Biomedical subjects

Paul Krueger

Publications and source records attributed to Paul Krueger.

16 recordsLinked to original sources

PubMed2006

Effect of a clinical pathway to reduce hospitalizations in nursing home residents with pneumonia: a randomized controlled trial.

CONTEXT: Nursing home residents with pneumonia are frequently hospitalized. Such transfers may be associated with multiple hazards of hospitalization as well as economic costs. OBJECTIVE: To assess whether using a clinical pathway for on-site treatment of pneumonia and other lower respiratory tract infections in nursing homes could reduce hospital admissions, related complications, and costs. DESIGN, SETTING, AND PARTICIPANTS: A cluster randomized controlled trial of 680 residents aged 65 years or older in 22 nursing homes in Hamilton, Ontario, Canada. Nursing homes began enrollment between January 2, 2001, and April 18, 2002, with the last resident follow-up occurring July 4, 2005. Residents were eligible if they met a standardized definition of lower respiratory tract infection. INTERVENTIONS: Treatment in nursing homes according to a clinical pathway, which included use of oral antimicrobials, portable chest radiographs, oxygen saturation monitoring, rehydration, and close monitoring by a research nurse, or usual care. MAIN OUTCOME MEASURES: Hospital admissions, length of hospital stay, mortality, health-related quality of life, functional status, and cost. RESULTS: Thirty-four (10%) of 327 residents in the clinical pathway group were hospitalized compared with 76 (22%) of 353 residents in the usual care group. Adjusting for clustering of residents in nursing homes, the weighted mean reduction in hospitalizations was 12% (95% confidence interval [CI], 5%-18%; P = .001). The mean number of hospital days per resident was 0.79 in the clinical pathway group vs 1.74 in the usual care group, with a weighted mean difference of 0.95 days per resident (95% CI, 0.34-1.55 days; P = .004). The mortality rate was 8% (24 deaths) in the clinical pathway group vs 9% (32 deaths) in the usual care group, with a weighted mean difference of 2.9% (95% CI, -2.0% to 7.9%; P = .23). There were no significant differences between the groups in health-related quality of life or functional status. The clinical pathway resulted in an overall cost savings of US 1016 dollars per resident (95% CI, 207 dollars-1824 dollars) treated. CONCLUSION: Treating residents of nursing homes with pneumonia and other lower respiratory tract infections with a clinical pathway can result in comparable clinical outcomes, while reducing hospitalizations and health care costs. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00157612.

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PubMed2006

Interobserver reliability of radiologists' interpretations of mobile chest radiographs for nursing home-acquired pneumonia.

OBJECTIVES: To determine the interobserver reliability of radiologists' interpretations of mobile chest radiographs for nursing home-acquired pneumonia. DESIGN: A cross-sectional reliability study. SETTING: Nursing homes and an acute care hospital. PARTICIPANTS: Four radiologists reviewed 40 mobile chest radiographs obtained from residents of nursing homes who met a clinical definition of lower respiratory tract infections. MEASUREMENTS: Radiologists were asked to interpret radiographs with respect to the film quality; presence, pattern, and extent of an infiltrate; and the presence of a pleural effusion or adenopathy. Interrater reliability was evaluated using the intraclass correlation coefficient derived from a 2-way random effects model. RESULTS: On average the radiologists reported that 6 of the 40 films were of very good or excellent quality and 16 of the 40 were of fair or poor quality. When the finding of an infiltrate was dichotomized (0 = no; 1 = possible, probable, or definite) all 4 radiologists agreed on 21 of the 37 chest radiographs. The intraclass correlation coefficient for the presence or absence of infiltrates was 0.54 (95% confidence intervals [CI] 0.38 to 0.69). For the 14 radiographs where infiltrates were observed by all radiologists, intraclass correlation coefficients for the presence of pleural effusions was 0.08 (95% CI -0.10 to 0.41), hilar adenopathy 0.54 (95% CI 0.29 to 0.79), and mediastinal adenopathy 0.49 (95% CI 0.21 to 0.76). CONCLUSION: In conclusion, the interrater agreement among radiologists for mobile chest radiographs in establishing the presence or absence of an infiltrate can be judged to be "fair." Treatment decisions need to include clinical findings and should not be made based on radiographic findings alone.

