Publications

Abstract

The organizational context of medical practice changed substantially over the past half century, resulting in new opportunities and a more favorable environment for the evolution of allied and nonphysician health professionals. This article chronicles the organizational developments leading to the growth in nonphysician health professions and the changing medical division of labor. Recent trends in nursing, the rise of advanced practice nurses and physician assistants (PAs), and the status of physical and occupational therapists are examined.

Abstract

Fifty percent of variability in HIV-1 susceptibility is attributable to host genetics. Thus identifying genetic associations is essential to understanding pathogenesis of HIV-1 and important for targeting drug development. To date, however, CCR5 remains the only gene conclusively associated with HIV acquisition. To identify novel host genetic determinants of HIV-1 acquisition, we conducted a genome-wide association study among a high-risk sample of 3,136 injection drug users (IDUs) from the Urban Health Study (UHS). In addition to being IDUs, HIV- controls were frequency-matched to cases on environmental exposures to enhance detection of genetic effects. We tested independent replication in the Women's Interagency HIV Study (N=2,533). We also examined publicly available gene expression data to link SNPs associated with HIV acquisition to known mechanisms affecting HIV replication/infectivity. Analysis of the UHS nominated eight genetic regions for replication testing. SNP rs4878712 in FRMPD1 met multiple testing correction for independent replication (P=1.38×10-4), although the UHS-WIHS meta-analysis p-value did not reach genome-wide significance (P=4.47×10-7 vs. P<5.0×10-8) Gene expression analyses provided promising biological support for the protective G allele at rs4878712 lowering risk of HIV: (1) the G allele was associated with reduced expression of FBXO10 (r=-0.49, P=6.9×10-5); (2) FBXO10 is a component of the Skp1-Cul1-F-box protein E3 ubiquitin ligase complex that targets Bcl-2 protein for degradation; (3) lower FBXO10 expression was associated with higher BCL2 expression (r=-0.49, P=8×10-5); (4) higher basal levels of Bcl-2 are known to reduce HIV replication and infectivity in human and animal in vitro studies. These results suggest new potential biological pathways by which host genetics affect susceptibility to HIV upon exposure for follow-up in subsequent studies.

Abstract

Background: Nursing unit is the micro-organization in the hospital health care system in which integrated patient care is provided. Nursing units of different types serve patients with distinct care goals, clinical tasks, and social structures and norms. However, empirical evidence is sparse on unit type differences in quality of care and its relation with nurse work environment. Nurse work environment has been found as an important nursing factor predicting nurse and patient outcomes. Objectives: To examine the unit type differences in nurse-reported quality of care, and to identify the association between unit work environment and quality of care by unit types. Methods: This is a cross-sectional study using nurse survey data (2012) from US hospitals nationwide. The nurse survey collected data on quality of care, nurse work environment, and other work related information from staff nurses working in units of various types. Unit types were systematically classified across hospitals. The unit of analysis was the nursing unit, and the final sample included 7677 units of 14 unit types from 577 hospitals in 49 states in the US. Multilevel regressions were used to assess the relationship between nurse work environment and quality of care across and by unit types. Results: On average, units had 58% of the nurses reporting excellent quality of care and 40% of the nurses reporting improved quality of care over the past year. Unit quality of care varied by unit types, from 43% of the nurses in adult medical units to 73% of the nurses in interventional units rating overall quality of care on unit as excellent, and from 35% of the nurses in adult critical care units to 44% of the nurses in adult medical units and medical-surgical combined units reporting improved quality of care. Estimates from regressions indicated that better unit work environments were associated with higher quality of care when controlling various hospital and unit covariates; and this association persisted among units of different types. Conclusions: Unit type differences exist in the overall quality of care as well as achievement in improving quality of care. The low rates of nurses reporting improvement in the quality of nursing care to patients suggest that further interventions focusing at the unit-level are needed for achieving high care quality. Findings from our study also suggest that improving nurse work environments can be an effective strategy to improve quality of care.

Abstract

Registered and advanced practice nurses are employed in substance user treatment facilities across the US and in most industrialized countries. Patterns of employment and job descriptions for nurses, however, are highly inconsistent and seriously flawed. Many regulatory system, legislative and government agency factors and to some degree, the nursing profession itself, sustain the flaws and limit the delivery of comprehensive care. Competencies linked to addictions nursing best practices are often underutilized because of narrow job descriptions. This results in limited health and nursing service delivery to vulnerable populations receiving treatment in these government funded programs. This article highlights the increasing demand for the delivery of integrated care to psychiatric and substance using populations. The author considers factors which stake holders can influence to change flawed employment patterns and limited access to comprehensive care for substance users.

