Hemodynamic changes associated with manual and automated lateral rotation in mechanically ventilated intensive care patients

Objective: To investigate hemodynamic responses to lateral rotation. ^ Design: Time-series within a randomized controlled trial pilot study. ^ Setting: A medical intensive care unit (ICU) and a medical-surgical ICU in two tertiary care hospitals. ^ Patients: Adult patients receiving mechanical ventilation. ^ Interventions: Two-hourly manual or continuous automated lateral rotation. ^ Measurements and Main Results: Heart rate (HR) and arterial pressure were sampled every 6 seconds for > 24 hours, and pulse pressure (PP) was computed. Turn data were obtained from a turning flow sheet (manual turn) or with an angle sensor (automated turn). Within-subject ensemble averages were computed for HR, mean arterial pressure (MAP), and PP across turns. Sixteen patients were randomized to either the manual (n = 8) or automated (n = 8) turn. Three patients did not complete the study due to hemodynamic instability, bed malfunction or extubation, leaving 13 patients (n = 6 manual turn and n = 7 automated turn) for analysis. Seven patients (54%) had an arterial line. Changes in hemodynamic variables were statistically significant increases ( p < .05), but few changes were clinically important, defined as ≥ 10 bpm (HR) or ≥ 10 mmHg (MAP and PP), and were observed only in the manual-turn group. All manual-turn patients had prolonged recovery to baseline in HR, MAP and PP of up to 45 minutes (p ≤ .05). No significant turning-related periodicities were found for HR, MAP, or PP. Cross-correlations between variables showed variable lead-lag relations in both groups. A statistically, but not clinically, significant increase in HR of 3 bpm was found for the manual-turn group in the back compared with the right lateral position ( F = 14.37, df = 1, 11, p = .003). ^ Conclusions: Mechanically ventilated critically ill patients experience modest hemodynamic changes with manual lateral rotation. A clinically inconsequential increase in HR, MAP, and PP may persist for up to 45 minutes. Automated lateral rotation has negligible hemodynamic effects. ^

Effect of primary care availability and health insurance coverage on risk and cost of Preventable Hospitalizations in Harris County

Preventable Hospitalizations (PHs) are hospitalizations that can be avoided with appropriate and timely care in the ambulatory setting and hence are closely associated with primary care access in a community. Increased primary care availability and health insurance coverage may increase primary care access, and consequently may be significantly associated with risks and costs of PHs. Objective. To estimate the risk and cost of preventable hospitalizations (PHs); to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs, first alone and then simultaneously; and finally, to estimate the impact of expansions in primary care availability and health insurance coverage on the burden of PHs among non-elderly adult residents of Harris County. Methods. The study population was residents of Harris County, age 18 to 64, who had at least one hospital discharge in a Texas hospital in 2008. The primary independent variables were availability of primary care physicians, availability of primary care safety net clinics and health insurance coverage. The primary dependent variables were PHs and associated hospitalization costs. The Texas Health Care Information Collection (THCIC) Inpatient Discharge data was used to obtain information on the number and costs of PHs in the study population. Risk of PHs in the study population, as well as average and total costs of PHs were calculated. Multivariable logistic regression models and two-step Heckman regression models with log-transformed costs were used to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs respectively, while controlling for individual predisposing, enabling and need characteristics. Predicted PH risk and cost were used to calculate the predicted burden of PHs in the study population and the impact of expansions in primary care availability and health insurance coverage on the predicted burden. Results. In 2008, hospitalized non-elderly adults in Harris County had 11,313 PHs and a corresponding PH risk of 8.02%. Congestive heart failure was the most common PH. PHs imposed a total economic burden of $84 billion at an average of $7,449 per PH. Higher primary care safety net availability was significantly associated with the lower risk of PHs in the final risk model, but only in the uninsured. A unit increase in safety net availability led to a 23% decline in PH odds in the uninsured, compared to only a 4% decline in the insured. Higher primary care physician availability was associated with increased PH costs in the final cost model (β=0.0020; p<0.05). Lack of health insurance coverage increased the risk of PH, with the uninsured having 30% higher odds of PHs (OR=1.299; p<0.05), but reduced the cost of a PH by 7% (β=-0.0668; p<0.05). Expansions in primary care availability and health insurance coverage were associated with a reduction of about $1.6 million in PH burden at the highest level of expansion. Conclusions. Availability of primary care resources and health insurance coverage in hospitalized non-elderly adults in Harris County are significantly associated with the risk and costs of PHs. Expansions in these primary care access factors can be expected to produce significant reductions in the burden of PHs in Harris County.^

