Abstract Objective To examine the extent to which the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines improved clinical trials reporting and subject attrition, which may ...undermine the credibility of published randomized clinical trials (RCTs). Study Design and Setting Published RCTs reported in two major medical journals before and after the CONSORT guidelines were systematically reviewed; one used the CONSORT statement (JAMA) and one did not (NEJM). Results The quality of RCT reporting improved for both journals, but JAMA showed more significant and consistent improvements in all aspects of RCT reporting. Subject attrition was better accounted for after the publication of CONSORT, although the attrition rates for various reasons actually increased. Attrition due to unknown reasons, as a percentage of total attrition, declined dramatically, from 68.7% pre-CONSORT to 13.0% post-CONSORT. Conclusions Attrition of study subjects remains a serious problem in RCTs. Bias from selective attrition can undermine the presumptive scientific advantage of RCTs. The CONSORT guidelines improved RCT reporting when they were implemented but did not substantially improve reported attrition rates.
While admissions of minorities to nursing homes (NHs) are increasing and prevalence of incontinence in NHs remains high, little is known about incontinence among racial-ethnic groups of NH admissions ...other than blacks. The purpose of this study was to describe the prevalence of incontinence among older adults admitted to NHs by race/ethnicity at three levels of measurement: individual resident, NH, and Census division.
Cross-sectional and descriptive.
Admissions of persons age 65 or older to 1 of 457 NHs of a national, for-profit chain over 3 years 2000-2002 (n = 111,640 residents).
Data sources were the Minimum Data Set v. 2.0 and 2000 US Census. Prevalence of the following definitions of incontinence was analyzed: Only Urinary Incontinence (UI), Only Fecal Incontinence (FI), Dual Incontinence (DI; UI and FI), Any UI (UI with or without FI), Any FI (FI with or without UI), and Any Incontinence (UI and/or FI and/or DI).
Asian patients, black patients, and Hispanic patients had a higher prevalence of Any Incontinence (67%, 66%, and 58%, respectively) compared to white patients (48%) and American Indian patients (46%). At the NH level, all prevalence measures of incontinence (except Only UI) appear to trend in the opposite direction from the percentage of NH admissions who were white. Among Asian and white patients, there was a higher prevalence of all types of incontinence in men compared with women except for Only UI. Among Census divisions, the prevalence of all types of incontinence, except Only UI, was lowest in the 2 divisions with the highest percentage of white admissions to their NHs.
NHs admitting more racial/ethnic minorities may be faced with managing more incontinence and needing additional staffing resources. The association of the prevalence of most types of incontinence with the race/ethnicity of NH admissions at all levels of measurement lend support to the growing evidence that contextual factors beyond individual resident characteristics may contribute to NH differences.
Little is known about the prevalence of pressure ulcers (PUs) among racial and ethnic groups of older individuals admitted to nursing homes (NHs). NHs admitting higher percentages of minority ...individuals may face resource challenges for groups with more PUs or ones of greater severity. This study examined the prevalence of PUs (Stages 2 to 4) among older adults admitted to NHs by race and ethnicity at the individual, NH, and regional levels. Results show that the prevalence of PUs in Black older adults admitted to NHs was greater than that in Hispanic older adults, which were both greater than in White older adults. The PU rate among admissions of Black individuals was 1.7 times higher than White individuals. A higher prevalence of PUs was observed among NHs with a lower percentage of admissions of White individuals. Little is known about the prevalence of pressure ulcers (PUs) among racial and ethnic groups of older individuals admitted to nursing homes (NHs). NHs admitting higher percentages of minority individuals may face resource challenges for groups with more PUs or ones of greater severity. This study examined the prevalence of PUs (Stages 2 to 4) among older adults admitted to NHs by race and ethnicity at the individual, NH, and regional levels. Results show that the prevalence of PUs in Black older adults admitted to NHs was greater than that in Hispanic older adults, which were both greater than in White older adults. The PU rate among admissions of Black individuals was 1.7 times higher than White individuals. A higher prevalence of PUs was observed among NHs with a lower percentage of admissions of White individuals.
