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State regulatory policies appear to constrain growth in nursing home beds

The total number of nursing home beds in the United States increased 24 percent from 1.39 million to 1.72 million between 1981 and 1993. However, this growth varied dramatically from State to State, ranging in 1993 from 23 beds per 1,000 elderly persons in Nevada to 85 beds per 1,000 elderly persons in Nebraska. States with Certificate of Need (CON) or moratorium (MOR) policies had less growth in nursing home beds than States without these policies, according to a study supported in part by the Agency for Health Care Policy and Research (HS07574).

The CON program, established nationally in 1974 to control the number of nursing home beds and expenditures, requires State CON approval for new construction or expansion of health care facilities, including nursing homes. Some States removed their CON requirements after the Federal legislation was repealed, but 40 States retained them for nursing homes. Some States also placed a moratorium on new nursing home beds. By 1991, a total of 44 States had a CON and/or a moratorium policy in an effort to lower State Medicaid nursing home expenditures.

This study used data from five telephone surveys of State officials about CON and MOR policies, State Medicaid nursing home reimbursement rates, and licensed nursing home beds in each State for 1979 through 1993. The researchers, led by Charlene Harrington, Ph.D., of the University of California, San Francisco, found that States with CON or MOR policies had a significant reduction in nursing home bed growth. Medicaid nursing home reimbursement rates were not related to changes in the number of beds. CON/MOR policies may be designed primarily to control costs to Medicaid and/or to assist in planning efforts to redistribute beds. Some States, such as Oregon, have made conscious decisions to direct new investments in long-term care to areas that provide alternatives to nursing homes, such as residential care, assisted living, and home care.

Details are in "The effect of certificate of need and moratoria policy on change in nursing home beds in the United States," by Dr. Harrington, James H. Swan, Ph.D., John A. Nyman, Ph.D., and Helen Carrillo, M.S., in Medical Care 35(6), pp. 574-588, 1997.

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Elderly/Long-term Care

Treating pneumonia in the nursing home rather than the hospital may be a better choice for some residents

Pneumonia is a leading cause of sickness, hospitalization, and death of nursing home residents. For many, the drawbacks of hospitalization for pneumonia may outweigh potential benefits. They face new caregivers in unfamiliar surroundings, and they may be immobile and suffer from urinary catheterization, pressure ulcers, and delirium. If pneumonia treatment in the nursing home is efficacious, caregiver continuity, patient comfort, and lower costs provide compelling reasons to treat it there, asserts David R. Mehr, M.D., M.S., of the University of Missouri-Columbia, in a recent editorial (supported in part by the Agency for Health Care Policy and Research, HS08551).

Dr. Mehr cites several recent studies, one of which found that most residents were cared for in the nursing home with oral or intramuscular antibiotics, with 6-week mortality rates of 19 percent for those cared for in the nursing home and 40 percent for those cared for in the hospital. Unfortunately, the study did not distinguish those treated initially in the hospital for pneumonia from those hospitalized only after failing initial care in the nursing home. This distinction and an objective assessment of risk for poor outcome are critical to understanding the effectiveness of nursing home treatment. Developing a predictive index that will identify low-risk residents likely to be appropriate for nursing home care is a major goal of Dr. Mehr's project.

Clinicians also must consider appropriate goals for the resident, according to Dr. Mehr. While some nursing home residents are candidates for aggressive therapy, palliative care might be most appropriate for others. Often, residents and their families do not desire aggressive care at the end of life, particularly if severe dementia has developed. Residents who are candidates for aggressive treatment and seem severely ill should probably be hospitalized. Many nursing home residents, however, may be appropriately treated in the facility. Whether treatment of pneumonia in the nursing home represents a step forward in care quality at a reduced cost will depend on how such care is delivered in individual facilities, concludes Dr. Mehr.

Details are in "Nursing-home-acquired pneumonia: How and where to treat?" by Dr. Mehr, in the March/April 1997 Journal of the American Board of Family Practice 10(2), pp. 168-170.

Researchers examine factors influencing choices for end-of-life care

Patients are often hospitalized without their family or doctor having any understanding of their preferences for cardiopulmonary resuscitation (CPR), tube feeding, and other life-sustaining treatments. In many cases, the patients themselves aren't fully aware of what is involved or the chance of survival with each treatment. For instance, very few nursing home residents survive CPR, but many patients with advanced dementia or debilitating stroke survive for long periods of time with tube feeding.

