Biomedical subjects

Joan L Buchanan

Publications and source records attributed to Joan L Buchanan.

6 recordsLinked to original sources

PubMed2006

Nursing home capabilities and decisions to hospitalize: a survey of medical directors and directors of nursing.

OBJECTIVES: To obtain information from decision makers about attitudes toward hospitalization and the factors that influence their decisions to hospitalize nursing home residents. DESIGN: Cross-sectional survey. SETTING: Four hundred forty-eight nursing homes, 76% of which were nonprofit, from 25 states. PARTICIPANTS: Medical directors and directors of nursing (DONs). MEASUREMENTS: Participants were surveyed about resource availability, determinants of hospitalization, causes of overhospitalization, and nursing home practice. RESULTS: The survey response rate was 81%, with at least one survey from 93% of the facilities. Medical directors and DONs agreed that resident preference was the most important determinant in the decision to hospitalize, followed by quality of life. Although both groups ranked on-site doctor/nurse practitioner evaluation within 4 hours as the least accessible resource, they did not rank doctors not being quickly available as an important cause of overhospitalization. Rather, medical directors perceived the lack of information and support to residents and families around end-of-life care and the lack of familiarity with residents by covering doctors as the most important causes of overhospitalization. DONs agreed but reversed the order. Medical directors and DONs expressed confidence in provider and staff ability, although DONs were significantly more positive. CONCLUSION: Medical directors and DONs agree about most factors that influence decisions to hospitalize nursing home residents. Patient-centered factors play the largest roles, and the most important causes of overhospitalization are potentially modifiable.

Attitude of Health Personnel↗

PubMed2006

Derivation and confirmation of scales measuring medical directors' attitudes about the hospitalization of nursing home residents.

OBJECTIVE: To derive and confirm scales measuring medical director's attitudes about hospitalization of nursing home residents. METHOD: The authors surveyed nursing facility medical directors about the necessity of hospitalizing residents for eight clinical conditions and compared the ratings to those obtained from an expert panel to derive a relative hospitalization score. They also asked about factors that might influence hospitalization decisions. They performed a factor analysis to derive scales that measure attitudinal determinants of hospitalization and used the relative hospitalization score to confirm the scales. RESULTS: The survey had a 79% response rate. The relative hospitalization score demonstrated that medical directors were slightly less likely to recommend hospitalization than expert panel physicians. Factor analyses yielded 10 scales focusing on nursing home functioning, economics, resident specific considerations, and physician attitudes. Eight of the 10 scales had significant bivariable associations with the relative hospitalization score, and 6 had significant multivariable associations. DISCUSSION: Medical directors identify multiple determinants of hospitalization for nursing facility residents across several domains. Hospitalization decisions for nursing facility residents are complex and involve clinical and nonclinical factors.

Attitude of Health Personnel↗

PubMed2004

Evaluating the planned substitution of the minimum data set-post acute care for use in the rehabilitation hospital prospective payment system.

OBJECTIVE: The objective of this study was to evaluate the payment implications of substituting the Minimum Data Set-Post Acute Care (MDS-PAC) for the FIM trade mark instrument for use in the planned prospective payment system (PPS) for inpatient rehabilitation hospitals. FIM trade mark is a trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activites, Inc. RESEARCH DESIGN: We used a prospective cross-sectional design using consecutive sampling. SUBJECTS: We studied all Medicare admissions with stays of 3 days or more over a 2-month period to 50 inpatient rehabilitation hospitals in 22 states. MEASUREMENTS AND METHODS: Each participating institution completed both the FIM and the MDS-PAC assessments on all participants. Items from the MDS-PAC were combined and translated to create "FIM-like" items. We assessed agreement of classification into prospective payment cells using FIM assessment data and also using MDS-PAC data. Statistical adjustments were applied to improve the level of agreement. RESULTS: The mean differences between the FIM motor and cognitive scales and their MDS-PAC translations were 2.4 (mean = 45) and 0.0 (mean = 28), respectively, with scale correlations of.85 and.84. Weighted kappas on individual items ranged from.32 to.64. There were substantial hospital-specific differences in scoring. Payment cell classification using FIM data agreed with that using MDS-PAC data only 56% of the time. Twenty percent of the facilities experienced revenue shifts larger than 10%. CONCLUSION: Despite better item-level agreement than previously observed, poor payment cell agreement and substantial revenue shifts indicated that the MDS-PAC should not be substituted for the FIM trade mark instrument in the rehabilitation hospital PPS.

