Abraham A. Brody

Abstract

Background: Care at the end of life is increasingly fragmented and is characterized by multiple hospitalizations, even among patients enrolled with hospice. Objective: To determine whether hospice spending on direct patient care (including the cost of home visits, drugs, equipment, and counseling) is associated with hospital utilization and Medicare expenditures of hospice enrollees. Design: Longitudinal, observational cohort study (2008-2010). Setting/Subjects: Medicare beneficiaries (N = 101,261) enrolled in a national random sample of freestanding hospices (N = 355). Measurements: We used Medicare Hospice Cost reports to estimate hospice spending on direct patient care and Medicare claim data to estimate rates of hospitalization and Medicare expenditures. Results: Hospice mean direct patient care costs were $86 per patient day, the largest component being patient visits by hospice staff (e.g., nurse, physician, and counselor visits). After case-mix adjustment, hospices spending the most on direct patient care had patients with 5.2% fewer hospital admissions, 6.3% fewer emergency department visits, 1.6% fewer intensive care unit stays, and $1,700 less in nonhospice Medicare expenditures per patient compared with hospices spending the least on direct patient care (p < 0.01 for each comparison). Ninety percent of hospices with the lowest spending on direct patient care and highest rates of hospital use were for-profit hospices. Conclusions: Patients cared for by hospices with lower direct patient care costs had higher hospitalization rates and were overrepresented by for-profit hospices. Greater investment by hospices in direct patient care may help Centers for Medicare and Medicaid Services avoid high-cost hospital care for patients at the end of life.

Abstract

Objective: Sexual minority women (lesbian and bisexual) experience significant stigma, which may increase their cardiovascular disease (CVD) risk. The purpose of this study was to examine the prevalence of modifiable risk factors for CVD (including mental distress, health behaviors, blood pressure, glycosylated hemoglobin, and total cholesterol) and CVD in sexual minority women compared with their heterosexual peers. Materials and Methods: A secondary analysis of the National Health and Nutrition Examination Survey (2001-2012) was conducted. Multiple imputation with chained equations was performed. Logistic regression models adjusted for relevant covariates were run. Self-report (medical history and medication use) and biomarkers for hypertension, diabetes, and high total cholesterol were examined. Results: The final analytic sample consisted of 7,503 that included 346 sexual minority women (4.6%). Sexual minority women were more likely to be younger, single, have a lower income, and lack health insurance. After covariate adjustment, sexual minority women exhibited excess CVD risk related to higher rates of frequent mental distress (adjusted odds ratio [AOR], 2.05; 95% confidence interval [CI], 1.45–2.88), current tobacco use (AOR, 2.11; 95% CI, 1.53–2.91), and binge drinking (AOR, 1.66; 95% CI, 1.17–2.34). Sexual minority women were more likely to be obese (AOR, 1.61; 95% CI, 1.23–2.33) and have glycosylated hemoglobin consistent with prediabetes (AOR, 1.56; 95% CI, 1.04–2.34). No differences were observed for other outcomes. Conclusions: Sexual minority women demonstrated increased modifiable risk factors for CVD, but no difference in CVD diagnoses. Several emerging areas of research are highlighted, in particular, the need for CVD prevention efforts that target modifiable CVD risk in sexual minority women.

Abstract

Purpose: Despite higher rates of modifiable risk factors for cardiovascular disease (CVD) in gay and bisexual men, few studies have examined sexual orientation differences in CVD among men. The purpose of this study was to examine sexual orientation differences in modifiable risk factors for CVD and CVD diagnoses in men. Methods: A secondary analysis of the National Health and Nutrition Examination Survey (2001-2012) was conducted. Multiple imputation was performed for missing values. Differences across four distinct groups were analyzed: gay-identified men, bisexual-identified men, heterosexual-identified men who have sex with men (MSM), and heterosexual-identified men who denied same-sex behavior (categorized as exclusively heterosexual). Multiple logistic regression models were run with exclusively heterosexual men as the reference group. Results: The analytic sample consisted of 7731 men. No differences between heterosexual-identified MSM and exclusively heterosexual men were observed. Few differences in health behaviors were noted, except that, compared to exclusively heterosexual men, gay-identified men reported lower binge drinking (adjusted odds ratio [AOR] 0.58, 95% confidence interval [CI] = 0.37-0.85). Bisexual-identified men had higher rates of mental distress (AOR 2.39, 95% CI = 1.46-3.90), obesity (AOR 1.69, 95% CI = 1.02-2.72), elevated blood pressure (AOR 2.30, 95% CI = 1.43-3.70), and glycosylated hemoglobin (AOR 3.01, 95% CI = 1.38-6.59) relative to exclusively heterosexual men. Conclusions: Gay-identified and heterosexual-identified MSM demonstrated similar CVD risk to exclusively heterosexual men, whereas bisexual-identified men had elevations in several risk factors. Future directions for sexual minority health research in this area and the need for CVD and mental health screenings, particularly in bisexual-identified men, are highlighted.

