30.2% vs. 44.3%; difference, -14.1 percentage points [CI, -22.7 to -5.3 percentage points]). Observed length of stay was not statistically different between treatment groups. However, when adjusted for discharge delays, mean length of stay for patients in the hospitalist model of care was shorter (5.1 days vs. 5.6 days; difference, -0.5 day [CI, -0.8 to -0.1 day]). Total costs did not differ between groups. Orthopedic surgeons and nurses preferred the hospitalist model. LIMITATIONS: Care providers and patients were aware of intervention assignments, and the study could not capture all costs associated with the hospitalist model. CONCLUSIONS: The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the comanagement hospitalist model. Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted.

Aged↗

PubMed2004

Estimation of unreimbursed patient education costs at a large group practice.

INTRODUCTION: A search of the literature on the cost of patient education found that provider education time per patient per day was rarely reported and usually not derivable from published reports. Costs of continuing education needed by health professionals to support patient education also were not given. Without this information, it is difficult to appraise the costs of existing or newly proposed patient education activities and technologies. METHODS: An extensive literature search was conducted. Clinic and hospital personnel at a large group practice were surveyed to obtain per patient per day estimates for comparison with the literature. RESULTS: Although the literature now spans several disciplines, few useful empiric studies exist. In the group practice, 18.6 minutes per patient per day were spent on patient education. Unreimbursed cost of patient education by nurses alone was $28,258,478 to $48,710,368 annually. These costs do not include costs of continuing education to maintain and upgrade patient education. DISCUSSION: The cost figures reported above are consistent with the limited information in the literature. The present study suggests that patient education costs are substantial, and more attention needs to be given to the costs of continuing education intended to improve patient education.

Costs and Cost Analysis↗

PubMed2004

Do complication screening programs detect complications present at admission?

BACKGROUND: A study was undertaken to verify the accuracy of computer algorithms on administrative data to identify hospital complications. The assessment was based on a medical records indicator that differentiated hospital-acquired conditions from preexisting comorbidities. METHODS: The indicators for identifying potential hospital complications were applied to all secondary diagnoses to distinguish hospital-acquired from preexisting conditions for all 1997-1998 discharges. RESULTS: Of the 95 defined complication types, cases were found with secondary diagnoses that met the criteria for 71 different complications. Sixty-nine of these complications had one or more cases with the trigger diagnosis coded as an acquired condition. Thirty-five complications had at least 30 cases with acquired conditions. Hospital complications add greatly to costs; for example, postoperative septicemia increased the hospital bill by more $25,000, added 13 hospital days to the stay, and increased hospital mortality by 16.6%. CONCLUSIONS: Current complication algorithms identify many cases where the condition was actually present on hospital admission. This fact, coupled with the known variability in coding between institutions, makes comparisons between hospitals on many of the complications problematic. Collection of the present-on-admission flag significantly reduces the noise in monitoring complication rates.

Algorithms↗

PubMed2004

Distinguishing hospital complications of care from pre-existing conditions.

OBJECTIVE: To compare cases identified through the Complications Screening Program (CSP) as complications with cases using the same ICD-9 secondary diagnosis codes, where the identifying diagnosis is also indicated as not present at admission. DESIGN: Observational study comparing two sources of potential hospital complications: published computer algorithms applied to coded diagnosis data versus a secondary diagnosis indicator, which distinguishes pre-existing from hospital-developed conditions. SETTING: All patients discharged from Mayo Clinic Rochester hospitals during 1998 and 1999. The Mayo Clinic is a large integrated delivery system in southeastern Minnesota, USA, providing services ranging from local, primary care to tertiary care for referral patients. Approximately 35% of Mayo patients travel >200 km for medical care. STUDY PARTICIPANTS: Hospital patients (total = 84 436). The numbers of cases with complications ranged from 0 to 2444 per algorithm. MAIN OUTCOME MEASURES: Percent of algorithm complication cases indicated as developing in the hospital, and percent of acquired conditions of that type detected by the computer algorithms. Incremental hospital charges, length of stay (LOS) and mortality associated with acquired complications. RESULTS: The percent of cases identified through the computer algorithm that were also coded as acquired varied from 8.8% to 100%. The ability of the computer algorithms to detect acquired conditions of that type also varied greatly, from 2% to 99%. Incremental charges and LOS were significant for patients with acquired complications except for hip fracture/falls. Many acquired complications also increased hospital mortality. CONCLUSIONS: Complication rates based strictly on standard discharge abstracts have limited use for inter-hospital comparisons due to large variability in coding across hospitals and the insensitivity of existing computer algorithms to exclude conditions present on admission from true complications. However, complications do carry high costs, including extended stays and increased hospital mortality. Enhancing secondary diagnoses with a simple indicator identifying which diagnoses were present on admission greatly increases the accurate identification of complications for internal quality and patient safety improvements.

Algorithms↗

PubMed2004

A nonresident cardiovascular inpatient service improves residents' experiences in an academic medical center: a new model to meet the challenges of the new millennium.