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PubMed2006

"I really should've gone to the doctor": older adults and family caregivers describe their experiences with community-acquired pneumonia.

BACKGROUND: Responding to acute illness symptoms can often be challenging for older adults. The primary objective of this study was to describe how community-dwelling older adults and their family members responded to symptoms of community-acquired pneumonia (CAP). METHODS: A qualitative study that used face-to-face semi-structured interviews to collect data from a purposeful sample of seniors aged 60+ and their family members living in a mid-sized Canadian city. Data analysis began with descriptive and interpretive coding, then advanced as the research team repeatedly compared emerging thematic categories to the raw data. Searches for disconfirming evidence and member checking through focus groups provided additional data and helped ensure rigour. RESULTS: Community-acquired pneumonia symptoms varied greatly among older adults, making decisions to seek care difficult for them and their family members. Both groups took varying amounts of time as they attempted to sort out what was wrong and then determine how best to respond. Even after they concluded something was wrong, older adults with confirmed pneumonia continued to wait for days, to over a week, before seeking medical care. Participants provided diverse reasons for this delay, including fear, social obligations (work, family, leisure), and accessibility barriers (time, place, systemic). Several older adults and family members regretted their delays in seeking help. CONCLUSION: Treatment-seeking delay is a variable, multi-phased decision-making process that incorporates symptom assessment plus psychosocial and situational factors. Public health and health care professionals need to educate older adults about the potential causes and consequences of unnecessary waits. Such efforts may reduce the severity of community-acquired pneumonia upon presentation at clinics and hospitals, and that, in turn, could potentially improve health outcomes.

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PubMed2006

The impact of a new universal postpartum program on breastfeeding outcomes.

The Ontario Mother and Infant Study II examined changes in postpartum health outcomes, including breastfeeding initiation and discontinuation, for mothers and their infants and compared these results to data collected prior to the initiation of the Universal Hospital Stay and Postpartum Home Visiting Program policy change in 1998. Data were collected using cross-sectional surveys before discharge and at 4 weeks postdischarge. Ninety percent of the women surveyed at 4 weeks postpartum initiated breastfeeding. Of these, 84% were still breastfeeding at 4 weeks postpartum. None of the 3 major program components-extended length of stay, a postpartum phone call from a public health worker, or a postpartum in-home visit-were associated with breastfeeding continuation to 4 weeks. Discontinuation before 4 weeks postdischarge was associated with maternal attitudes toward breastfeeding, formula feeding or supplementation in hospital, infant readmission, and use of walk-in clinics for infant care.

Adult↗

PubMed2006

Quality of care for residents dying in Ontario long-term care facilities: findings from a survey of directors of care.

The purpose of this study was to collect information on the practice of end-of-life (EOL) care in long-term care (LTC) facilities in the Province of Ontario, Canada. A cross-sectional survey of directors of care in all licensed LTC facilities in the province was conducted between September 2003 and April 2004. Directors of care from 426 (76% response rate) facilities completed the postal survey questionnaire. The survey results identified communication problems between service providers and families, inadequate staffing levels to provide quality care to dying residents, and the need for training to improve staff skills in providing EOL care. Directors of care endorsed the use of a number of strategies that would improve the care of dying residents. Logistic regression analysis identified the eight most important items predictive of facility staff having the ability to provide quality EOL care. The findings contribute to the current discussion on policies for meeting the care needs of residents in LTC facilities until life's end.

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PubMed2005

Longer postpartum hospitalization options--who stays, who leaves, what changes?

