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Biomedical subjects

Lisa R Shugarman

Publications and source records attributed to Lisa R Shugarman.

16 recordsLinked to original sources
PubMed2006

Quality measures for symptoms and advance care planning in cancer: a systematic review.

PURPOSE: Measuring quality of care for symptom management and ascertaining patient goals offers an important step toward improving palliative cancer management. This study was designed to identify systematically the quality measures and the evidence to support their use in pain, dyspnea, depression, and advance care planning (ACP), and to identify research gaps. METHODS: English-language documents were selected from MEDLINE, Cumulative Index to Nursing and Allied Health, PsycINFO (1995 to 2005); Internet-based searches; and contact with measure developers. We used terms for each domain to select studies throughout the cancer care continuum. We included measures that expressed a normative relationship to quality, specified the target population, and specified the indicated care. Dual data review and abstraction was performed by palliative care researchers describing populations, testing, and attributes for each measure. RESULTS: A total of 4,599 of 5,182 titles were excluded at abstract review. Of 537 remaining articles, 19 contained measures for ACP, six contained measures for depression, five contained measures for dyspnea, and 20 contained measures for pain. We identified 10 relevant measure sets that included 36 fully specified or fielded measures and 14 additional measures (16 for pain, five for dyspnea, four for depression, and 25 for ACP). Most measures were unpublished, and few had been tested in a cancer population. We were unable to describe the specifications of all measures fully and did not search for measures for pain and depression that were not cancer specific. CONCLUSION: Measures are available for assessing quality and guiding improvement in palliative cancer care. Existing measures are weighted toward ACP, and more nonpain symptom measures are needed. Additional testing is needed before the measures are used for accountability, and basic research is required to address measurement when self-report is impaired.

Advance Care Planning↗
PubMed2006

The influence of staff and resident immunization rates on influenza-like illness outbreaks in nursing homes.

OBJECTIVE: To evaluate the influence of immunization rates on the likelihood of influenza-like illness (ILI) clusters in nursing facilities. DESIGN: Retrospective cross-sectional study. SETTING: Nursing facilities in a single for-profit chain (N = 301). PARTICIPANTS: Nursing home residents and staff in each facility. MEASUREMENTS: Resident and staff influenza immunization rates during the 2004-2005 influenza season, indicator of ILI cluster in facility defined as 3+ ILI cases reported within 72 hours in close proximity within the facility, hospitalization and mortality rates for facilities reporting ILI clusters, indicator of confirmatory laboratory testing for ILI cases in facility. RESULTS: Staff (median = 38%) and resident (median = 85%) rates of immunization did not independently predict the likelihood of an outbreak but jointly were strong predictors. For example, facilities having greater than 55% of staff and greater than 89% of residents immunized were almost 60% less likely to have an ILI cluster (odds ratio [OR]: 0.410; 95% CI: 0.19, 0.89) compared to all others. Facilities with higher proportions of Medicaid-funded residents were less likely to have an outbreak. Each 1% increase in the proportion of residents with Medicaid was associated with a 2.5% decrease in the risk of a cluster (OR: 0.975; 95% CI: 0.956, 0.995). Bed size and staff size did not significantly influence the likelihood of an outbreak. Among facilities with outbreaks, higher vaccination rates did not predict lower rates of hospitalizations or deaths. Approximately two thirds of all ILI clusters had laboratory testing to confirm the diagnosis of influenza. Three quarters of the facilities in which outbreaks occurred and for which confirmatory tests were performed (50/67, 74.6%) had 1+ cases positively identified as influenza. CONCLUSION: Both staff and residents must have high rates of vaccination to substantially alter the rate and impact of influenza outbreaks in nursing facilities.

Aged↗
PubMed2006

Building integrated information systems for chronic care: the California experience.

For over three decades, chronic-care services have been described as fragmented, complex, difficult to access, overlapping, and duplicative in function. Although a number of remedies have been implemented to improve service delivery, little has been written about the potential of integrated information systems (IIS) to serve as a remedy to fragmentation. We begin to address this gap by comparing and contrasting three unique models of chronic-care IIS developed in California to improve service delivery. To analyze the current status of each IIS, we apply six design criteria: (1) the information on programs and services is comprehensive, (2) the system has the capacity to serve the needs of diverse users, (3) the system integrates multiple layers and levels of information, (4) information from multiple sources is standardized and uniform, (5) information can be accessed in a timely manner, and (6) provisions are adequate to meet all requirements for privacy and confidentiality. Although much work remains to be done, there is reason to be optimistic that innovative IIS can contribute to the development of more effective chronic-care delivery systems.