PURPOSE: Hospital practices in academic medical centers have fewer medical residents available to provide hospital care, necessitating alternative models for patient care. This article reports a new model for care of inpatients with cardiovascular diseases. METHOD: In 1998, a new nonresident cardiovascular patient care (Cardiology IV) service was implemented that used a team approach of staff attending cardiologists, cardiovascular fellows, midlevel practitioners (nurse practitioners and physician's assistants), and nurses to evaluate and treat patients. Standard dismissal information was collected for all patients dismissed in 1998 to compare diagnosis-related group, length of stay, in-hospital mortality, and 30-day readmission rates for Cardiology IV. These characteristics were compared with those for the remaining resident teaching services. Patients' satisfaction surveys from 1997 and 1998 were compared. Attending physicians' and internal medicine residents' satisfaction before and after the implementation of the new service was also compared. RESULTS: Staff and resident physicians were more satisfied with their hospital rotations after this intervention was introduced. Optimal patient care was maintained, and efficiency enhanced. Patients on Cardiology IV had a shorter length of stay compared with patients on the resident teaching service. CONCLUSIONS: This new hospital model has provided an alternative to patient care without the need for residents and protects education on the conventional teaching services. This model maintains optimal patient care and has resulted in enhanced satisfaction of attending staff and residents.

Academic Medical Centers↗

PubMed2002

A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice.

BACKGROUND: Disease registries are powerful tools with the potential to transform the way chronic diseases are managed. To date, however, little work has been done to determine how to optimize the implementation of a chronic disease registry in practice. METHODS: Twenty-nine physicians and their nurse teams in a large community internal medicine practice participated in this 6-month prospective randomized trial in 2000. Teams were assigned to one of three implementation strategies using information from a diabetes registry. Process and outcome measures for diabetes management were analyzed. Process measures included the percentage of patients completing glycosylated hemoglobin (Hgb) testing within 6 months and low-density lipoprotein (LDL) testing within 12 months. Outcome measures included the percentage of patients with a glycosylated Hgb > 9.3% (equivalent to a HgbA1c > 8.0%), the percentage of patients with an LDL cholesterol > 130 mg/dl, and the percentage of patients with controlled blood pressure, defined as < 130/85 millimeters of mercury. Mean change in LDL and glycosylated Hgb values was also measured. RESULTS: Teams randomized to an intervention strategy that included direct letters to patients showed significant improvement across a number of measures. The improvement was most apparent among patients without recent testing or with poorly controlled disease. The two interventions that did not include direct patient letters resulted in limited improvement. DISCUSSION: Disease registries can be used to improve outcomes in the management of diabetes and other chronic diseases. Better outcomes were seen in patients who received letters based on registry-generated data. This strategy should be included as part of a comprehensive chronic disease management plan. Further refinements in the use of registries should result in further incremental improvement.

Aged↗

PubMedDate not supplied

Predicting persistently high primary care use.

PURPOSE: We wanted to identify risk factors for persistently high use of primary care. METHODS: We analyzed outpatient office visits to practitioners in family medicine, general internal medicine, general pediatrics, and obstetrics for 1997-1999 among patients in a small Midwestern city covered by a fee-for-service insurance plan with no co-payments for physician visits and no requirement for referral to specialty care. Logistic regression was used to predict which patients with 10 or more primary care visits in 1997 would repeat high use in 1998 based on demographic and diagnostic categories (adjusted clinical groups [ACGs]). A confirmatory data set (high primary care use in 1998 persistent into 1999) was used to evaluate the model. RESULTS: Two percent of the 54,074 patients had 10 or more primary care visits in 1997, and of these, almost 19% had 10 or more visits in the next year. Among adults, 4 ambulatory diagnosis groups (ADGs) were simultaneously positive predictors of repeated high primary care visits: unstable chronic medical conditions, see and reassure conditions, minor time-limited psychosocial conditions, and minor signs and symptoms. Meanwhile, pregnancy was negatively associated. The area under the receiver operating characteristic (ROC) curve was 0.794 for adults in the developmental data set and 0.752 in the confirmatory data set, indicating a moderately accurate assessment. A satisfactory model was not developed for pediatric patients. CONCLUSIONS: Many persistently high primary care users appear to be overserviced but underserved, with underlying problems not addressed by a medical approach. Some may benefit from psychosocial support, whereas others may be good candidates for disease management interventions.

Adult↗

PubMedDate not supplied

Performance of the provider satisfaction inventory to measure provider satisfaction with diabetes care.

OBJECTIVE: To develop and validate an inventory to measure provider satisfaction with diabetes management. METHODS: Using the Mayo Clinic Model of Care, a review of the literature, and expert input, we developed a 4-category (chronic disease management, collaborative team practice, outcomes, and supportive environment), 29-item, 7-point-per-item Provider Satisfaction Inventory (PSI). For evaluation of the PSI, we mailed the survey to 192 primary-care and specialized providers from 8 practice sites (of whom 60 primary-care providers were participating in either usual or planned diabetes care). The Cronbach a score was used to assess the instrument's internal reliability. Participating providers indicated satisfaction or dissatisfaction with management of chronic disease by responding to 29 statements. RESULTS: The response rate was 58%. In each category, the Cronbach a score ranged from 0.71 to 0.90. Providers expressed satisfaction with patient-physician relationships, with the contributions of the nurse educator to the team, and with physician leadership. Providers were dissatisfied with their ability to spend adequate time with the patient (3.6 +/- 1.4), their ability to give patients with diabetes necessary personal attention (4.1 +/- 1.2), the efficient passing of communication (4.3 +/- 1.2), and the opportunities for input to change practice (4.3 +/- 1.6). No statistically significant difference (P = 0.12) was found in mean total scores between planned care (5.0 +/- 0.5) and usual care (4.7 +/- 0.6) providers. Moreover, no significant differences were noted across practice sites. CONCLUSION: The PSI is a reliable and preliminarily valid instrument for measuring provider satisfaction with diabetes care. Use in research and quality improvement activities awaits further validation.

Delivery of Health Care↗