BACKGROUND: This paper examines the practice implications of a policy initiative, namely, offering women in Ontario Canada up to a 60-hour postpartum in-hospital stay following an uncomplicated vaginal delivery. This change was initiated out of concern for the effects of 'early' discharge on the health of mothers and their infants. We examined who was offered and who accepted extended stays, to determine what factors were associated with the offer and acceptance of this option, and the impact that these decisions had on post-discharge health status and service utilization of mothers and infants. METHODS: The data reported here came from two related studies of health outcomes and service utilization of mothers and infants. Data were collected from newly delivered mothers who had uncomplicated vaginal deliveries. Questionnaires prior to discharge and structured telephone interviews at 4-weeks post discharge were used to collect data before and after policy implementation. Qualitative data were collected using focus groups with hospital and community-based health care managers and providers at each site. For both studies, samples were drawn from the same five purposefully selected hospitals. Further analysis compared postpartum health outcomes and post discharge service utilization of women and infants before and after the practice change. RESULTS: Average length of stay (LOS) increased marginally. There was a significant reduction in stays of <24 hours. The offer of up to a 60-hour LOS was dependent upon the hospital site, having a family physician, and maternal ethnicity. Acceptance of a 60-hour LOS was more likely if the baby had a post-delivery medical problem, it was the woman's first live birth, the mother identified two or more unmet learning needs in hospital, or the mother was unsure about her own readiness for discharge. Mother and infant health status in the first 4 weeks after discharge were unchanged following introduction of the extended stay option. Infant service use also was unchanged but rate of maternal readmission to hospital increased and mothers' use of community physicians and emergency rooms decreased. CONCLUSION: This research demonstrates that this policy change was selectively implemented depending upon both institutional and maternal factors. LOS marginally increased overall with a significant decrease in <24-hour stays. Neither health outcomes nor service utilization changed for infants. Women's health outcomes remained unchanged but service utilization patterns changed.

Journal Article↗

PubMed2005

Implementation of a health care policy: an analysis of barriers and facilitators to practice change.

BACKGROUND: Governments often create policies that rely on implementation by arms length organizations and require practice changes on the part of different segments of the health care system without understanding the differences in and complexities of these agencies. In 2000, in response to publicity about the shortening length of postpartum hospital stay, the Ontario government created a universal program offering up to a 60-hour postpartum stay and a public health follow-up to mothers and newborn infants. The purpose of this paper is to examine how a health policy initiative was implemented in two different parts of a health care system and to analyze the barriers and facilitators to achieving practice change. METHODS: The data reported came from two studies of postpartum health and service use in Ontario Canada. Data were collected from newly delivered mothers who had uncomplicated vaginal deliveries. The study samples were drawn from the same five purposefully selected hospitals for both studies. Questionnaires prior to discharge and structured telephone interviews at 4-weeks post discharge were used to collect data before and after policy implementation. Qualitative data were collected using focus groups with hospital and community-based health care practitioners and administrators at each site. RESULTS: In both studies, the respondents reflected a population of women who experienced an "average" or non-eventful hospital-based, singleton vaginal delivery. The findings of the second study demonstrated wide variance in implementation of the offer of a 60-hour stay among the sites and focus groups revealed that none of the hospitals acknowledged the 60-hour stay as an official policy. The uptake of the offer of a 60-hour stay was unrelated to the rate of offer. The percentage of women with a hospital stay of less than 25 hours and the number with the guideline that the call be within 48 hours of hospital discharge. Public health telephone contact was high although variable in relation to compliance the guideline that the call be within 48 hours of hospital discharge. Home visits were offered at consistently high rates. CONCLUSION: Policy enactment is sometimes inadequate to stimulate practice changes in health care. Policy as a tool for practice change must thoughtfully address the organizational, professional, and social contexts within which the policy is to be implemented. These contexts can either facilitate or block implementation. Our examination of Ontario's universal postpartum program provides an example of differential implementation of a common policy intended to change post-natal care practices that reflects the differential influence of context on implementation.

Adult↗

PubMed2005

Assessing, treating and preventing community acquired pneumonia in older adults: findings from a community-wide survey of emergency room and family physicians.

