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AIMS: To identify clusters of risk factors in home health care and determine if the clusters are associated with hospitalizations or emergency department visits. DESIGN: A retrospective cohort study. METHODS: This study included 61,454 patients pertaining to 79,079 episodes receiving home health care between 2015 and 2017 from one of the largest home health care organizations in the United States. Potential risk factors were extracted from structured data and unstructured clinical notes analysed by natural language processing. A K-means cluster analysis was conducted. Kaplan–Meier analysis was conducted to identify the association between clusters and hospitalizations or emergency department visits during home health care. RESULTS: A total of 11.6% of home health episodes resulted in hospitalizations or emergency department visits. Risk factors formed three clusters. Cluster 1 is characterized by a combination of risk factors related to “impaired physical comfort with pain,” defined as situations where patients may experience increased pain. Cluster 2 is characterized by “high comorbidity burden” defined as multiple comorbidities or other risks for hospitalization (e.g., prior falls). Cluster 3 is characterized by “impaired cognitive/psychological and skin integrity” including dementia or skin ulcer. Compared to Cluster 1, the risk of hospitalizations or emergency department visits increased by 1.95 times for Cluster 2 and by 2.12 times for Cluster 3 (all p < .001). CONCLUSION: Risk factors were clustered into three types describing distinct characteristics for hospitalizations or emergency department visits. Different combinations of risk factors affected the likelihood of these negative outcomes. IMPACT: Cluster-based risk prediction models could be integrated into early warning systems to identify patients at risk for hospitalizations or emergency department visits leading to more timely, patient-centred care, ultimately preventing these events. PATIENT OR PUBLIC CONTRIBUTION: There was no involvement of patients in developing the research question, determining the outcome measures, or implementing the study.

Aims Self-management is believed to be an important behavioral capacity in people with chronic illness, and self-efficacy is an important component contributing to self-management. Two new and related measures for urinary catheter self-efficacy (C-SE) and self-management (C-SMG) were developed based on existing tools and tested for psychometrics for use in a randomized clinical trial (RCT) teaching urinary catheter self-management. Methods The instruments were evaluated at baseline (intake face to face interview) with 202 persons and with 158 of the same individuals 6 months later by telephone interviews. Exploratory factor analysis was conducted in an iterative process related to items’ theoretical and statistical appropriateness. To assess construct validity and goodness of fit for model testing, confirmatory factor analysis was conducted with the samples at intake and 6 months. Also, bivariate analyses were conducted of the measures in relation to each other. Results Both scales were modified reducing the items to 13 in each, with four factors in C-SE and three factors in C-SMG. Reliability testing (Cronbach's alpha) was viewed as satisfactory for both scales, though some of the subscale (factors) reliabilities were lower in the self-management measure. Confirmatory factor analysis was adequate. Correlation of the two instruments (r = 0.25, P

To characterise a sample of 202 adult community-living long-term indwelling urinary catheter users, to describe self-care practices and catheter problems, and to explore relationships among demographics, catheter practices and problems.Long-term urinary catheter users have not been well studied, and persons using the device indefinitely for persistent urinary retention are likely to have different patterns of catheter practices and problems.The study was a cross-sectional descriptive and exploratory analysis.Home interviews were conducted with catheter users who provided information by self-reported recall over the previous two months. Data were analysed by descriptive statistics and tests of association between demographics, catheter practices and catheter problems.The sample was widely diverse in age (19-96 years), race and medical diagnosis. Urethral catheters were used slightly more often (56%) than suprapubic (44%), for a mean of six years (SD 7 years). Many persons were highly disabled, with 60% having difficulty in bathing, dressing, toileting and getting out of the bed; 19% also required assistance in eating. A high percentage of catheter problems were reported with: 43% experiencing leakage (bypassing of urine), 31% having had a urinary tract infection, 24% blockage of the catheter, 23% catheter-associated pain and 12% accidental dislodgment of the catheter. Treatments of catheter-related problems contributed to additional health care utilisation, including extra nurse or clinic visits, trips to the emergency department or hospitalisation. Symptoms of catheter-associated urinary tract infections were most often related to changes in the colour or character of urine or generalised symptoms.Catheter-related problems contribute to excess morbidity and health care utilisation and costs.More research is needed in how to minimise catheter-associated problems in long-term catheter users. Information from this study could help inform the development of interventions in this population.