California↗
PubMed2005

Meta-analysis: pharmacologic treatment of obesity.

BACKGROUND: In response to the increase in obesity, pharmacologic treatments for weight loss have become more numerous and more commonly used. PURPOSE: To assess the efficacy and safety of weight loss medications approved by the U.S. Food and Drug Administration and other medications that have been used for weight loss. DATA SOURCES: Electronic databases, experts in the field, and unpublished information. STUDY SELECTION: Up-to-date meta-analyses of sibutramine, phentermine, and diethylpropion were identified. The authors assessed in detail 50 studies of orlistat, 13 studies of fluoxetine, 5 studies of bupropion, 9 studies of topiramate, and 1 study each of sertraline and zonisamide. Meta-analysis was performed for all medications except sertraline, zonisamide, and fluoxetine, which are summarized narratively. DATA EXTRACTION: The authors abstracted information about study design, intervention, co-interventions, population, outcomes, and methodologic quality, as well as weight loss and adverse events from controlled trials of medication. DATA SYNTHESIS: All pooled weight loss values are reported relative to placebo. A meta-analysis of sibutramine reported a mean difference in weight loss of 4.45 kg (95% CI, 3.62 to 5.29 kg) at 12 months. In the meta-analysis of orlistat, the estimate of the mean weight loss for orlistat-treated patients was 2.89 kg (CI, 2.27 to 3.51 kg) at 12 months. A recent meta-analysis of phentermine and diethylpropion reported pooled mean differences in weight loss at 6 months of 3.6 kg (CI, 0.6 to 6.0 kg) for phentermine-treated patients and 3.0 kg (CI, -1.6 to 11.5 kg) for diethylpropion-treated patients. Weight loss in fluoxetine studies ranged from 14.5 kg of weight lost to 0.4 kg of weight gained at 12 or more months. For bupropion, 2.77 kg (CI, 1.1 to 4.5 kg) of weight was lost at 6 to 12 months. Weight loss due to topiramate at 6 months was 6.5% (CI, 4.8% to 8.3%) of pretreatment weight. With one exception, long-term studies of health outcomes were lacking. Significant side effects that varied by drug were reported. LIMITATIONS: Publication bias may exist despite a comprehensive search and despite the lack of statistical evidence for the existence of bias. Evidence of heterogeneity was observed for all meta-analyses. CONCLUSIONS: Sibutramine, orlistat, phentermine, probably diethylpropion, bupropion, probably fluoxetine, and topiramate promote modest weight loss when given along with recommendations for diet. Sibutramine and orlistat are the 2 most-studied drugs.

Adult↗
PubMed2005

Meta-analysis: surgical treatment of obesity.

BACKGROUND: Controversy exists regarding the effectiveness of surgery for weight loss and the resulting improvement in health-related outcomes. PURPOSE: To perform a meta-analysis of effectiveness and adverse events associated with surgical treatment of obesity. DATA SOURCES: MEDLINE, EMBASE, Cochrane Controlled Trials Register, and systematic reviews. STUDY SELECTION: Randomized, controlled trials; observational studies; and case series reporting on surgical treatment of obesity. DATA EXTRACTION: Information about study design, procedure, population, comorbid conditions, and adverse events. DATA SYNTHESIS: The authors assessed 147 studies. Of these, 89 contributed to the weight loss analysis, 134 contributed to the mortality analysis, and 128 contributed to the complications analysis. The authors identified 1 large, matched cohort analysis that reported greater weight loss with surgery than with medical treatment in individuals with an average body mass index (BMI) of 40 kg/m2 or greater. Surgery resulted in a weight loss of 20 to 30 kg, which was maintained for up to 10 years and was accompanied by improvements in some comorbid conditions. For BMIs of 35 to 39 kg/m2, data from case series strongly support superiority of surgery but cannot be considered conclusive. Gastric bypass procedures result in more weight loss than gastroplasty. Bariatric procedures in current use (gastric bypass, laparoscopic adjustable gastric band, vertical banded gastroplasty, and biliopancreatic diversion and switch) have been performed with an overall mortality rate of less than 1%. Adverse events occur in about 20% of cases. A laparoscopic approach results in fewer wound complications than an open approach. LIMITATIONS: Only a few controlled trials were available for analysis. Heterogeneity was seen among studies, and publication bias is possible. CONCLUSIONS: Surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with a BMI of 40 kg/m2 or greater. More data are needed to determine the efficacy of surgery relative to nonsurgical therapy for less severely obese people. Procedures differ in efficacy and incidence of complications.

