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Biomedical subjects

R Lavizzo-Mourey

Publications and source records attributed to R Lavizzo-Mourey.

12 recordsLinked to original sources
PubMed1991

The Patient Self-Determination Act and the future of advance directives.

Living wills and other advance directives currently play a limited role in medical decision making. A new federal law, the Patient Self-Determination Act, will require health care providers in hospitals, nursing homes, and other facilities to inquire about the presence of advance directives, to record patient preferences in the medical record, and to develop institutional policies regarding the implementation of these directives. Unfortunately, the law does little to promote discussion or preparation of advance directives before hospitalization. Additional efforts to promote the use of advance directives can take place in the outpatient medical care system, in attorneys' offices, or through health insurers. Because most people have not yet prepared an advance directive, we suggest that institutions develop treatment policies for situations in which the wishes of patients who lack decisional capacity are not known. These policies should be designed to promote the patients' best interests, as defined by the consensus of the institutions' staff and members of the surrounding community.

Advance Directives↗
PubMed1991

Completeness of admission of residents assessments in teaching nursing homes.

In order to assess one aspect of the quality of care within teaching nursing homes, we examined how well these homes conform to geriatric experts' expectations for the admission assessment of elderly nursing home residents. Four hundred-sixty records representing new admissions to five teaching nursing homes over a 1-year period were assessed for completion of items considered important parts of the admission assessment by geriatric experts. Univariate and multivariate analyses both suggest the following four findings. First, the admission assessments performed at teaching nursing homes reflect geriatric experts' priority areas with two exceptions: (1) the assessment of affective disorders and (2) the identification of advance directives. Second, physician-nurse practitioner teams perform the high priority parts of the admission assessment to a degree similar to that of physicians alone. Third, resident's age and expected length of stay partially determine the extent of the admission assessment, as patients with shorter lengths of stay generally received a more complete assessment. Fourth, even among teaching nursing homes, there are significant differences between nursing homes in the performance of comprehensive admission assessment by nursing home clinicians.

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PubMed1988

Measuring the economic impact of perioperative total parenteral nutrition: principles and design.

Although the use of total parenteral nutrition (TPN) has been increasing in recent years, few studies have been performed on both its costs and its effectiveness or benefits. This paper provides a general review of the methods of cost-effectiveness and cost-benefit analysis, summarizes briefly the existing cost-analysis studies of TPN, and outlines the authors' proposed study design for their economic assessment of TPN.

Clinical Trials as Topic↗
PubMed1988

Risk factors for dehydration among elderly nursing home residents.

Dehydration is the most common fluid and electrolyte disorder among the elderly, yet risk factors are not known. This study identifies risk factors for dehydration in acutely ill nursing home residents. All 339 elderly resident of two nursing homes who developed an acute illness requiring hospitalization during 1984 were included in the study. The 173 patients having a serum Na less than 150 mg/dL and blood urea nitrogen to creatinine ratio (BUN:Cre) less than 20 were designated controls; 91 patients having a serum Na greater than 150 mg/dL or a serum BUN:Cre greater than 25 were designated cases. Odds ratios (OR) and confidence intervals were calculated for age, sex, chronic conditions, acute illnesses, medications, functional status measures, and season. Acutely ill dehydrated patients were female (OR, 3.3); over 85 years old (OR, 2.2); had more than four chronic conditions (OR, 4.0); took more than four medications (OR, 2.8); and were bedridden (OR, 2.9). Among the most severely dehydrated (serum Na greater than 150 mg/dL and BUN:Cre greater than 25), the odds ratios for the above factors were strengthened and other factors, such as inability to feed oneself and type of acute diagnosis, emerged as risk factors. Among the variables unrelated to functional status, laxatives (OR, 3.2) and chronic infections (OR, 1.8) were risk factors. We conclude that a group at high risk for dehydration can be defined and that they are better characterized by the number of chronic diseases and debilitated functional status than by acute disease processes.

Acute Disease↗
PubMed1988

Special skills for the clinical management of the older patient.

The elderly represent a unique and diverse group of patients. Physicians who care for elderly patients face not only the problem of distinguishing normal aging from disease, but also must deal with patients who commonly do not report symptoms. To provide effective care for this population, the physician must develop particular skills.

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PubMedDate not supplied

Management of stage III pressure ulcers in moderately demented nursing home residents.

PURPOSE: To determine whether the myocutaneous flap procedure, the preferred treatment for young patients with stage III pressure ulcers, is appropriate for moderately demented nursing home residents. SUBJECTS AND METHODS: A model of the treatment decision was created using the decision-tree format. The probabilities of treatment outcomes in the decision tree were derived from the literature. Utilities for treatment outcomes were obtained from five internists, five geriatricians, six nurse practitioners, five plastic surgeons, and six lay people. RESULTS: A majority in each group of respondents favored surgery, according to the decision analysis. Sensitivity analysis showed that surgery was preferred unless its success rate was less than 30%, or the rate of healing with conservative measures was at least 40%, which are unlikely values. Economic analysis demonstrated that surgery was $17,000 more expensive than conservative therapy. CONCLUSION: The myocutaneous flap procedure is preferred by the majority of relevant decision makers when cost is not a consideration. The relative underutilization of surgery in practice has many possible explanations. The most likely are the failure of providers to appreciate the morbidity of pressure ulcers and the reluctance of practitioners to perform expensive procedures on demented patients.

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PubMedDate not supplied

Integrating residency training in geriatrics into existing outpatient curricula.

In recent years, the need for increasing the geriatrics component of residency training has been repeatedly addressed; however, there are still many programs that have been unable to meet this need. While alternative sites, such as geriatric evaluation units and nursing homes, may be the ideal sites to teach some aspects of geriatrics, this article argues that the ambulatory care program, required in all residency programs, is the appropriate setting for teaching many of the core skills needed to care for most older adults. Teaching geriatrics in the ambulatory setting, which eliminates the strategic and financial obstacles of developing non-hospital-based sites, can be accomplished with relatively modest additional resources. This article describes the methods used to integrate geriatrics into the ambulatory care component of one internal medicine residency program and the necessary faculty resources as well as the documentation, via chart audit, of the interns' compliance with recommended practice patterns in five categories. With the exception of vaccination status, interns documented 18% or less of possible pieces of information for their patients. While this assessment showed statistically significant improvement in interns' care of older patients after the program intervention, the overall level of performance was still low, underscoring the need for the integration of geriatrics principles in the ambulatory curriculum.

Ambulatory Care↗
PubMedDate not supplied

Preventive care for the elderly.

While prevention has received a great deal of attention in the medical community in the last 15 to 20 years, little of this research or clinical activity has been addressed directly to the elderly population. Today, with an increasing emphasis on geriatric care, there is a rising awareness that clinicians' preventive efforts on behalf of the elderly can yield important benefits not only for individuals, by improving their quality of life, but also for society through potential cost savings. This chapter describes the effects of prevention strategies for the elderly.

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