Translating research into health care practice is a complex, challenging process aimed ultimately at yielding improvements in patient outcomes. Most of the literature in the field has focused on efforts to increase the use of clinical guidelines in hospitals and by physicians (Davis et al. 1995; Bero et al. 1998; Hunt et al. 1998; Grimshaw et al. 2001; 2004). Although such guidelines usually incorporate practices shown in clinical trials and/or judged by experts to produce clinically meaningful benefits for patients, relatively few “translation” studies have attempted to trace the impact of changes in practitioner behavior to actual improvements in patients' self-management of chronic conditions or to patient outcomes (Worrall, Chaulk, and Freake 1997). This study moves out of the hospital setting and beyond physician practice changes to describe the impact and relative cost-effectiveness of a basic and an augmented e-mail reminder intervention designed to help home health nurses improve the self-management skills and outcomes of their heart failure (HF) patients. The interventions, described in a companion article by Murtaugh et al. (2005), delivered evidence-based, condition-specific information to nurses each time they began to care for a new HF patient—“just-in-time” to incorporate the recommended assessment and instruction practices into each patient's individualized plan of care. The interventions, selected for their reported effectiveness in other settings (Oxman et al. 1995; Bero et al. 1998; Grimshaw et al. 2001), were grounded in the “dual task theory of human performance.” This theory suggests that busy, information-overloaded clinicians will be more likely to perform “secondary” management tasks in conjunction with hands-on care when they receive well organized, cogent information for the right patient at the right time (Litzelman et al. 1993). HF—a debilitating chronic condition characterized by symptoms such as severe shortness of breath, edema, and fatigue—is a high frequency, high cost disease that imposes a significant burden on older adults and their families. The leading cause of hospitalization among elders, HF accounted for nearly one million discharges in 1999 (Rich 2003). HF is also one of the major conditions for which older persons receive home health services. In 1999 it accounted for approximately 8.6 percent of Medicare home health discharges, 226,000 cases, and payments of $646 million (HCFA 2001). HF care has benefited over the past 20 years from the completion of several large-scale, randomized clinical trials and the development of authoritative evidence-based guidelines for clinical evaluation and treatment (Konstam, Dracup, and Baker 1994; Hunt et al. 2001; Rich 2003). Yet HF management among older adults has been suboptimal—marked by under use of effective therapies and lack of patient adherence to diet and medication regimens (Rich 2003). To improve HF care and reduce hospital readmission, experts have recommended early discharge planning (Naylor et al. 1999; Phillips et al. 2004) and disease management approaches that entail post hospital follow-up, close monitoring of patient symptoms, and education regarding diet, medication, and exercise (Rich et al. 1995; Naylor et al. 1999; 2004; Stewart, Marley, and Horowitz 1999; Quaglietti et al. 2000; McAlister et al. 2001; Harrison et al. 2002; Weingarten et al. 2002; Rich 2003; Phillips et al. 2004). In theory, if not in practice, the role of a home health nurse encompasses the close patient follow-up that is a key element of disease management programs. Over the course of an HF home care episode—51 days on average (Centers for Disease Control and Prevention 2004)—home health nurses are routinely responsible for ongoing patient assessment, individualized care planning in consultation with the patient's physician, patient instruction in self-care management, monitoring of patient symptoms and support of patient adherence to medications and diet. Thus rather than mounting a new care management program, this study focused on the use of just-in-time, condition-specific information to improve the evidence-based knowledge and practices of home care staff already serving in the community. The interventions capitalized on existing intranet communication channels, so no significant organizational systems changes needed to be made. As an inexpensive and convenient mechanism, e-mail reminders were hypothesized to be an effective new medium for home care agencies and other decentralized health care practices to upgrade and standardize service provision and improve patient self-management and outcomes. The results reported here describe the comparative impact and cost-effectiveness of two variations of the information-based interventions.