Abstract

Research evidence suggests that educating nurses about traditional Chinese medicine (TCM) significantly improves their nursing care practice and the health care outcomes of community residents. The purpose of this study was to describe the current use of TCM by China's nursing workforce, as well as the typical nurse to physician ratio and types of TCM education that nurses receive in health care facilities. A large retrospective survey was conducted in Hubei Province, China, in 2010. The sample included 620 non-TCM hospitals, 120 TCM hospitals, and 1254 community health centers (CHCs). Descriptive analysis and 1-way analysis of variance were used to test statistical differences. There were 79 447 nurses employed, of which 1527 had a TCM degree and 5689 had on-the-job TCM education. Non-TCM hospitals employed more nurses than TCM hospitals and CHCs, and TCM hospitals employed more TCM nurses than non-TCM hospitals and CHCs. The median nurse to physician ratio varied by level of urbanization and type of health care facility, from 0.6 in rural CHCs to 1.3 in rural non-TCM hospitals. Differences in TCM education preparation of nurses were significantly different in the urban and rural settings and by type of health care facility. The study suggested a shortage of nurses educated in TCM in Hubei Province China, as well as uneven TCM workforce distribution. More opportunities for TCM education are needed for nurses, especially in CHCs where health promotion and chronic disease management are the most important and mandated functions.

Abstract

Introduction: The purposes of the study were to determine (a) the knowledge base of mothers of newborns on oral health for newborns and young infants and (b) the effectiveness of an oral health education program provided to mothers of newborns prior to discharge from the postpartum unit. Methods: Ninety-four mothers of healthy newborns on a postpartum unit were randomized to the treatment or control group. A pretest was administered to each mother to assess the mother's knowledge of infant oral health. The treatment intervention was a DVD designed collaboratively by an interprofessional team of nurse practitioners and dental faculty to educate the mothers on oral health care for their newborns. The control intervention was a DVD on newborn nutrition. All participants received routine newborn nursery discharge instructions by the postpartum nurses and physicians. Follow-up appointments were scheduled 6 and 12months later for administration of the posttest to the mothers and for oral health assessments of the infants. Results: Pretest questionnaire results revealed that most mothers lacked knowledge about oral health care for infants and young children, especially concerning vertical transmission of streptococcus mutans through food-sharing practices. In addition, 28.4% of the mothers were not aware of the benefits of fluoride as a prevention strategy for dental caries. A significant no-show rate for the planned follow-up visits in the dental clinic hindered our plans to evaluate the effectiveness of the oral health educational program on prevention of dental white spots or decay when the study infants were 6 and 12months old, respectively. Discussion: The knowledge deficit of mothers of newborns regarding oral health care for infants may be one of the contributing factors to the high prevalence rate of dental caries in children younger than 71months. An oral health educational program provided to mothers on the postpartum unit prior to discharge from the hospital may help increase mothers' knowledge about oral health care and prevention of dental caries in infants and young children.

Abstract

This study reviewed the existing literature on oral health among older Chinese immigrants and discussed intervention strategies for improving the oral health of older Chinese immigrants in the context of social work practice. A systematic review was conducted of the existing empirical studies on oral health, dental care utilization, and traditional oral health beliefs among older Chinese immigrants. There were very limited studies published in the topic area. The findings showed that older Chinese immigrants had poorer oral health and less dental care use than the general population in their host country. Higher levels of English-language proficiency, stronger social support, and longer length of stay in the host country were positively related to increased dental care utilization. Cultural beliefs and knowledge were related to oral health status and dental care utilization. Overall, the findings support the need to consider the cultural characteristics and background of older Chinese immigrants when strengthening oral health promotion. It is critical to partner with Chinese community agencies to conduct community-based oral health promotion programs and advocate for policy changes.

