Browsing by Subject "Home Care Services"
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Item Open Access At-Home Versus In-Clinic INR Monitoring: A Cost-Utility Analysis from The Home INR Study (THINRS).(Journal of general internal medicine, 2016-09) Phibbs, Ciaran S; Love, Sean R; Jacobson, Alan K; Edson, Robert; Su, Pon; Uyeda, Lauren; Matchar, David B; writing for the THINRS Executive Committee and Site InvestigatorsBackground
Effective management of patients using warfarin is resource-intensive, requiring frequent in-clinic testing of the international normalized ratio (INR). Patient self-testing (PST) using portable at-home INR monitoring devices has emerged as a convenient alternative. As revealed by The Home INR Study (THINRS), event rates for PST were not significantly different from those for in-clinic high-quality anticoagulation management (HQACM), and a cumulative gain in quality of life was observed for patients undergoing PST.Objective
To perform a cost-utility analysis of weekly PST versus monthly HQACM and to examine the sensitivity of these results to testing frequency.Patients/interventions
In this study, 2922 patients taking warfarin for atrial fibrillation or mechanical heart valve, and who demonstrated PST competence, were randomized to either weekly PST (n = 1465) or monthly in-clinic testing (n = 1457). In a sub-study, 234 additional patients were randomized to PST once every 4 weeks (n = 116) or PST twice weekly (n = 118). The endpoints were quality of life (measured by the Health Utilities Index), health care utilization, and costs over 2 years of follow-up.Results
PST and HQACM participants were similar with regard to gender, age, and CHADS2 score. The total cost per patient over 2 years of follow-up was $32,484 for HQACM and $33,460 for weekly PST, representing a difference of $976. The incremental cost per quality-adjusted life year gained with PST once weekly was $5566 (95 % CI, -$11,490 to $25,142). The incremental cost-effectiveness ratio (ICER) was sensitive to testing frequency: weekly PST dominated PST twice weekly and once every 4 weeks. Compared to HQACM, weekly PST was associated with statistically significant and clinically meaningful improvements in quality of life. The ICER for weekly PST versus HQACM was well within accepted standards for cost-effectiveness, and was preferred over more or less frequent PST. These results were robust to sensitivity analyses of key assumptions.Conclusion
Weekly PST is a cost-effective alternative to monthly HQACM and a preferred testing frequency compared to twice weekly or monthly PST.Item Open Access Complexities and Challenges of Singapore Nurses Providing Postacute Home Care in Multicultural Communities: A Grounded Theory Study.(Journal of transcultural nursing : official journal of the Transcultural Nursing Society, 2018-09) Wong, Alfred Ka-Shing; Ong, Shu Fen; Matchar, David Bruce; Lie, Desiree; Ng, Reuben; Yoon, Kirsten Eom; Wong, Chek HooiINTRODUCTION:Studies are needed to inform the preparation of community nurses to address patient behavioral and social factors contributing to unnecessary readmissions to hospital. This study uses nurses' input to understand challenges faced during home care, to derive a framework to address the challenges. METHODS:Semistructured interviews were conducted to saturation with 16 community nurses in Singapore. Interviews were transcribed verbatim and transcripts independently coded for emergent themes. Themes were interpreted using grounded theory. RESULTS:Seven major themes emerged from 16 interviews: Strained social relationships, complex care decision-making processes within families, communication barriers, patient's or caregiver neglect of health issues, building and maintaining trust, trial-and-error nature of work, and dealing with uncertainty. DISCUSSION:Community nurses identified uncertainty arising from complexities in social-relational, personal, and organizational factors as a central challenge. Nursing education should focus on navigating and managing uncertainty at the personal, patient, and family levels.Item Open Access Dose of early intervention treatment during children's first 36 months of life is associated with developmental outcomes: an observational cohort study in three low/low-middle income countries.(BMC pediatrics, 2014-10-25) Wallander, Jan L; Biasini, Fred J; Thorsten, Vanessa; Dhaded, Sangappa M; de Jong, Desiree M; Chomba, Elwyn; Pasha, Omrana; Goudar, Shivaprasad; Wallace, Dennis; Chakraborty, Hrishikesh; Wright, Linda L; McClure, Elizabeth; Carlo, Waldemar AThe positive effects of early developmental intervention (EDI) on early child development have been reported in numerous controlled trials in a variety of countries. An important aspect to determining the efficacy of EDI is the degree to which dosage is linked to outcomes. However, few studies of EDI have conducted such analyses. This observational cohort study examined the association between treatment dose and children's development when EDI was implemented in three low and low-middle income countries as well as demographic and child health factors associated with treatment dose.Infants (78 males, 67 females) born in rural communities in India, Pakistan, and Zambia received a parent-implemented EDI delivered through biweekly home visits by trainers during the first 36 months of life. Outcome was measured at age 36 months with the Mental (MDI) and Psychomotor (PDI) Development Indices of the Bayley Scales of Infant Development-II. Treatment dose was measured by number of home visits completed and parent-reported implementation of assigned developmental stimulation activities between visits. Sociodemographic, prenatal, perinatal, and child health variables were measures as correlates.Average home visits dose exceeded 91% and mothers