BACKGROUND: Respiratory infections, like pneumonia, represent an important threat to the health of older Canadians. Our objective was to determine, at a community level, family and emergency room physicians' knowledge and beliefs about community acquired pneumonia (CAP) in older adults and to describe their self-reported assessment, management and prevention strategies. METHODS: All active ER and family physicians in Brant County received a mailed questionnaire. An advance notification letter and three follow-up mailings were used to maximize physician participation rate. The questionnaire collected information about physicians' assessment, management, and prevention strategies for CAP in older adults (>or=60 years of age) plus demographic, training, and practice characteristics. The analysis highlights differences in approaches between office-based and emergency department physicians. RESULTS: Seventy-seven percent of physicians completed and returned the survey. Although only 16% of physicians were very confident in assessing CAP in older adults, more than half reported CAP to be a very important health concern in their practices. In-service training for family physicians was associated with increased confidence in CAP assessment and more frequent use of diagnostic tests. Family physicians who reported always requesting chest x-rays were also more likely to request pulse oximetry (OR 5.6, 95% CI 1.40 to 22.5) and recommend both follow-up x-rays (OR 5.4, 95% CI 1.7 to 16.6) and pneumococcal vaccination (OR 3.4, 95% CI 1.1 to 10.0). CONCLUSION: The findings of this study provide a snapshot of how non-specialists from a non-urban Ontario community assess, manage and prevent CAP in older adults and highlight differences between office-based and emergency department physicians. This information can guide researchers and clinicians in their efforts to improve the management and prevention of CAP in older adults.

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PubMed2005

Service preferences among family caregivers of the terminally ill.

OBJECTIVE: The ability of families to assume caregiving responsibilities is contingent on material, social, and professional support. Inadequate or inappropriate support to the terminally ill and their family caregivers can result in the misuse of resources and add burden to the family. In this report, we describe service preferences among informal caregivers of the terminally ill. DESIGN: Three hundred seventy-three caregivers participated in telephone interviews at two points in time: when the terminally ill person was designated as palliative and 5 months subsequent to the first interview. In the case that the care recipient died during the study period, the caregiver participated in the interview three months after the death. MEASURES: After reviewing possible services received by the care recipients and caregivers, caregivers were asked to identify the five services they found most valuable and which services they would have liked to have had or received more of when caregiving. RESULTS: The five services caregivers reported as most valuable included: in-home nursing care, (90.7%); family physicians, (45.6%); medical specialists, (46.4%); housekeeping, (23.6%); and, religious support, (11.3%). The five most frequently reported services that family caregivers would have liked to have received or had more available included: housekeeping, (13.1%); caregiver respite, (10.2%); in-home nursing care, (8.0%); personal support workers, (4.6%); and, self-help/support groups, (3.8%). Analyses revealed that most (64.8%) perceived service needs were of a supportive nature for caregivers. Caregiver perceptions of the value and perceived need of services were consistent over time and into bereavement. Logistic regression analyses suggested that younger caregivers who were not employed, reported higher levels of burden and cared for someone with a diagnosis of cancer had greater perceived service needs. CONCLUSIONS: The findings reported in this paper provide important insights into caregiver perceptions of valued services when caring for a terminally ill family member. These finding also highlight the stability of caregiver service perceptions over time and into bereavement.

Adult↗

PubMed2005

Preferences for place of care and place of death among informal caregivers of the terminally ill.

