Background:There is a concerted effort underway to evaluate and reform our nation's approach to the health of people with ongoing or elevated needs for care, particularly persons with chronic conditions and/or disabilities. Objective: This literature review characterizes the current state of knowledge on the measurement of chronic disease and disability in population-based health services research on working age adults (age 18–64). Methods: Scoping review methods were used to scan the health services research literature published since the year 2000, including medline, psycINFO and manual searches. The guiding question was: “How are chronic conditions and disability defined and measured in studies of healthcare access, quality, utilization or cost?” Results: Fifty-five studies met the stated inclusion criteria. Chronic conditions were variously defined by brief lists of conditions, broader criteria-based lists, two or more (multiple) chronic conditions, or other constructs. Disability was generally assessed through ADLs/IADLs, functional limitations, activity limitations or program eligibility. A smaller subset of studies used information from both domains to identify a study population or to stratify it by subgroup. Conclusions: There remains a divide in this literature between studies that rely upon diagnostically-oriented measures and studies that instead rely on functional, activity or other constructs of disability to identify the population of interest. This leads to wide ranging differences in population prevalence and outcome estimates. However, there is also a growing effort to develop methods that account for the overlap between chronic disease and disability and to “segment” this heterogeneous population into policy or practice relevant subgroups.
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Stephen P. Gulley;
Elizabeth K. Rasch;
Barbara M. Altman;
Christina D. Bethell;
Adam C. Carle;
Benjamin G Druss;
Amy J. Houtrow;
Amanda Reichard;
Leighton Chan
Background: Among working age adults in the United States, there is a large, heterogeneous population that requires ongoing and elevated levels of healthcare and related services. At present, there are conflicting approaches to the definition and measurement of this population in health services research.
Objective: An expert panel was convened by the National Institutes of Health with the objective of developing a population-level definition of Adults with Chronic Healthcare Needs (ACHCN). In addition, the panel developed a screening instrument and methods for its use in health surveys to identify and stratify the population consistently.
Methods: The panel employed multiple methods over the course of the project, including scoping literature reviews, quantitative analyses from national data sources and cognitive testing.
Results: The panel defined the ACHCN population as “Adults (age 18–65) with [1] ongoing physical, cognitive, or mental health conditions or difficulties functioning who [2] need health or related support services of a type or amount beyond that needed by adults of the same sex and similar age.” The screener collects information on chronic health conditions, functional difficulties, and elevated use of or unmet need for healthcare services.
Conclusions: Adapted from the Maternal and Child Health Bureau definition that identifies Children with Special Healthcare Needs, aligned with the ACS-6 disability measure, and consistent with the HHS Multiple Chronic Condition Framework, this definition and screener provide the research community with a common denominator for the identification of ACHCN.
Background: Poor sleep is common in the ICU setting and may represent a modifiable risk factor for patient participation in ICU-based physical therapy (PT) interventions. This study evaluates the association of perceived sleep quality, delirium, sedation, and other clinically important patient and ICU factors with participation in physical therapy (PT) interventions.
Method: This was a secondary analysis of a prospective observational study of sleep in a single academic medical ICU (MICU). Perceived sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates included demographics, pre-hospitalization ambulation status, ICU admission diagnosis, daily mechanical ventilation status, and daily administration of benzodiazepines and opioids via bolus and continuous infusion. Associations with participation in PT interventions were assessed among patients eligible for PT using a multinomial Markov model with robust variance estimates.
Results: Overall, 327 consecutive MICU patients completed ≥1 assessment of perceived sleep quality. After adjusting for all covariates, daily assessment of perceived sleep quality was not associated with transitioning to participate in PT the following day (relative risk ratio [RRR] 1.02, 95 % CI 0.96-1.07, p = 0.55). However, the following factors had significant negative associations with participating in subsequent PT interventions: delirium (RRR 0.58, 95 % CI 0.41-0.76, p <0.001), opioid boluses (RRR 0.68, 95 % CI 0.47-0.99, p = 0.04), and continuous sedation infusions (RRR 0.58, 95 % CI 0.40-0.85, p = 0.01). Additionally, in patients with delirium, benzodiazepine boluses further reduced participation in subsequent PT interventions (RRR 0.25, 95 % CI 0.13-0.50, p <0.001).