Adolescent↗
PubMed2005

End-of-life care: an agenda for policy improvement.

Current arrangements for health care in the United States do not adequately address the needs of a growing population that has serious, eventually fatal chronic illness. New programs and policies are necessary to encourage coordination of care; better match services to the needs of patients; better provide education and incentives; and better support formal and informal caregivers. Models of end-of-life care, such as MediCaring, are described along with a research and policy agenda that focuses on modifying the health care system and building on new innovations.

Aged↗
PubMed2004

Medicare program expenditures associated with hospice use.

BACKGROUND: Hospice providers contend that enrollment reduces the cost of the Medicare programs, but estimates of effects are dated, methodologically limited, and focused on persons with cancer. OBJECTIVE: To estimate the effects of hospice care on Medicare program payments during the last year of life from 1996 to 1999 within cohorts defined by age and diagnosis. DESIGN: Retrospective cohort. SETTING: Deceased Medicare enrollees. PARTICIPANTS: Elderly Medicare fee-for-service beneficiaries who received 36 months of continuous Part A and B coverage before death during 1996 to 1999 (n = 245 326). Age- and condition-specific (cancer or noncancer and principal condition) cohorts were defined. MEASUREMENTS: Medicare expenditures in the last year of life, as a total figure and by service type. The cost effects of hospice were estimated by using linear regression within the cohorts for hospice enrollees compared with nonenrollees after adjustment for propensity to use hospice, gender, race, enrollment in Medicaid, urban setting, duration of illness, comorbid conditions, low use of Medicare, nursing home residence, and year of death. RESULTS: Adjusted mean expenditures were 4.0% higher overall among hospice enrollees than among nonenrollees. Adjusted mean expenditures were 1% lower for hospice enrollees with cancer than for patients with cancer who did not use hospice. Savings were highest (7% to 17%) among enrollees with lung cancer and other very aggressive types of cancer diagnosed in the last year of life. Expenditures for hospice enrollees without cancer were 11% higher than for nonenrollees, ranging from 20% to 44% for patients with dementia and 0% to 16% for those with chronic heart failure or failure of most other organ systems. Hospice-related savings decreased and relative costs increased with age. CONCLUSION: Hospice enrollment correlates with reduced Medicare expenditures among younger decedents with cancer but increased expenditures among decedents without cancer and those older than 84 years of age. Future studies should assess the effects of hospice on quality and on expenditures from all payment sources.

Aged↗
PubMed2004

Is telephone screening feasible? Accuracy and cost-effectiveness of identifying people medically eligible for home- and community-based services.

PURPOSE: To determine the accuracy of a telephone-screening system to identify persons eligible for home- and community-based long-term care. DESIGN AND METHODS: Data from Michigan telephone screens were compared to data from in-person assessments using the Minimum Data Set for Home Care (MDS-HC). Weighted kappa statistics measured the level of agreement between the two assessments. RESULTS: Overall, recommendations based on the telephone screen produced a marginal match compared to recommendations based on in-person assessment. "False positives" (individuals scoring as more impaired on the telephone screen than in person) occurred in 27% of all cases, while "false negatives" (individuals scoring as less impaired on the telephone screen) only occurred among 6% of the callers. Neither individual screen questions, source of information, location of the individual, timing between screen and assessment, nor temporal changes accounted for mismatches. Telephone screens resulted in an 11% savings over the cost of providing in-person assessments to all program seekers. IMPLICATIONS: The telephone screen has utility as a broad targeting mechanism that allows agencies to avoid costly in-person assessments for all program seekers. Evidence does not support use of the telephone screen alone to determine either medical eligibility or a specific level of care.

Algorithms↗
PubMed2004

The Health Insurance Portability and Accountability Act Privacy Rule: a practical guide for researchers.