Abstract

Background: Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing-a critical organizational component of hospital service system-in relation to readmissions. Objectives: To determine the relationships between hospital nursing factors-nurse work environment, nurse staffing, and nurse education-and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery. Method and Design: We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-Adjusted robust logistic regressions were used for analyses. Results: The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR = 1.03; 95% CI, 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR = 0.97; 95% CI, 0.95-0.99). Administrative support to nursing practice (OR = 0.96; 95% CI, 0.94-0.99) and nurse-physician relations (OR = 0.97; 95% CI, 0.95-0.99) were 2 main attributes of the work environment that were associated with readmissions. Conclusions: Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

Abstract

Objective: To describe adverse outcomes and fetal abnormalities in women with a positive prenatal screening result for more than one disorder. Study design: Study participants were drawn from a population of 452901 women pregnant with singletons entering the California Prenatal Screening Program in their first-trimester. Risk assessment was provided for trisomy 21 and trisomy 18 in the first-trimester and trisomy 21, trisomy 18, neural tube defects, and Smith-Lemli-Opitz syndrome in the second-trimester. Inclusion in this study required positive screening for more than one of the screened conditions and a completed outcome of pregnancy survey. Results: A total of 874 women met our study inclusion criteria. Over 25% of these pregnancies had a fetus with a chromosomal abnormality. Of the euploid pregnancies, 6.9% had a fetus with a major birth defect. Of the pregnancies with a fetus with neither a chromosomal abnormality nor a major birth defect, 9.3% ended in fetal demise. Overall, more than 50% of women with multiple positive screening results had either a fetus with a birth defect or a poor pregnancy outcome. Conclusion: Although it is rare to screen positive for more than one condition, such results indicate a very high risk for chromosomal abnormality, fetal demise, or structural abnormality.

Abstract

Context: In rural areas of Canada, people with acute coronary syndromes (ACS) can wait up to 32 hours for transfer for diagnostic cardiac catheterization (CATH). While awaiting CATH, it is critical that pain and anxiety management be optimal to preserve myocardial muscle and minimize the risk of further deterioration. Objectives: The aim of this study was to examine the relationship between clinical management, cardiac pain intensity, and state anxiety for rural ACS patients awaiting diagnostic CATH. Methods: In a prospective, descriptive-correlational repeated-measures design involving 121 ACS rural patients, we examined the associations of analgesic and nitroglycerin administration with cardiac pain intensity (numeric rating scale) and state anxiety (Spielberger State Anxiety Inventory) and also nurses' pain knowledge and attitudes (Toronto Pain Management InventoryYACS Version and Knowledge and Attitudes Survey Regarding Pain) using linear mixed models. Results: The mean age of patients was 67.6 T 13, 50% were men, and 60% had unstable angina and the remainder had non-ST-elevated myocardial infarction. During follow-up, cardiac pain intensity scores remained in the mild range from 1.1 T 2.2 to 2.4 T 2.7. State anxiety ranged from 44.0 T 7.2 to 46.2 T 6.6. Cumulative analgesic dose was associated with a reduction in cardiac pain by 1.0 points (numeric rating scale, 0Y10) (t108 = j2.5; SE, j0.25; confidence interval, j0.45 to j0.06; P = .013). Analgesic administration was not associated with state anxiety. Over the course of follow-up, ACS patients reported consistently high anxiety scores. Conclusions: Whereas cardiac pain declines in most patients in the early hours after admission, many patients experience a persistent anxious state up to 8 hours later, which suggest that development and testing of protocols for anxiety reduction may be needed. More urgently, the development and examination of a treatment intervention, early on in the ACS trajectory, are warranted that targets pain and anxiety for those for whom immediate angioplasty is not possible and who continue to experience cardiac pain and persistent high levels of anxiety. Moreover, a larger prognostic study is required to determine whether high levels of anxiety in rural ACS patients are predictive of major adverse cardiac events.

Abstract

BACKGROUND: Panel Management can expand prevention and chronic illness management beyond the office visit, but there is limited evidence for its effectiveness or guidance on how best to incorporate it into practice. OBJECTIVE: We aimed to test the effectiveness of incorporating panel management into clinical practice by incorporating Panel Management Assistants (PMAs) into primary care teams with and without panel management education. DESIGN: We conducted an 8-month cluster-randomized controlled trial of panel management for improving hypertension and smoking cessation outcomes among veterans. PATRICIPANTS: Twenty primary care teams from the Veterans Affairs New York Harbor were randomized to control, panel management support, or panel management support plus education groups. Teams included 69 clinical staff serving 8,153 hypertensive and/or smoking veterans. INTERVENTIONS: Teams assigned to the intervention groups worked with non-clinical Panel Management Assistants (PMAs) who monitored care gaps and conducted proactive patient outreach, including referrals, mail reminders and motivational interviewing by telephone. MAIN MEASURES: Measurements included mean systolic and diastolic blood pressure, proportion of patients with controlled blood pressure, self-reported quit attempts, nicotine replacement therapy (NRT) prescriptions, and referrals to disease management services. KEY RESULTS: Change in mean blood pressure, blood pressure control, and smoking quit rates were similar across study groups. Patients on intervention teams were more likely to receive NRT (OR = 1.4; 95 % CI 1.2–1.6) and enroll in the disease management services MOVE! (OR = 1.2; 95 % CI 1.1–1.6) and Telehealth (OR = 1.7, 95 % CI 1.4–2.1) than patients on control teams. CONCLUSIONS: Panel Management support for primary care teams improved process, but not outcome variables among veterans with hypertension and smoking. Incorporating PMAs into teams was feasible and highly valued by the clinical staff, but clinical impact may require a longer intervention.