An analysis of the effects of a peer mentor program and other factors on HIV patients' retention in care and clinical outcomes at Thomas Street Health Clinic, Houston Texas

Research examining programs designed to retain patients in health care focus on repeated interactions between outreach workers and patients (Bradford et al. 2007; Cheever 2007). The purpose of this study was to determine if patients who are peer-mentored at their intake exam remain in care longer and attend more physicians' visits than those who were not mentored. Using patients' medical records and a previously created mentor database, the study determined how many patients attended their intake visit but subsequently failed to establish regular care. The cohort study examined risk factors for establishing care, determined if patients lacking a peer mentor failed to establish care more than peer mentor assisted patients, and subsequently if peer mentored patients had better health outcomes. The sample consists of 1639 patients who were entered into the Thomas Street Patient Mentor Database between May 2005 and June 2007. The assignment to the mentored group was haphazardly conducted based on mentor availability. The data from the Mentor Database was then analyzed using descriptive statistical software (SPSS version 15; SPSS Inc., Chicago, Illinois, USA). Results indicated that patients who had a mentor at intake were more likely to return for primary care HIV visits at 90 and 180 days. Mentored patients also were more likely to be prescribed ART within 180 days from intake. Other risk factors that impacted remaining in care included gender, previous care status, time from diagnosis to intake visit, and intravenous drug use. Clinical health outcomes did not differ significantly between groups. This supports that mentoring did improve outcomes. Continuing to use peer-mentoring programs for HIV care may help in increasing retention of patients in care and improving patients' health in a cost effective manner. Future research on the effects of peer mentoring on mentors, and effects of concordance of mentor and patient demographics may help to further improve peer-mentoring programs. ^

A study of patient satisfaction with medical care services in Yanbu al-Sinaiya, Saudi Arabia

This study attempts to provide reliable scientific data that will enable the health services department of the Royal Commission of Yanbu Al Sinaiyah, Saudi Arabia to improve the quality of health care services provided in their facilities. Patient satisfaction and dissatisfaction were investigated along seven dimensions: General satisfaction scale, Communication, Technical quality, Art of care, Continuity of care, Time spent with the doctor, and Access/Convenience/ and availability. Patient satisfaction parameters were compared for Saudi vs. non-Saudi, males vs. females, and for patients seen in the hospital vs. those seen in Al-nawa and Radwa primary care centers. The information was obtained by using a self-administered questionnaire. The results indicate that patients seen in Al-nawa primary care center were more satisfied with care than patients seen in the hospital who in turn were more satisfied than those seen in Radwa primary care center. The non-Saudi patients were more satisfied than the Saudi patients across all three facilities and satisfaction scales. The female patients were more satisfied than the male patients across all three facilities and satisfaction scales. ^

Factors associated with hospital admission of elder cardiovascular patients in an emergency center

Context. Healthcare utilization of elder cardiovascular patients in United States will increase in near future, due to an aging population. This trend could burden urban emergency centers, which have become a source of primary care. ^ Objective. The objective of this study was to determine the association of age, gender, ethnicity, insurance and other presenting variables on hospital admission in an emergency center for elder cardiovascular patients. ^ Design, setting and participants. An anonymous retrospective review of emergency center patient login records of an urban emergency center in the years 2004 and 2005 was conducted. Elder patients (age ≥ 65 years) with cardiovascular disease (ICD91 390-459) were included. Multivariate logistic regression analysis was used to identify independent factors for hospital admission. Four major cardiovascular reasons for hospitalisation – ischemic heart disease, heart failure, hypertensive disorders and stroke were analysed separately. ^ Results. The number of elder patients in the emergency center is increasing, the most common reason for their visit was hypertension. Majority (59%) of the 12,306 elder patients were female. Forty five percent were uninsured and 1,973 patients had cardiovascular disease. Older age (OR 1.10; CI 1.02-1.19) was associated with a marginal increase in hospital admission in elder stroke patients. Elder females compared to elder males were more likely to be hospitalised for ischemic heart disease (OR 2.71; CI 1.22-6.00) and heart failure (OR 1.58; CI 1.001-2.52). Furthermore, insured elder heart failure patients (OR 0.54; CI 0.31-0.93) and elder African American heart failure patients (OR 0.32; CI 0.13-0.75) were less likely to be hospitalised. Ambulance use was associated with greater hospital admissions in elder cardiovascular patients studied, except for stroke. ^ Conclusion. Appropriate health care distribution policies are needed for elder patients, particularly elder females, uninsured, and racial/ethnic minorities. These findings could help triage nurse evaluations in emergency centers to identify patients who were more likely to be hospitalised to offer urgent care and schedule appointments in primary care clinics. In addition, health care plans could be formulated to improve elder primary care, decrease overcrowding in emergency centers, and decrease elder healthcare costs in the future. ^