BACKGROUND: The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, intended to address potential threats to patient privacy posed by the computerization and standardization of medical records, provides a new floor level of federal protection for health information in all 50 states. In most cases, compliance with the Privacy Rule was required as of April 2003. Yet considerable confusion and concern remain about the Privacy Rule and the specific changes it requires in the way healthcare providers, health plans, and others use, maintain, and disclose health information. Researchers worry that the Privacy Rule could hinder their access to health information needed to conduct their research. OBJECTIVES: In this article, we explain how the final version of the Privacy Rule governs disclosure of health information, assess implications of the Privacy Rule for research, and offer practical suggestions for researchers who require access to health information. CONCLUSION: The Privacy Rule is fundamentally changing the way that healthcare providers, health plans, and others use, maintain, and disclose health information and the steps that researchers must take to obtain health data. The Privacy Rule requires researchers who seek access to identifiable health information to obtain written authorization from subjects, or, alternatively, to demonstrate that their research protocols meet certain Privacy Rule requirements that permit access without written authorization. To ensure continued access to data, researchers will need to work more closely than before with healthcare providers, health plans, and other institutions that generate and maintain health information.

Computer Security↗
PubMed2004

Differences in Medicare expenditures during the last 3 years of life.

OBJECTIVE: To examine age, gender, race, and area income differences in Medicare expenditures in the 3 years before death. DESIGN: Cross-sectional study. PARTICIPANTS: A random sample of aged Medicare beneficiaries who died 1996 to 1999, N = 241,047. MEASURES: We estimate differences in mean Medicare expenditures by year before death and by age, gender, race, and area income, adjusting for comorbidities and Medicaid enrollment. RESULTS: Expenditures for blacks are lower in the second and third years before death and are not significantly different from whites in the last year of life (LYOL) (y3 = 70%, P <.0001; y2 = 82%, P <.0001; LYOL = 119%, P =.098). Differences in expenditures between decedents with area incomes over $35,000 compared to under $20,000 attenuate by the LYOL (y3 = 116%, P <.0001; y2 = 107%, P <.0001; LYOL = 96%, P <.0001). Expenditure patterns for women versus men vary by age. Among the younger cohorts (68 to 74 and 75 to 79), expenditures are higher for women in all 3 years before death. This difference attenuates among older cohorts; in the oldest cohort (90+), expenditures for men exceed those for women by 11% in the LYOL (P <.0001). Older beneficiaries have higher expenditures in the second and third years before death but lower expenditures in the LYOL. On average, the youngest cohort expended $8,017 more in the LYOL relative to the oldest cohort, whereas in the third year before death, the oldest cohort's expenditures were $5,270 more than those for the youngest cohort (P <.0001). CONCLUSIONS: Age-associated differences in aggregate Medicare payments for end-of-life care are more substantial than other differences. The fact that other differences attenuate in the LYOL may reflect having overcome barriers to health care, or reflect an effective ceiling on the opportunities to provide services for persons with overwhelming illness.

Black or African American↗
PubMed2003

Identifying older people at risk of abuse during routine screening practices.

OBJECTIVES: To examine the association between various characteristics of community-based older people and a constructed measure of potential elder abuse. DESIGN: Cross-sectional design. SETTING: Public community-based long-term care programs in Michigan. PARTICIPANTS: Individuals aged 60 and older seeking home and community-based services in Michigan between November 1996 and October 1997 (N = 701). MEASUREMENTS: Data were collected using the Minimum Data Set for Home Care (MDS-HC) assessment. The dependent variable is a constructed measure of potential elder abuse reflecting physical and emotional abuse and neglect. Independent variables include demographic characteristics; diagnoses; behavioral measures; and cognitive, physical, and social functioning. RESULTS: Several measures of social support and social function were strongly associated with the signs of a potentially abusive environment: brittle support (odds ratio (OR) = 3.5, 90% confidence interval (CI) = 1.5-8.1), older person feels lonely (OR = 2.4, 90% CI = 1.3-4.5), and older person expresses conflict with family/friends (OR = 2.3, 90% CI = 1.2-4.3). Home care participants' alcohol abuse, psychiatric illness, lack of ease interacting with others, and short-term memory problems were also significantly associated with the signs of potential elder abuse. CONCLUSIONS: The results of this study suggest that the signs of potential elder abuse are associated with a diminishing social network and poor social functioning, although some characteristics of the older person's health are contributing factors. Improved understanding of the link between those characteristics and potential abuse will help healthcare providers, case managers, and others identify older people at high risk of abuse.