Conclusions: Perceived sleep quality was not associated with participation in PT interventions the following day. However, continuous sedation infusions, opioid boluses, and delirium, particularly when occurring with administration of benzodiazepine boluses, were negatively associated with subsequent PT interventions and represent important modifiable factors for increasing participation in ICU-based PT interventions.
Many studies have demonstrated that closed intensive care units (ICUs), staffed by trained intensivists, are associated with improved patient outcomes. However, the mechanisms by which ICU organizational factors, such as physician staffing, influence patient outcomes are unclear. One potential mechanism is the increased utilization of evidence-based practices in closed ICUs. Cooke and colleagues investigated this hypothesis in a cohort of 759 acute lung injury patients in 23 ICUs in King County, Washington, USA. Although closed ICUs were independently associated with a modestly lower mean tidal volume, this finding did not explain the mortality benefit associated with a closed ICU model in this patient cohort. Future studies should evaluate other potential mechanisms by which closed ICUs improve patient outcomes. An improved understanding of these mechanisms may yield new targets for improving the quality of medical care for all ICU patients.
OBJECTIVE: This study examined the accuracy of new wheelchair user predictions about their future wheelchair use. DESIGN: This was a prospective cohort study of 84 community-dwelling veterans provided a new manual wheelchair. RESULTS: The association between predicted and actual wheelchair use was strong at 3 mos (ϕ coefficient = 0.56), with 90% of those who anticipated using the wheelchair at 3 mos still using it (i.e., positive predictive value = 0.96) and 60% of those who anticipated not using it indeed no longer using the wheelchair (i.e., negative predictive value = 0.60, overall accuracy = 0.92). Predictive accuracy diminished over time, with overall accuracy declining from 0.92 at 3 mos to 0.66 at 6 mos. At all time points, and for all types of use, patients better predicted use as opposed to disuse, with correspondingly higher positive than negative predictive values. Accuracy of prediction of use in specific indoor and outdoor locations varied according to location. CONCLUSIONS: This study demonstrates the importance of better understanding the potential mismatch between the anticipated and actual patterns of wheelchair use. The findings suggest that users can be relied upon to accurately predict their basic wheelchair-related needs in the short-term. Further exploration is needed to identify characteristics that will aid users and their providers in more accurately predicting mobility needs for the long-term.
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William Whang;
Matthew M. Burg;
Robert M. Carney;
Kenneth E. Freedland;
J. Thomas Bigger;
Diane Catellier;
Susan Czajkowski;
Nancy Frasure-Smith;
Donald C. Haas;
Allan S. Jaffe;
Francois Lesperance;
Vivian Medina;
Joan Duer-Hefele;
Gabrielle A. Osorio;
Faith Parsons;
Peter A. Shapiro;
David S. Sheps;
Viola Vaccarino;
Karina W. Davidson
Despite evidence of stabilization in some areas of the USA, HIV infection in black women is not declining in the Deep South. Using a phenomenological approach to qualitative inquiry, we investigated women's experiences influencing their adherence to highly active antiretroviral therapy (HAART) in an urban setting. Inclusion criteria specified black women who had been aware of their HIV status for at least two years and were engaged in HIV outpatient care. Twelve single face-to-face confidential in-depth semi-structured interviews were conducted from a sample of predominantly middle-aged women retained in care at an HIV clinic in Atlanta, Georgia. Data were analyzed by two independent reviewers and three themes emerged from the group of women's accounts of their experiences. First, sentinel events led to changes in perspective and motivated women to adhere to HAART. Second, recognition that one had the personal strength necessary to cope with HIV fostered adherence. Finally, relationships with healthcare providers especially trust issues surrounding this relationship, impacted adherence both positively and negatively. These findings suggest that HAART adherence is a complex issue among middle-aged urban black women with HIV in the Deep South. Providers caring for this patient population should recognize that sentinel events, personal strength, and positive healthcare relationships are opportunities to improve adherence.