Abstract

Purpose of review Despite increased survivorship and the subsequent need for chronic management of cancer, the association of self-management and palliative care is still emerging within cancer care. Routine and timely use of selfmanagement strategies in the palliative setting can help reduce self-management burden and maximize quality of life. In this review, we consider the complementary relationship of self-management and palliative care and how they support living with cancer as a chronic illness. Recent findings Recent studies provide evidence of support among patients, family caregivers and healthcare professionals for integration of self-management interventions into palliative cancer care. As a guiding framework, components of the revised Self and Family Management Framework correspond to the provision of palliative care across the care trajectory, including the phases of curative care, palliative care, end-of-life care and bereavement. Additional work among self-management partners facing cancer and other lifelimiting illnesses, that is patients, family caregivers and healthcare professionals, would be useful in developing interventions that incorporate self-management and palliative care to improve health outcomes. Summary There is an increasing acceptance of the complementarity of self-management and palliative care in cancer care. Their integration can support patients with cancer and their family caregivers across the care trajectory.

Abstract

Background Managing diversity dynamics in academic or clinical settings for men in nursing has unique challenges resulting from their minority status within the profession. Purpose The purpose of this study was to share challenges and lessons learned identified by male scholars in the Robert Wood Johnson Foundation Nurse Faculty Scholars program and suggest strategies for creating positive organizations promoting inclusive excellence. Methods Multiple strategies including informal mentored discussions and peer-to-peer dialogue throughout the program, formal online surveys of scholars and National Advisory Committee members, and review of scholar progress reports were analyzed as part of the comprehensive evaluation plan of the program. Discussion Diversity dynamic issues include concerns with negative stereotyping, microaggression, gender intelligence, and differences in communication and leadership styles. Conclusion Male nurse faculty scholars report experiencing both opportunities and challenges residing in a predominately female profession. This article attempts to raise awareness and suggest strategies to manage diversity dynamics in service of promoting the development of a culture of health that values diversity and inclusive excellence for both men and women in academic, research, and practice contexts.

Abstract

Implementing evidence based practices into practice settings is exceedingly difficult. Knowledge translation is a framework used for moving practices from the literature into the real world. This article discusses how six articles in this special issue of Gerontology and Geriatrics Education use various knowledge translation approaches to implement evidence based practices in older adults with behavioral health issues including dementia, delirium and serious mental illness across a variety of settings, as well as lessons learned for future knowledge translation and implementation science studies.

Abstract

Background: Mental health and HIV disparities are well documented among sexual minorities, but there is a dearth of research on other chronic conditions. Cardiovascular disease remains the leading cause of death worldwide. Although sexual minorities have high rates of several modifiable risk factors for cardiovascular disease (including stress, tobacco use, and alcohol consumption), there is a paucity of research in this area. Objectives: In this systematic review, we synthesized and critiqued the existing evidence on cardiovascular disease among sexual minority adults. Search Methods: We conducted a thorough literature search of 6 electronic databases for studies published between January 1985 and December 2015 that compared cardiovascular disease risk or prevalence between sexual minority and heterosexual adults. Selection Criteria: We included peer-reviewed English-language studies that compared cardiovascular disease risk or diagnoses between sexual minority and heterosexual individuals older than 18 years. We excluded reviews, case studies, and gray literature. A total of 31 studies met inclusion criteria. Data Collection and Analysis: At least 2 authors independently abstracted data from each study. We performed quality assessment of retrieved studies using the Crowe Critical Appraisal Tool. Main Results: Sexual minority women exhibited greater cardiovascular disease risk related to tobacco use, alcohol consumption, illicit drug use, poor mental health, and body mass index, whereas sexual minority men experienced excess risk related to tobacco use, illicit drug use, and poor mental health. We identified several limitations in the extant literature. The majority of included studies were crosssectional analyses that used self-reported measures of cardiovascular disease. Even though we observed elevated cardiovascular disease risk, we found few differences in cardiovascular disease diagnoses (including hypertension, diabetes, and high cholesterol). Overall, 23 of the 26 studies that examined cardiovascular disease diagnoses used subjective measures. Only 7 studies used a combination of biomarkers and self-report measures to establish cardiovascular disease risk and diagnoses. Authors' Conclusions: Social conditions appear to exert a negative effect on cardiovascular disease risk among sexual minorities. Although we found few differences in cardiovascular disease diagnoses, we identified an elevated risk for cardiovascular disease in both sexual minority men and women. There is a need for research that incorporates subjective and objective measures of cardiovascular disease risk. Public Health Implications: Cardiovascular disease is a major health concern for clinicians, public health practitioners, and policymakers. This systematic review supports the need for culturally appropriate interventions that address cardiovascular disease risk in sexual minority adults. ((The full article is available online.