Activities of Daily Living↗
PubMed2002

Caregiver attitudes and hospitalization risk in michigan residents receiving home- and community-based care.

OBJECTIVES: To study a cohort of participants in home- and community-based services (HCBS) in Michigan to evaluate the relationship between (1) caregiver attitudes and participant characteristics and (2) the risk of hospitalization. SETTING: HCBS programs funded by Medicaid or state/local funds in Michigan. PARTICIPANTS: Five hundred twenty-seven individuals eligible for HCBS in Michigan were studied. These HCBS participants were randomly selected clients of all agencies providing publicly funded HCBS in Michigan from November 1996 to October 1997. MEASUREMENTS: Data for this study were collected using the Minimum Data Set for Home Care. Assessments were collected longitudinally, and the baseline (initial admission assessment) and 90-day follow-up assessments were used. Key measures were caregiver attitudes (distress, dissatisfaction, and decreased caregiving ability) and HCBS participant characteristics (cognition, functioning, diseases, symptoms, nutritional status, medications, and disease stability). Multinomial logistic regression was used to evaluate how these characteristics were associated with the competing risks of hospitalization and death within 90 days of admission to HCBS. RESULTS: We found a strong association between caregiver dissatisfaction (caregiver dissatisfied with the level of care the home care participant was currently receiving) and an increased likelihood of hospitalization. HCBS participant cancer, chronic obstructive pulmonary disease, pain, and flare-up of a chronic condition were also associated with increased hospitalization. Poor food intake and prior hospitalization were associated with hospitalization and death. CONCLUSIONS: We conclude that, within a cohort of people receiving HCBS who are chronically ill, highly disabled, and at high risk for hospitalization and death, interventions addressing caregiver dissatisfaction, pain control, and medical monitoring should be evaluated for their potential to decrease hospitalization.

Aged↗
PubMed2002

Age and gender differences in health care utilization and spending for medicare beneficiaries in their last years of life.

Men's and women's health care experiences differ as they age. While increasing attention has been focused on gender differences in health status, prevalence of illnesses, and access to quality care among older adults, little is known about differences in their health care in the last years of their lives. This paper uses claims data for a 0.1% random sample of Medicare beneficiaries who died between January 1, 1994 and December 31, 1998 to assess age and gender differences among Medicare-eligible adults in their utilization of health care services in the last year of life. Overall, age is much more important than gender in explaining most of the variation in end-of-life care. The combination of being a Medicare beneficiary and being sick enough to die appears to attenuate gender disparities in health care services utilization.

Age Distribution↗
PubMed2002

A screening system for Michigan's home- and community-based long-term care programs.

PURPOSE: To develop a screening system for Michigan's MI Choice publicly funded home- and community-based services programs, to aid in identifying both individuals eligible for services and their most appropriate level of care (LOC). DESIGN AND METHODS: Identify assessment items from the Minimum Data Set for Home Care (MDS-HC) assessment instrument that are predictive of five LOCs determined by expert care managers: nursing home, home care, intermittent personal care, homemaker, and information and referral (without services). RESULTS: The algorithm based on approximately 30 client characteristics agrees with expert opinions substantially better (kappa =.62) than systems based on activities of daily living and instrumental activities of daily living only (kappa <.40). IMPLICATIONS: The screening algorithm can be used both over the telephone to identify clients who will not be fully assessed (as they are unlikely to receive services) and in person to recommend the appropriate LOC.

Algorithms↗
PubMedDate not supplied

Shortcomings in Medicare bonus payments for physicians in underserved areas.

This study examines trends in Medicare spending for basic payments and bonus payments for physician services provided to beneficiaries residing in nonmetropolitan counties. For our analysis, we used Medicare Part B physician/supplier claims data for 1992, 1994, 1996, and 1998. Payments under the congressionally mandated bonus payment program acccounted for less than 1 percent of expenditures for physician services in nonmetropolitan, underserved counties. Physician payments increased from 1992 to 1998, while bonus payments increased through 1996 but then declined by 13 percent by 1998. The share of bonus payments to primary care physicians declined throughout the decade, but the share for primary care services increased.

Humans↗