Journal of Gerontological Nursing, xx
(x), xx–xx.
Background. The predictive validity of Drug Utilization Review (DUR) and drugs-to-avoid criteria in elders is unknown. Objectives. To evaluate the relationship between use of inappropriate drugs as ...determined by these explicit criteria and mortality and decline in functional status in community dwelling elders. Research Design. Cohort study. Subjects. The fourth wave (3234 participants) of the Duke Established Populations for Epidemiologic Studies of the Elderly. Measures. Two sets of inappropriate drug-use criteria: (1) DUR with respect to dosage, duplication, drug-drug interactions, duration, and drug-disease interactions; and (2) Beers-modified criteria regarding drugs-to-avoid were applied to drug use reported in an in-home interview. Death was identified from the National Death Index; change in four functional status measures (basic self-care, intermediate self-care, complex self-management, physical function) was determined during the following 3 years. Results. Use of inappropriate drugs identified by either set of criteria was not significantly associated with mortality. The drugs-to-avoid criteria identified no significant associations between use of these drugs and decline in functional status. With DUR criteria, however, the association between use of inappropriate drugs and basic self-care was significant and pronounced among those with drug-drug or drug-disease interaction problems (Adj. OR 2.04; 95% CI 1.32-3.16). Conclusions. Identifying the impact of inappropriate drug use may depend on the criteria applied. Further studies are needed that measure additional outcomes and use alternate measures of inappropriate drug use.
GOALSTo determine the outcomes of implementing clinical care guidelines for Hepatitis C screening, evaluation, and treatment in a large urban Veterans Affairs Medical Center.
BACKGROUNDLittle ...information exists regarding the actual outcomes of institutional screening programs for Hepatitis C.
STUDYRetrospective review of all patients tested for Hepatitis C at the Minneapolis Veterans Affairs Medical Center from January 1, 2000 to December 31, 2001. Logistic regression was used to determine factors related to successful referral and treatment.
RESULTSDuring this period 36,422 unique patients were screened for Hepatitis C virus (HCV) risk factors, resulting in 12,485 HCV enzyme-linked immunoassay antibody tests. HCV antibodies were positive in 681 (5.4%) patients and 520 (4.2%) were HCV-RNA–positive. Of HCV-RNA–positive patients, 430 (83%) were referred, 382 (73%) attended the Hepatitis clinic, and 232 (44.6%) received liver biopsies. Patients referred had significantly fewer comorbidities, known marital status, and greater prior clinic attendance than those not referred. Overall, 124 patients with established fibrosis received antiviral therapy (32% of patients attending clinic or 24% of viremic cohort). White race, fewer major medical problems, and age less than 60 years predicted antiviral treatment. Sustained virologic response occurred in 46 (37%) of treated patients (9% of the viremic cohort). Patients with a sustained virologic response include 17 patients with stage 3 to 4 fibrosis.
CONCLUSIONSThis screening and referral program resulted in 73% of HCV-RNA–positive patients attending a specialty Hepatitis C clinic and 24% of those most likely to benefit received antiviral therapy. Measures to increase referral, engagement in care, and antiviral treatment are needed.
Objectives: To determine the prevalence of mono‐ and poly‐antiepileptic drug (AED) therapy in a cohort of nursing home (NH) residents and to describe specific AED combinations used, as well as ...demographic, clinical, and functional factors associated with poly‐AED therapy and the most common AED combination.
Design: Retrospective, point prevalence study.
Setting: All NHs owned/managed by Beverly Enterprises.
Participants: All residents aged 65 and older residing in one of the study NHs on July 1, 1999, and receiving an AED (N=3,881).
Measurements: Data were gathered using two secondary source data sets: physicians' orders (AED use) and the Minimum Data Set (health status indicators).