The following two studies, which were supported by the Agency for Health Care Policy and Research, explore these end-of-life issues. The first study (AHCPR grant HS06815) shows that demographic and social factors are associated with nursing home residents' preferences for tube feeding. The second study (AHCPR grant HS07632) suggests that physicians subtly influence patients' views of life-sustaining treatments.

O'Brien, L.A., Siegert, E.A., Grisso, J.A., and others (1997, June). "Tube feeding preferences among nursing home residents," Journal of General Internal Medicine 12, pp. 364-371.

This study found that one-third of nursing home residents would prefer to have tube feedings even in the presence of irreversible brain damage. Persons most likely to prefer tube feeding in this situation were males, blacks, those who had never discussed treatment preferences with family members or health care providers, those who had never signed an advance directive, and persons who believed that tube feeding preferences would be respected by the nursing home staff. When informed that wrist restraints could be used if the patients became confused and tried to pull out the tube, one-fourth of those who initially wanted tube feeding or were unsure changed their minds and decided against it. These findings were based on a survey of a random sample of 379 residents from 49 nursing homes.

There are several potential reasons why decisions about use of tube feedings are particularly difficult for patients and caregivers, explains Jean Ann Grisso, M.D., M.Sc., of the University of Pennsylvania School of Medicine, the study's principal investigator. Patients may fear that withholding food and water leads to a painful death. Many may find it difficult to conceptualize provision of food and hydration as a medical treatment rather than a basic life necessity.

For them, forgoing food and water may be equated with neglect and abandonment. Finally, those who have not signed advance directives specifying their preference for tube feeding may believe that advance directives are primarily mechanisms for refusing but not requesting medical intervention.

Gramelspacher, G.P., Zhou, X-H, Hanna, M.P., and Tierney, W.M. (1997, June). "Preferences of physicians and their patients for end-of-life care." Journal of General Internal Medicine 12, pp. 346-351.

Terminally ill patients are more apt to want life-sustaining treatments than their physicians, particularly if they are male, black, and older. But the specific preferences of primary care physicians correlate well with their patients. This indicates there may be a subtle influence on patients by the physicians' attitudes about the treatments' benefits, notes William M. Tierney, M.D., of the Regenstrief Institute for Health Care, Indianapolis. Dr. Tierney and his colleagues surveyed 78 residents and faculty physicians at an inner-city, academic primary care practice and their patients, who were either very old (75 years or older) or between 50 and 74 years with conditions such as congestive heart failure, cancer, stroke, or chronic renal or liver disease. They asked both patients and physicians about their preferences for six life-sustaining treatments if they were terminally ill and the doctor believed there was little hope of recovery: hospitalization, intensive care, cardiac resuscitation, surgery, mechanical ventilation, and medically provided nutrition and hydration.

The researchers found significant differences between physicians' and patients' preferences for all six treatments, with physicians wanting less treatment than their patients for five of them, the exception being artificial nutrition and hydration. Patients desiring more care were more likely to be male, black, and older, but religiosity was not a factor. There was no association between physicians' age, sex, and professional status (resident or faculty) and their treatment preference scores. However, physicians' scores were highly correlated with their primary care patients—that is, if the physician did not opt for a certain treatment, his or her patient also would not choose that treatment most of the time.

Fewer than 5 percent of patients had ever discussed advance care issues with their current physician, so more subtle interaction between doctor and patient is most likely responsible for this correlation. For example, during a clinical visit, physicians may be assuming more aggressive or passive postures toward diagnosis and treatment. Some physicians may be generally optimistic about treatments and their outcomes, while others may be more skeptical or pessimistic. Their attitudes may affect the hope or skepticism with which their patients view therapeutic options.

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Research on Heart Disease

Echocardiography rarely changes diagnosis or management of patients with suspected mitral valve prolapse

Echocardiography, essentially a sonogram of the heart, rarely provides a change in diagnosis or management of patients with suspected mitral valve prolapse (MVP). Thus, the gain from this diagnostic test in patients with suspected MVP may not be worth the expense, concludes a study supported by the Agency for Health Care Policy and Research (HS00028).