Abstract

We formulated a conceptual framework that begins to answer the national call to improve health care access, delivery, and quality by explaining the processes through which community health workers (CHWs) facilitate patients' adoption of healthy behaviors. In September 2011 to January 2012, we conducted a qualitative study that triangulated multiple data sources: 26 in-depth interviews, training documents, and patient charts. CHWs served as partners in health to immigrant Filipinos with hypertension, leveraging their cultural congruence with intervention participants, employing interpersonal communication techniques to build trust and rapport, providing social support, and assisting with health behavior change. To drive the field forward, this work can be expanded with framework testing that may influence future CHW training and interventions.

Abstract

The purpose of this study was to calculate the event rate for inpatients in the radiology department (RD) developing instability leading to calls for medical emergency team (MET) assistance (MET-RD) compared with general ward (MET-W) patients. A retrospective comparison was done of MET-RD and MET-W calls in 2009 in a US tertiary hospital with a well-established MET system. MET-RD and MET-W event rates represented as MET calls/hr/1,000 admissions, adjusted for length of stay (LOS); rates also calculated for RD modalities. There were 31,320 hospital ward admissions that had 1,230 MET-Ws, and among 149,569 radiology admissions there were 56 MET-RDs. When adjusted for LOS, the MET-RD event rate was two times higher than the MET-W rate (0.48 vs. 0.24 events/hr/1,000 admissions). Event rates differed by procedure: computed tomography (CT) had 38% of MET-RDs (event rate, 0.89), and magnetic resonance imaging (MRI) accounted for 27% of MET-RDs (event rate, 1.56). Nuclear medicine had 1% of RD admissions, but these patients accounted for 5% of MET-RD (event rate, 1.53). Interventional radiology (IR) had 6% of RD admissions but 16% of MET-RD admissions (event rate, 0.61). Although general X-ray comprised 63% of RD admissions, only 11% of MET-RD involved their care (event rate, 0.09). In conclusion, the overall MET-RD event rate was twice the MET-W event rate; CT, MRI, and IR rates were 3.7 to 6.5 times higher than on wards. RD patients are at increased risk for an MET call compared with ward patients when the time at risk is considered. Increased surveillance of RD patients is warranted.

Abstract

BACKGROUND The purpose of this study was to examine and compare the effects of the first 18 months of anastrozole therapy on cognitive function in women with breast cancer. METHODS This large, longitudinal cohort study was composed of postmenopausal women with early-stage breast cancer who received chemotherapy plus anastrozole (n=114) or anastrozole alone (n=173) and a control group (n=110). Cognitive function was assessed before systemic therapy and 6, 12, and 18 months after therapy initiation and at comparable time points in controls. RESULTS The chemotherapy-anastrozole and anastrozole-alone groups had poorer executive function than the controls at nearly all time points (P<.0001 to P=.09). A pattern of deterioration in working memory and concentration was observed during the first 6 months of anastrozole therapy for the chemotherapy-anastrozole group (P<.0001 and P<.0009, respectively) and the anastrozole-alone group (P=.0008 and P=.0002, respectively). This was followed by improved working memory and concentration from 6 to 12 months in both groups. The anastrozole-alone group had a second decline in working memory and concentration from 12 to 18 months after the initiation of therapy (P<.0001 and P=.02, respectively). CONCLUSIONS Women with breast cancer had poorer executive functioning from the period before therapy through the entire first 18 months of therapy. A pattern of decline in working memory and concentration with initial exposure to anastrozole was observed. Women receiving anastrozole alone had a second deterioration in working memory and concentration from 12 to 18 months after therapy initiation. The longer term effects (>18 months) of anastrozole on cognitive function remain to be determined. Cancer 2015;121:2627-2636.