Results: Of residents taking AEDs, 370 (9.5%) were taking two or more; 268 of those (72%) were taking problematic AED combinations (those with the potential of undesirable pharmacokinetic or pharmacodynamic interactions). Phenytoin (PHT) with phenobarbital (PB) was the most common combination (27.0%). Logistic regression indicated that poly‐AED subjects were more likely to have a diagnosis of epilepsy/seizure (epi/sz) and less likely to have a diagnosis of cerebrovascular accident (CVA). Residents taking the PHT/PB combination were more likely to have an epi/sz diagnosis and longer NH stay. The association between CVA and PHT/PB polytherapy differed by presence or absence of aphasia.
Conclusion: The overall prevalence of poly‐AED therapy is less than 10% in NH residents, but 72% of those residents were receiving problematic polytherapy combinations, thereby exposing them to potential risk of adverse reactions and toxicity.
To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost.
Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota.
...Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516).
Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates.
Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database.
Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges.
This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.
•There was a disparity in pressure ulcer healing of Black nursing home admissions.•Functional limitations and a more severe pressure ulcer predicted delayed healing.•Blacks’ pressure ulcer healing ...was worse than expected based on clinical status.
Pressure ulcers increase the risk of costly hospitalization and mortality of nursing home residents, so timely healing is important. Disparities in healthcare have been identified in the nursing home population but little is known about disparities in the healing of pressure ulcers.
To assess racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Multi-levels predictors, at the individual resident, nursing home, and community/Census tract level, were examined in three large data sets.
Minimum Data Set records of older individuals admitted to one of 439 nursing homes of a national, for-profit chain over three years with a stages 2–4 pressure ulcer (n=10,861) were searched to the 90-day assessment for the first record showing pressure ulcer healing. Predictors of pressure ulcer healing were analyzed for White admissions first using logistic regression. The Peters-Belson method was used to assess racial or ethnic disparities among minority group admissions.
A significantly smaller proportion of Black nursing home admissions had their pressure ulcer heal than expected had they been part of the White group. There were no disparities in pressure ulcer healing disadvantaging other minority groups. Significant predictors of a nonhealing of pressure ulcer were greater deficits in activities of daily living and pressure ulcer severity.
Reducing disparities in pressure ulcer healing is needed for Blacks admitted to nursing homes. Knowledge of disparities in pressure ulcer healing can direct interventions aiming to achieve equity in healthcare for a growing number of minority nursing home admissions.
We examined the prevalence and clinical correlates of pathological gambling among 1228 American Indian and Hispanic American veterans in the southwest and north central regions of the United States.
...We surveyed a community sample of American Indian and Hispanic American veterans to obtain data on psychiatric disorder and treatment.
American Indian veterans had a 10% lifetime prevalence of pathological gambling. The Hispanic American lifetime prevalence was less than that of the American Indian veterans but higher than the prevalence found for Hispanic American veterans in other surveys. Comorbid conditions associated with pathological gambling included substance, mood, and antisocial personality disorders. Ready access to casino gambling may encourage, support, or contribute to high rates of pathological gambling in both men and women.
A 70% lifetime comorbidity of psychiatric disorders suggests that early interventions for pathological gambling should consider common psychiatric conditions rather than focusing on pathological gambling alone.
Objective: The objective of this study was to assess whether there are racial and ethnic disparities in the time to development of a pressure ulcer and number of pressure ulcer treatments in ...individuals aged 65 and older after nursing home admission. Method: Multi-level predictors of time to a pressure ulcer from three national surveys were analyzed using Cox proportional hazards regression for White Non-Hispanic residents. Using the Peters–Belson method to assess for disparities, estimates from the regression models were applied to American Indians/Alaskan Natives, Asians/Pacific Islanders, Blacks, and Hispanics separately resulting in estimates of expected outcomes as if they were White Non-Hispanic, and were then compared with their observed outcomes. Results: More Blacks developed pressure ulcers sooner than expected. No disparities in time to a pressure ulcer disadvantaging other racial/ethnic groups were found. There were no disparities in pressure ulcer treatment for any group. Discussion: Reducing disparities in pressure ulcer development offers a strategy to improve the quality of nursing home care.
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