The difficulty of translating research findings into sustainable improvements in care practices and clinical outcomes is well documented (Grimshaw and Russell 1993; Woolf et al. 1999; AHRQ 2001; Grimshaw et al. 2001; Grol 2001; Gross et al. 2001). A growing number of studies show that passive approaches, such as unsolicited distribution of consensus recommendations or guidelines, and traditional didactic lectures and seminars, generally are ineffective in changing clinical practice (Davis et al. 1995; Oxman et al. 1995; Bero et al. 1998). Strategies having more influence on provider behavior are audit and feedback by peers or opinion leaders, reminder systems, and multi-faceted interventions (Davis and Taylor-Vaisey 1997; Grimshaw et al. 2001; Wagner et al. 2001). Physicians generally have been the focus of studies examining practice change strategies, with the interventions targeting specific behaviors such as preventive care, prescribing practices, and test ordering. The study reported here expands the literature on translating research into practice by testing the effectiveness of two computer-based interventions designed to promote evidence-based practice among home care nurses. We describe the effect of these interventions on the adoption of evidence-based care practices for the treatment of heart failure (HF) patients. Three relatively recent phenomena fuel interest in evidence-based practice among home care agencies. On the market front, rapid enrollment of Medicare beneficiaries in managed care organizations during the mid-to-late 1990s led to agency competition for managed care contracts and to the adoption of various disease management programs thought to be attractive to, and sometimes required by, managed care customers. On the regulatory front, the development and dissemination of the uniform home health assessment (i.e., the Outcome and Assessment Information Set, or OASIS) now mandated by the Centers for Medicare and Medicaid Services, has made outcomes-based reporting and regulation a reality for most home health agencies. Finally, on the payment front, the Balanced Budget Act of 1997 replaced cost-based reimbursement with a prospective payment system for Medicare home health that pays agencies a fixed dollar amount per episode of care and puts a premium on more efficient and effective use of clinical resources. HF patients frequently are admitted to home care following a hospital stay with the objective of improving patient and family management of the disease. Referrals to home care, whether from a hospital or community-based physician, will include a preliminary set of medical orders that form the basis of the plan of care to be implemented by the home care nurse. At the first visit the nurse will perform an initial assessment of the patient and the home environment, seek verbal orders for necessary changes in the plan of care (e.g., updating an incomplete list of medications) and send the revised plan of care to the physician for signature. During subsequent visits nurses are responsible for ongoing assessment of the patient's condition, monitoring medications (and infrequently for HF patients, medication administration), instructing the patient about HF management, and implementing all medical orders. Home care nurses usually are generalists who vary in educational background and experience. All nurses, however, receive HF management training at the agency orientation. The interventions tested were a basic intervention consisting of a single just-in-time e-mail reminder to nurses, and an augmented intervention in which the e-mail reminder was supplemented by additional provider prompts and patient education materials. Reminders trigger the action of the informed person without a preceding specific request, as compared with passive systems that require an individual to recognize when advice would be helpful and make an active effort to retrieve information. Litzelman and colleagues (1993) postulate that reminders work in the realm of prevention because they are consistent with the dual task theory of human performance. This theory suggests that performance of “secondary” preventive tasks in conjunction with hands-on medical care can be improved by organizing and presenting cogent information at critical times to reduce clinician overload and direct clinicians to tasks needing their attention. Chueh and Barnett (1997) describe the use of “just-in-time” reminders to identify patients who are candidates for a particular guideline and to send that guideline to the clinician at the right time and place. Employing a “system driven, ‘push’ approach,” software programs can be used to trigger just-in-time e-mails to push out information to the clinician. Electronic patient-specific clinical reminders were selected for study because of their efficacy in other settings and because they enabled us to address some of the unique challenges that the home care environment poses for quality improvement initiatives. Nurses in this setting usually care for a very diverse group of patients; the nurse workforce is largely decentralized; communication is impeded by the dispersion of patients and referring physicians; and few evidence-based practice recommendations have been adapted or developed for home health care (Brannon and Dansky 2001; Peterson 2004). We hypothesized that nurses receiving care recommendations at the time they are assigned a HF patient would be more likely than others to provide evidence-based care.