Abstract

Obesity is one of the risk factors for developing lymphedema following breast cancer treatment. We prospectively enrolled 140 women and followed the participants for 12 months after surgery to investigate patterns of obesity and lymph fluid level in the first year of cancer treatment. Electrical bioimpedance devices were used to measure weight, BMI, and percent of body fat as well as lymph fluid level. General instructions were given to the participants on maintaining pre-surgery weight. Among the 140 participants, 136 completed the study with 2.9% attrition. More than 60% of the participants were obese (30.8%) or overweight (32.4%), while only two participants were underweight and about 35% had normal weight. This pattern of obesity and overweight was consistent at 4–8 weeks and 12 months post-surgery. At 12 months post-surgery, the majority of the women (72.1%) maintained pre-surgery weight and 15.4% had >5% weight loss; 12.5% of the women increase >5% of their weight. Significantly more patients in the obesity group had lymphedema defined by L-Dex ratio >7.1 than those in the normal/underweight and overweight group at pre-surgery and 4–8 weeks post-surgery. There was a trend of more patients in the obesity group had L-Dex ratio >7.1 at 12 months post-surgery. Obesity and overweight remain among women at the time of cancer diagnosis and the patterns of obesity and overweight continue during the first year of treatment. General instructions on having nutrition-balanced and portion-appropriate diet and physical activities daily or weekly can be effective to maintain pre-surgery weight.

Abstract

Healthcare-associated infections, while preventable, result in increased morbidity and mortality in nursing home (NH) residents. Frontline personnel, such as certified nursing assistants (CNAs), are crucial to successful implementation of infection prevention and control (IPC) practices. The purpose of this study was to explore barriers to implementing and maintaining IPC practices for NH CNAs as well as to describe strategies used to overcome these barriers. We conducted a multi-site qualitative study of NH personnel important to infection control. Audio-recorded interviews were transcribed verbatim and transcripts were analyzed using conventional content analysis. Five key themes emerged as perceived barriers to effective IPC for CNAs: 1) language/culture; 2) knowledge/training; 3) per-diem/part-time staff; 4) workload; and 5) accountability. Strategies used to overcome these barriers included: translating in-services, hands on training, on-the-spot training for per-diem/part-time staff, increased staffing ratios, and inclusion/empowerment of CNAs. Understanding IPC barriers and strategies to overcome these barriers may better enable NHs to achieve infection reduction goals.

Abstract

Introduction: Perineal lacerations during childbirth affect more than 65% of women in the United States. Little attention has been given to the long-term biologic consequences associated with perineal lacerations or possible associations with postpartum mental health. In this article, we describe the results of a study that explored inflammatory cytokines in women who reported perineal lacerations during childbirth and the relationship with stress and depressive symptoms during the first 6 months postpartum. Methods: A repeated measures design was used to explore the relationship between varying degrees of perineal lacerations, inflammatory cytokines, postpartum stress, and depressive symptoms in 153 women over 6 months. Depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), and maternal stress was measured using the Perceived Stress Scale. Plasma was analyzed for proinflammatory (tumor necrosis factor alpha, interleukin 6 (IL-6), interleukin-1 beta, interferon gamma) and anti-inflammatory (interleukin 10) cytokines. Levels of cytokines were compared between women with or without varying degrees of injury. Results: A relationship was identified between symptoms of depression and a second-degree or more severe perineal laceration starting at one month postpartum (P = .04) and continuing through 3 months postpartum (P = .03). Similarly, stress symptoms were higher at 3 months postpartum (P = .02). Markers of inflammation were significantly higher among this group, with IL-6 increased at 2 weeks postpartum (P = .02) and remaining elevated through 2 months postpartum (P = .003); there were also significant differences in pro- to anti-inflammatory cytokine ratios out to 6 months postpartum. Regression analysis indicated that second-degree or more severe lacerations accounted for 5.9% of the variance in EPDS score at one month postpartum (P = .024, F = 2.865, t = 2.127), increasing substantially when the one month stress score was included as well. Discussion: This study suggests that perineal lacerations, inflammation, stress, and depressed mood are associated; however, more research is needed to elucidate the actual relationship between inflammation and mental health in women who experience such injuries.