Cross-Sectional Studies↗

PubMed2003

An assessment tool translation study.

Policymakers hoped to substitute a new, multi-purpose, functional assessment instrument, the minimum data set post-acute care (MDS-PAC), into the planned prospective payment system (PPS) for inpatient rehabilitation hospitals. PPS design requires a large database linking treatment costs with measures of the need for care, so the PPS was designed using the functional independence measure (FIM) database linked to Medicare hospital claims. An accurate translation from the MDS-PAC items to FIM--like items was needed to ensure payment equity under the substitution. This article describes the translation efforts and some of the problems that led policymakers to abandon the effort.

Activities of Daily Living↗

PubMedDate not supplied

Tube-feeding versus hand-feeding nursing home residents with advanced dementia: a cost comparison.

OBJECTIVE: To compare the costs associated with caring for severely demented residents nursing homes with and without feeding tubes. DESIGN: Retrospective cohort study. SETTING: A 700-bed long-term care facility in Boston Participants: Nursing home residents aged 65 years and over with advanced dementia and eating problems for whom long-term feeding tube had been discussed as a treatment option. MEASUREMENTS: Costs were compared over the 6 months that followed the tube-feeding decision for those residents who did and did not undergo feeding tube placement for the following items: nursing time, physician assessments, food, hospitalizations, emergency room visits, diagnostic tests, treatment with antibiotics and parenteral hydration, and feeding tube insertion. RESULTS: Twenty-two subjects were included, 11 were tube-fed (mean age 84.3 years +/- 6.0) and 11 were hand-fed (mean age 90.2 years +/- 9.1). The daily costs of nursing home care were higher for the residents without feeding tubes compared with residents with tubes ($4219 +/- 1546 vs $2379 +/- 1032, P = 0.006). Nonetheless, Medicaid reimbursement to nursing homes in at least 26 states is higher for demented residents who are tube-fed than for residents with similar deficits who are not tube-fed. Costs typically billed to Medicare were greater for the tube-fed patients ($6994 +/- 5790 vs. $959 +/- 591, P < 0.001), primarily because of the high costs associated with initial feeding tube placement and hospitalizations or emergency rooms visits for the management of complications of tube-feeding. CONCLUSIONS: Nursing homes are faced with a potential fiscal incentive to tube-feed residents with advanced dementia: tube-fed residents generate a higher daily reimbursement rate from Medicaid, yet require less expensive nursing home care. From a Medicare perspective, tube-fed patients are expensive due to the high costs associated with feeding tube placement and acute management of complications. Further work is needed to determine whether these potential financial incentives influence tube-feeding decisions in practice.

Activities of Daily Living↗

PubMedDate not supplied

Transmission of financial incentives to physicians by intermediary organizations in California.

Many U.S. physicians participate in provider-sponsored organizations that act as their intermediaries in contracting with managed care plans, particularly where capitation contracts are used. Examining a survey of 153 intermediary entities in California, we trace the cascade of financial incentives from health plans through physician organizations to primary care physicians. Although the physician organizations received the vast majority (84 percent) of their revenues through capitation contracts, most of the financial risk related to utilization and costs was retained at the group level. Capitation of primary care physicians was common in independent practice associations (IPAs), but payments typically were restricted to primary care services. Thirteen percent of medical groups and 19 percent of IPAs provided bonuses or withholds based on utilization or cost performance, which averaged 10 percent of base compensation.

California↗