OBJECTIVES: (1) To determine informal caregivers perceptions about place of care and place of death; and (2) to identify variables associated with a home death among terminally ill individuals who received in-home support services in a publicly funded home care system. PARTICIPANTS AND DESIGN: A total of 216 informal caregivers participated in a bereavement interview. Data collection included care recipient and informal caregiver characteristics, the use of and satisfaction with community services, and preferences about place of death. RESULTS: Most caregivers reported that they and the care recipient had a preferred place of death (77 and 68%, respectively) with over 63% reporting home as the preferred place of death. Caregivers had a greater preference for an institutional death (14%) than care recipients (4.7%). While 30% of care recipients did not die in their preferred location, most caregivers (92%) felt, in retrospect, that where the care recipient died was the appropriate place of death. Most caregivers reported being satisfied with the care that was provided. The odds of dying at home were greater when the care recipient stated a preference for place of death (OR: 2.92; 95% CI: 1.25, 6.85), and the family physician made home visits during the care recipients last month of life (Univariate odds ratios (OR): 4.42; 95% CI: 1.46, 13.36). DISCUSSION: The ethic of self-control and choice for the care recipient must be balanced with consideration for the well being of the informal caregiver and responsiveness of the community service system.

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PubMed2004

Implementation, uptake, and impact of a provincial postpartum program.

This paper examines implementation and uptake of the Hospital Stay and Postpartum Home Visiting Program at 5 sites in the Canadian province of Ontario using a cross-sectional survey. It also examines concomitant changes in satisfaction with services and maternal and infant health indicators by comparing the findings of this survey, administered after policy implementation, with those of a previous survey. In both surveys, data were collected via a self-administered in-hospital questionnaire and a structured telephone interview at 4 weeks post-discharge. There were statistically significant differences in implementation of the 60-hour hospital-stay option across sites, with between 11.7% and 81.2% of women having been offered an extended stay. However, there were no significant differences in acceptance rates (21.1-39.4%) among those women given this option. There were no statistically significant differences in the offer of a home visit by a public health nurse (91.5-96.6%), but there were significant differences in uptake of a visit. Between 21.1% and 39.4% of those women who were offered a home visit accepted. When compared to the previous survey findings, there were few changes in client satisfaction with services and health indicators following program implementation.This study raises questions about the utility of the postpartum program as currently implemented and highlights the need for further research.

Adult↗

PubMed2002

A cross-sectional study of early identification of postpartum depression: implications for primary care providers from The Ontario Mother & Infant Survey.

BACKGROUND: This survey's objective was to provide planning information by examining utilization patterns, health outcomes and costs associated with existing practices in the management of postpartum women and their infants. In particular, this paper looks at a subgroup of women who score >or= 12 on the Edinburgh Postnatal Depression Survey (EPDS). METHODS: The design is cross-sectional with follow-up at four weeks after postpartum hospital discharge. Five Ontario hospitals, chosen for their varied size, practice characteristics, and geographic location, provided the setting for the study. The subjects were 875 women who had uncomplicated vaginal deliveries of live singleton infants. The main outcome measures were the EPDS, the Duke UNC Functional Social Support Questionnaire and the Health and Social Services Utilization Questionnaire. RESULTS: EPDS scores of >or= 12 were found in 4.3 to 15.2% of otherwise healthy women. None of these women were being treated for postpartum depression. Best predictors of an EPDS score of >or= 12 were lack: of confident support, lack of affective support, household income of <20,000 dollars, wanting to stay in hospital longer, identification of learning needs while in hospital, self-identified care needs for an emotional/mental health problem that have not been met and mother's rating of own and baby's health as fair or poor. CONCLUSIONS: Primary care physicians, midwives, and public health nurses need to screen for depression at every opportunity early in the postpartum period. A mother's expression of undue concern about her own or her baby's health may be predictive of postpartum depression. Flexible, mother-focused support from community providers may decrease the prevalence of postpartum depression.

Analysis of Variance↗

PubMed2002

Organization specific predictors of job satisfaction: findings from a Canadian multi-site quality of work life cross-sectional survey.