Background: Home care organizations are relatively isolated from academic health centers, university-based schools of nursing, and centers of health services research that have advanced the knowledge base for quality improvement. Thus limited information exists about how best to promote evidence-based practice in this setting. Aims: This article examines research and translation issues posed by the decentralized home care setting and considers how these issues compare to issues in other settings. Methods: A case study approach is used to frame a discussion of the contextual and practical factors that can influence the design and future acceptance of different translation strategies in the home care setting. Use of a recently concluded randomized trial that tested the effectiveness of two interventions designed to improve the adoption of evidence-based practices by home health nurses has been made to inform this discussion. Discussion: Effective translation interventions in home health care need to address the unique nature of this setting including the dispersed, generalist workforce that serves a diverse patient population and lacks strong peer contact or on-site support and supervision. Proactive push translation strategies such as reminders that have been effective in other settings show promise in this service area but had a differential effect across conditions. Significantly, the cost-effectiveness analysis of this intervention showed that net patient care costs actually increased for one condition. Implications: The study described in this article demonstrates that rigorous translation research can be conducted in highly decentralized practice settings. It also points to the value of assessing different levels of intensity of interventions in a single study, looking at process measures and patient outcomes, and conducting a cost-effectiveness analysis. To encourage broader adoption of translation strategies, additional incentives from purchasing or regulatory agencies may be needed.

BACKGROUND. Lymphedema of the upper extremity following breast carcinoma is highly distressing and disabling. METHODS. A review is presented of the literature on psychosocial aspects of lymphedema. RESULTS. Studies have shown that women who develop lymphedema exhibit higher levels of psychological, social, sexual, and functional morbidity than women with breast carcinoma who do not develop this complication. Women who have poor social support, pain, lymphedema in the dominant hand, and/or a passive and avoidant coping style report the highest levels of disability. CONCLUSIONS. Due to the mobidity of lymphedema once it develops, prevention and information given early are extremely important. However, the recommendations made to women sometimes involve considerable changes in lifestyle but are not based on solid, prospective evidence. In addition, how to best impart and time information about lymphedema pre- and postoperatively require investigation. In this paper, the authors discuss the psychological and functional impact of lymphedema and strategies for intervention and research to help women prevent the condition or enhance coping with it once it develops.

The feasibility, utility and reliability of the Zung Self-Rating Depression Scale (ZSDS) was examined in a large sample of ambulatory cancer patients. This tool and a brief 11-item version of the ZSDS (excluding nine items concerning somatic symptoms), which was developed during the course of the survey, were used to estimate the prevalence of self-reported depressive symptoms. Patient characteristics that may be associated with an increased risk of clinically significant depressive symptoms were also explored. Twenty-five ambulatory oncology clinics affiliated with Community Cancer Care, Inc. enrolled and surveyed 1109 subjects. The alpha coefficients for the ZSDS (0.84) and the Brief ZSDS (0.84) indicated high levels of internal consistency. The overall prevalence of clinically significant depressive symptoms as defined by the ZSDS was 35.9% and by the Brief ZSDS was 31.1%. The ZSDS and the Brief ZSDS were highly correlated (r = 0.92). The medical and demographic variables most associated with clinically significant depressive symptoms were more advanced stage of disease at time of diagnosis, lung cancer as primary tumor type, higher ECOG rating (greater degree of physical disability), and having been prescribed antidepressant medications. The high prevalence of depressive symptoms observed in this study is consistent with rates found in other studies of self-report depression instruments in cancer patients. The initial indicators of internal consistency and validity suggest that the Zung SDS or the brief version may be useful screening tools to identify depressive symptoms in oncology patients.