MVP, which affects 4 percent of the population, is associated with a small but significant increased risk of potentially life-threatening endocarditis (inflammation of the membrane lining the heart cavities). Physicians now tend to use echocardiograms (ECHOs) rather than just a stethoscope to identify patients with suspected MVP who may be at high risk for endocarditis. These patients have at least mild mitral regurgitation or abnormal thickening of at least one part of the valve and are generally prescribed lifelong antibiotics to prevent development of endocarditis.

In this study, Paul A. Heidenreich, M.D., of Stanford University, and his colleagues performed ECHOs on 147 patients who were referred to a university hospital echocardiography laboratory to rule out MVP. Based on ECHO results, 14 percent of patients either should have begun (6 patients) or discontinued (14 patients) antibiotic prophylaxis. However, only 4 of the 20 patients actually changed their use of antibiotics. Thus, only 4 management changes were made per 131 ECHOs (3 percent), resulting in $36,250 in hospital and physician costs per management change.

ECHOs rarely led to changes in antibiotic use in patients with suspected MVP, in part because MVP was rarely present in the referred patients, probably due to physician overdiagnosis. Physicians may believe the benefit to the patient of confirming even a slight suspicion of MVP with ECHO outweighs the cost or may order an ECHO for marginal indications or to disprove prior diagnosis of MVP. The physicians may feel that the chance to eliminate lifelong use of antibiotics and the anxiety associated with an MVP diagnosis is well worth the price of an ECHO.

See "The clinical impact of echocardiography on antibiotic prophylaxis use in patients with suspected mitral valve prolapse," by Dr. Heidenreich, Jeffrey Bear, B.S., Warren Browner, M.D., and Elyse Foster, M.D., in the April 1997 American Journal of Medicine 102, pp. 337-343.

Early exercise ECG to evaluate chest pain in ER patients improves heart attack diagnosis over standard evaluation

Each year, about 1.5 million out of the 5 million patients who arrive at the emergency department (ED) with chest pain are admitted to the hospital for heart attack or unstable angina. It costs about $3 billion for initial workup of chest pain patients who are at first suspected of having acute myocardial infarction (AMI or heart attack) but end up with a diagnosis other than AMI. Extending the standard ED workup by adding serial creatine kinase MB isoenzyme (CK-MB) measurements, serial electrocardiograms (ECGs), and exercise electrocardiography (ExECG) may save money and prevent admission of many individuals who don't need to be hospitalized.

In a study supported by the Agency for Health Care Policy and Research (HS07103), ExECG identified one-third of patients who had tested negative on the diagnostic workup as being at higher risk for acute cardiac ischemia (restricted blood flow to the heart). The ExECG, which records variations in the electrical activity of the heart muscle while the person exercises on a treadmill, was able to confirm that the remaining two-thirds of patients who tested negative for acute ischemia on the extended ED workup were in fact negative and could be sent home.

Each of the diagnostic tests used to evaluate ED patients with chest pain added to the protocols sensitivity: serial CK-MB measurements, ECGs, and clinical assessments followed by early ExECG for those who tested negative on the initial series of tests.

The research was conducted at Cook County Hospital and the University of Illinois School of Public Health under the direction of Robert J. Zalenski, M.D., M.A., who is now with the Wayne State University School of Medicine in the Departments of Emergency Medicine and Cardiology. The research team used the extended protocol to assess acute cardiac ischemia (including AMI or unstable angina) for patients who had a low probability of these conditions but were in need of diagnostic evaluation beyond the standard ED workup.

The 224 patients whose results were negative (71 percent) by the first three tests of the protocol underwent ExECG; 66 percent reached target heart rate and had no ECG irregularities or clinical problems on the treadmill. In addition, 98 percent of these patients were found to be disease-free after an inpatient workup, suggesting that the new protocol did indeed identify patients who could be sent home. The remaining 34 percent had either abnormal ExECGs (ST-segment depression) or inconclusive tests because of failure to reach at least 85 percent of predicted heart rate during the test.

For more details, see "An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department," by Dr. Zalenski, Madeline McCarren, Ph.D., Rebecca Roberts, M.D., and others in the May 26, 1997, Archives of Internal Medicine 157, pp. 1085-1091.