BACKGROUND: Organizational features can affect how staff view their quality of work life. Determining staff perceptions about quality of work life is an important consideration for employers interested in improving employee job satisfaction. The purpose of this study was to identify organization specific predictors of job satisfaction within a health care system that consisted of six independent health care organizations. METHODS: 5,486 full, part and causal time (non-physician) staff on active payroll within six organizations (2 community hospitals, 1 community hospital/long-term care facility, 1 long-term care facility, 1 tertiary care/community health centre, and 1 visiting nursing agency) located in five communities in Central West Ontario, Canada were asked to complete a 65-item quality of work life survey. The self-administered questionnaires collected staff perceptions of: co-worker and supervisor support; teamwork and communication; job demands and decision authority; organization characteristics; patient/resident care; compensation and benefits; staff training and development; and impressions of the organization. Socio-demographic data were also collected. RESULTS: Depending on the organization, between 15 and 30 (of the 40 potential predictor) variables were found to be statistically associated with job satisfaction (univariate analyses). Logistic regression analyses identified the best predictors of job satisfaction and these are presented for each of the six organizations and for all organizations combined. CONCLUSIONS: The findings indicate that job satisfaction is a multidimensional construct and although there appear to be some commonalities across organizations, some predictors of job satisfaction appear to be organization and context specific.

Adult↗

PubMed2002

Patterns of family adaptation to childhood asthma.

This study examined patterns in adaptation among parents with a child who had moderate to severe persistent asthma. Specifically, we were interested in examining the differences in adaptation between mothers and fathers in which it was hypothesized that gender effects would be obtained in patterns of coping. Eighty-four parents participated in the study, representing 37 intact families in which both parents were present and 13 single-parent families. Within intact families, mothers exhibited greater efforts than fathers in coping patterns including strategies to acquire social support outside the family, enhance self-worth, and decrease psychological tensions. When compared to mothers in single-parent families, mothers within intact families had a greater tendency to use coping patterns related to family integration and cooperation. Such findings demonstrate a need for additional support for mothers in their role in caring for the chronically ill child. The implications of these findings for clinical practice are discussed.

Adaptation, Psychological↗

PubMed2002

Have we met the educational challenges of obstetrics and gynecology? A response to the Association of Professors of Gynecology and Obstetrics Initiative of 1986.

OBJECTIVE: The purpose of this study was to assess the progress that has been made toward meeting the educational challenges in obstetrics and gynecology that were made at an Association of Professors of Obstetrics and Gynecology special forum in 1986. STUDY DESIGN: We placed the five major issues and specific problems that were identified within the context of developments that have occurred in medical education, the Association of Professors of Obstetrics and Gynecology, and the specialty over the last 15 years. We used the medical education literature and the accomplishments of the members of the Association of Professors of Obstetrics and Gynecology to measure progress. RESULTS: Many of the challenges that were raised at the original forum remain. Significant progress, much of it spearheaded by the Association of Professors of Obstetrics and Gynecology, has been made in the areas of teaching methods and skills, evaluation techniques, faculty development, computer usage, teaching recognition, counseling for the fourth-year student, and an integrated curriculum in women's health. CONCLUSION: Progress has occurred within the context and demands of a changing health care system that constricts the time and funding that are available for medical education.

Curriculum↗

PubMedDate not supplied

Postpartum health, service needs, and access to care experiences of immigrant and Canadian-born women.

OBJECTIVE: To describe immigrant women's postpartum health, service needs, access to services, and service use during the first 4 weeks following hospital discharge compared to women born in Canada. DESIGN: Data were collected as part of a larger cross-sectional study. SETTING: Women were recruited from 5 hospitals purposefully selected to provide a diverse sample. PARTICIPANTS: A sample of 1,250 women following vaginal delivery of a healthy infant; approximately 31% were born outside of Canada. MAIN OUTCOME MEASURES: Self-reported health status, postpartum depression, postpartum needs, access to services, service use. RESULTS: Immigrant women were significantly more likely than Canadian-born women to have low family incomes, low social support, poorer health, possible postpartum depression, learning needs that were unmet in hospital, and a need for financial assistance. However, they were less likely to be able to get financial aid, household help, and reassurance/support. There were no differences between groups in ability to get care for health concerns. CONCLUSIONS: Health care professionals should attend not only to the basic postpartum health needs of immigrant women but also to their income and support needs by ensuring effective interventions and referral mechanisms.

Adult↗