Influence of trust on HIV diagnosis and care practices

Many factors have been studied as potential correlates in delayed HIV diagnosis and delayed linkage to HIV healthcare. Few studies have analyzed the association of trust as a correlate in HIV diagnosis and HIV medical treatment delays. This study sought to assess the effect of patient trust in physicians and trust in the healthcare system, and whether diminished levels of trust affect delays in HIV diagnosis and/or linking to HIV healthcare, among a cohort of newly diagnosed HIV-infected persons, in Harris County, Texas.^ This study is a secondary data analysis from the Attitude and Beliefs and the Steps of HIV Care Study, also known as the Steps Study, a prospective observational cohort study. From January 2006 to October 2007 patients newly diagnosed with HIV infection and not yet in HIV primary care were recruited from publically funded HIV testing sites in Houston, Texas.^ Two outcomes were assessed in this study. The first outcome sought to determine the influence of trust and whether decreased levels of trust predicted delays in HIV diagnosis. Trust in physicians and trust in the healthcare system were measured via 2 validated trust scales. Trust scores of those with late diagnosis (CD4 counts <200 cells/mm3) were compared statistically with those with early diagnosis (CD4 counts ≥ 200 cells/mm3) in a cross sectional study design. Trust was not found to be predictive of delays in HIV diagnosis. ^ The second outcome utilized the same trust scales and a prospective cohort study design to assess whether there were differences in trust scores between those who successfully linked to HIV healthcare, compared to those who failed to link to HIV healthcare, within 6 months of diagnosis. Patients with higher trust in physicians and trust in the healthcare system were significantly more likely to be linked to HIV healthcare than those with lower trust.^ Overall, this study showed that among low-income persons with undiagnosed HIV infection, low trust is not a barrier to timely diagnosis of HIV infection. Trust may be a factor in promoting a prompt linkage to HIV healthcare among those who are newly diagnosed.^

QUALITY OF MATERNITY CARE IN RURAL TEXAS (MEXICAN-AMERICAN)

The purpose of the study was to describe regionalized systems of perinatal care serving predominantly low income Mexican-American women in rural underserved areas of Texas. The study focused upon ambulatory care; however, it provided a vehicle for examination of the health care system. The questions posed at the onset of the study included: (1) How well do regional organizations with various patterns of staffing and funding levels perform basic functions essential to ambulatory perinatal care? (2) Is there a relationship between the type of organization, its performance, and pregnancy outcome? (3) Are there specific recommendations which might improve an organization's future performance?^ A number of factors--including maldistribution of resources and providers, economic barriers, inadequate means of transportation, and physician resistance to transfer of patients between levels of care--have impeded the development of regionalized systems of perinatal health care, particularly in rural areas. However, studies have consistently emphasized the role of prenatal care in the early detection of risk and treatment of complications of pregnancy and childbirth, with subsequent improvement in pregnancy outcomes.^ This study has examined the "system" of perinatal care in rural areas, utilizing three basic regional models--preventive care, limited primary care, and fully primary care. Information documented in patient clinical records was utilized to compare the quality of ambulatory care provided in the three regional models.^ The study population included 390 women who received prenatal care in one of the seven study clinics. They were predominantly hispanic, married, of low income, with a high proportion of teenagers and women over 35. Twenty-eight percent of the women qualified as migrants.^ The major findings of the study are listed below: (1) Almost half of the women initiated care in the first trimester. (2) Three-fourths of the women had or exceeded the recommended number of prenatal visits. (3) There was a low rate of clinical problem recognition. Additional follow-up is needed to determine the reasons. (4) Cases with a tracer condition had significantly more visits with monitoring of the clinical condition. (5) Almost 90% of all referrals were completed. (6) Only 60% of mothers had postpartum follow-up, while almost 90% of their newborns received care. (7) The incidence of infants weighing 2500 grams or less was 4.2%. ^