Abnormal blood TnT levels indicate patients at risk for heart complications following major noncardiac surgery

Cardiac troponin T (TnT) is a muscle protein that inhibits contraction of the heart muscle. Patients with abnormally high blood levels of cardiac TnT after major noncardiac surgery have over five times the risk of cardiac problems during the subsequent 6 months, concludes a study supported in part by the Agency for Health Care Policy and Research (HS06573). It found that of the few patients (2.5 percent) who had congestive heart failure or new cardiac arrhythmias within 6 months of hospitalization, 42 percent had elevated peak TnT levels compared with only 11 percent of patients without complications after hospital discharge.

In contrast, measures of creatine kinase-MB (CK-MB, an enzyme found in the heart muscle that plays a role in exercise initiation) were not significantly correlated with subsequent complications. Elevated TnT levels in these patients may reflect degrees of myocardial ischemia (reduced blood flow to the heart) that were not sufficient to cause CK-MB abnormalities or to lead to chest pain and electrocardiogram abnormalities which would be detected through routine clinical care. Postoperative cardiovascular events such as heart failure and arrhythmias often have an ischemic pathophysiology, and cardiac TnT may enhance identification of high-risk patients, concludes Lee Goldman, M.D., M.P.H., F.A.C.C., of the University of California, San Francisco, School of Medicine.

Dr. Goldman and his colleagues studied 772 patients who underwent major noncardiac procedures and did not have major cardiovascular complications while hospitalized. They measured total serum CK and cardiac TnT while patients were in the recovery room and over the next 2 days and conducted interviews with 722 of the patients 6 months later. After adjusting for preoperative clinical and CK-MB data, they found that TnT values greater than 0.1 ng/ml increased the odds nearly 5-fold for postdischarge cardiac events, defined as cardiac death, nonfatal heart attack, or hospital admission for unstable angina. CK-MB was not correlated with postdischarge cardiac problems. Other correlates of complications within 6 months of surgery included male sex, a history of diabetes or ischemic chest pain, congestive heart failure, prior coronary arteriography or revascularization, postoperative congestive heart failure, or sustained new arrhythmias.

Details are in "Prognostic value of cardiac troponin T after noncardiac surgery: 6-month follow-up data," by Francisco Lopez-Jimenez, M.D., Dr. Goldman, David B. Sacks, M.D., and others, in the May 1997 Journal of the American College of Cardiology 29, pp. 1241-1245.

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Clinical Decisionmaking

Erythromycin compares favorably with other, more costly antibiotics for outpatient treatment of pneumonia

Direct outpatient treatment costs for community-acquired pneumonia (CAP) exceed $1 billion per year, of which roughly $100 million is spent on antibiotic therapy. Using the antibiotic erythromycin for treating CAP in most outpatients aged 60 and younger significantly reduces treatment costs compared with use of other antibiotics ($5.43 vs. $18.51), has no adverse effects on medical outcomes, and is recommended by American Thoracic Society (ATS) guidelines.

The ATS does not recommend using erythromycin alone for nonhospitalized CAP patients over 60 years of age or for patients of any age with an additional illness. However, a recent study by the Community-Acquired Pneumonia Patient Outcomes Research Team (PORT), which is funded by the Agency for Health Care Policy and Research (HS06468), found that the ATS-recommended antibiotics for these patients (most often amoxicillin/clavulanate, sulfamethoxazole-trimethoprim, or cefuroxime) cost 10 times as much as erythromycin or other nonrecommended antibiotics ($73.50 vs. $7.50 for erythromycin) and were no more effective.

These findings support ATS recommendations for younger CAP patients with no coexisting illnesses. They also indicate that there is no apparent benefit for the more costly ATS-recommended therapy in CAP patients who are older than 60 or have other illnesses along with CAP, concludes Wishwa N. Kapoor, M.D., M.P.H., of the University of Pittsburgh.

Dr. Kapoor and colleagues evaluated the ATS guidelines by comparing medical outcomes and prescription costs among outpatients whose therapy was or was not consistent with ATS recommendations. Their study included 864 adult patients: 546 aged 60 or younger with no other illnesses besides pneumonia, and 318 older than 60 years of age or any age with at least one other illness besides pneumonia.

More details are in "Medical outcomes and antimicrobial costs with the use of American Thoracic Society guidelines for outpatients with community-acquired pneumonia," by Patrick P. Gleason, Pharm.D., Dr. Kapoor, Roslyn A. Stone, Ph.D., and others, in the July 2, 1997, Journal of the American Medical Association 278(1), pp. 32-39.

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