Abstract

To evaluate the efficacy of Parent Education Through Simulation–Diabetes (PETS-D; clinical trial registration NCT01517269) for parents of children <13 years old newly diagnosed with type 1 diabetes with 3 parent education vignette sessions using human patient simulation (HPS) as compared with formal parent-nurse education sessions (vignette only) regarding diabetes knowledge, problem-solving skills, hypoglycemia fear, anxiety, and self-efficacy. Subjects were randomized to the HPS parent diabetes education or the vignette-only arm. Using linear mixed modeling, we compared HPS and vignette-only groups at 2, 6, and 14 weeks. Effect modification of treatment by dichotomized child's age (<6 and ≥6 years old) and parent education (≤high school and >high school) was also tested. All analyses were intent to treat and adjusted for baseline outcome level and clustering within site. We recruited 191 parents (116 children). Mean baseline A1C was 12%. Overall treatment-related differences were modest. There was a statistically significant effect modification of HPS by child's age, with a larger HPS benefit among parents of younger children for several outcomes: A1C (8.16% vs 9.48% in control; P =.006), lower state anxiety (P =.0094), and higher fear of hypoglycemia (P =.03) for parents of children <6 years old in the HPS group. Modest treatment-related differences may reflect ceiling/floor effects in many of the outcomes; we also compared HPS with another intervention rather than to usual education. Parents of younger children receiving the intervention may feel more comfortable with lower A1C levels because of management awareness gleaned from the HPS experience. Future research will include a retrospective case-control study of very young children.

Abstract

Context Little is known about energy levels in oncology patients and their family caregivers. Objectives This study sought to identify latent classes of participants, based on self-reported energy levels and evaluate for differences in phenotypic and genotypic characteristics between these classes. Methods Energy subscale scores from the Lee Fatigue Scale were used to determine latent class membership. Morning and evening energy scores were obtained just before, during, and for four months after the completion of radiation therapy. Genetic associations were evaluated for 15 proinflammatory and anti-inflammatory cytokine genes. Results Two latent classes with distinct morning energy trajectories were identified. Participants who were younger, female, not married/partnered, black, and had more comorbidities, and a lower functional status were more likely to be in the low morning energy class. Two polymorphisms (IL2 rs1479923 and NFKB1 rs4648110) were associated with morning energy latent class membership. Two latent classes with distinct evening energy trajectories were identified. Participants who were younger and male and who had more comorbidities, decreased body weight, and a lower functional status were more likely to be in the moderate evening energy class. Five different polymorphisms (IL1R2 rs4141134, IL6 rs4719714, IL17A rs8193036, NFKB2 rs1056890, and TNFA rs1800683) were associated with evening energy latent class membership. Conclusion This study provides preliminary evidence that decrements in morning and evening energy are associated with different phenotypic risk factors and cytokine gene variations.

Abstract

Objectives: To evaluate physician-perceived strengths and limitations of the Thrombolysis in Myocardial Infarction (TIMI) risk scores for use in older adults with acute myocardial infarction (AMI). Background: The TIMI risk scores are risk stratification models developed to estimate mortality risk for patients hospitalized for AMI. However, these models were developed and validated in cohorts underrepresenting older adults (≥75 years). Methods: Qualitative study using semi-structured telephone interviews and the constant comparative method for analysis. Results: Twenty-two physicians completed interviews ranging 10-30 min (mean = 18 min). Median sample age was 37 years, with a median of 11.5 years of clinical experience. TIMI strengths included familiarity, ease of use, and validation. Limitations included a lack of risk factors relevant to older adults and model scope and influence. Conclusions: Physicians report that the TIMI models, while widely used in clinical practice, have limitations when applied to older adults. New risk models are needed to guide AMI treatment in this population.

Abstract

The number of older adults emigrating to the United States is expected to quadruple by 2050. The health of immigrant older adults is complicated by the limited options for low-cost health insurance available to this population. Welfare reform has limited new immigrants' access to public assistance programs, such as Medicaid; and low-cost private insurance options rarely exist for individuals older than 65, even with the passage of the Patient Protection and Aff ordable Care Act (PPACA). Uninsured immigrant older adults have been found to forgo preventive care due to cost and are among the leading users of emergency departments for preventable complications of chronic disease, primarily cardiovascular disease (CVD). A review of the literature found that insurance coverage has a signifi cant impact on CVD risk among immigrant older adults. The current article discusses the implications of welfare reform initiatives and the shortcomings of the PPACA in addressing the health care needs of immigrant older adults.