engaged the children in activities on average 62.5% of days. Higher home visits dose was significantly associated with higher MDI (mean for dose quintiles 1-2 combined = 97.8, quintiles 3-5 combined = 103.4, p = 0.0017). Higher treatment dose was also generally associated with greater mean PDI, but the relationships were non-linear. Location, sociodemographic, and child health variables were associated with treatment dose.Receiving a higher dose of EDI during the first 36 months of life is generally associated with better developmental outcomes. The higher benefit appears when receiving ≥91% of biweekly home visits and program activities on ≥67% of days over 3 years. It is important to ensure that EDI is implemented with a sufficiently high dose to achieve desired effect. To this end groups at risk for receiving lower dose can be identified and may require special attention to ensure adequate effect.Item Open Access Effect of a Universal Postpartum Nurse Home Visiting Program on Child Maltreatment and Emergency Medical Care at 5 Years of Age: A Randomized Clinical Trial.(JAMA network open, 2021-07) Goodman, W Benjamin; Dodge, Kenneth A; Bai, Yu; Murphy, Robert A; O'Donnell, KarenImportance
The Family Connects (FC) program, a community-wide nurse home visiting program for newborns, has been shown to provide benefits for children and families through the first 2 years of life. Potential longer-term outcomes for child well-being remain unknown.Objective
To determine the effect of randomization to FC on child maltreatment investigations and emergency medical care through 5 years of age.Design, setting, and participants
In this randomized clinical trial, families of all 4777 resident births in Durham County, North Carolina, from July 1, 2009, to December 31, 2010, were randomly assigned to receive the FC program or treatment as usual. Impact evaluation was on an intent-to-treat basis and focused on a subsample of 549 families randomly selected from the full population and included review of hospital and Child Protective Services (CPS) administrative records. Statistical analysis was conducted from November 6, 2020, to April 25, 2021.Interventions
The FC programs includes 1 to 3 nurse home visits beginning at the infant age of 3 weeks designed to identify family-specific needs, deliver education and intervention, and connect families with community resources matched to their needs. Ongoing program engagement with service professionals and an electronic resource directory facilitate effective family connections to the community.Main outcomes and measures
Two primary trial outcomes were CPS-recorded child maltreatment investigations and emergency medical care use based on hospital records.Results
Of the 4777 randomized families, 2327 were allocated to the intervention, and 2440 were allocated to services as usual. Among the children in the full study population, 2380 (49.8%) were female, 2397 (50.2%) were male, and 3359 (70.3%) were from racial/ethnic minority groups; of the 531 children included in the impact evaluation follow-up, 284 (53.5%) were female, 247 (46.5%) were male, and 390 (73.4%) were from racial/ethnic minority groups. Negative binomial models indicated that families assigned to FC had 39% fewer CPS investigations for suspected child maltreatment through 5 years of age (95% CI, -0.80 to 0.06; 90% CI, -0.73 to -0.01; control = 44 total investigations per 100 children and intervention = 27 total investigations per 100 children); intervention effects did not differ across subgroups. Families assigned to FC also had 33% less total child emergency medical care use (95% CI, -0.59 to -0.14; 90% CI, -0.55 to -0.18; control = 338 visits and overnight hospital stays per 100 children and intervention = 227 visits and overnight hospital stays per 100 children). Positive effects held across birth risk, child health insurance, child sex, single-parent status, and racial/ethnic groups. Effects were larger for nonminority families compared with minority families.Conclusions and relevance
The findings of this randomized clinical trial suggest that, when implemented with high quality and broad reach, a brief postpartum nurse home visiting program can reduce population rates of child maltreatment and emergency medical care use in early childhood.Trial registration
ClinicalTrials.gov Identifier: NCT01406184.Item Open Access From Hospital to Home: Impact of Transitional Care on Cost, Hospitalisation and Mortality.(Annals of the Academy of Medicine, Singapore, 2019-10) Ang, Yan Hoon; Ginting, Mimaika Luluina; Wong, Chek Hooi; Tew, Chee Wee; Liu, Chang; Sivapragasam, Nirmali Ruth; Matchar, David BruceItem Open Access Perceived acceptability of home-based couples voluntary HIV counseling and testing in Northern Tanzania.(AIDS Care, 2012) Njau, B; Watt, MH; Ostermann, J; Manongi, R; Sikkema, KJIt is estimated that 5.6% of the Tanzanian population ages 15-49 are infected with HIV, but only 30% of adults have ever had an HIV test. Couples' testing has proven to increase testing coverage and introduce HIV prevention, but barriers include access to testing services and unequal gender dynamics in relationships. Innovative approaches are needed to address barriers to couple's testing and increase uptake of HIV testing. Using qualitative data collection methods, a formative study was conducted to assess the acceptability of a home-based couples counseling and testing (HBCCT) approach. Eligible study participants included married men and women, HIV-infected individuals, health care and home-based care providers, voluntary counseling and testing counselors, and community leaders. A total of 91 individuals participated in focus group discussions (FGDs) and in-depth interviews conducted between September 2009 and January 2010 in rural settings in Northern Tanzania. An HBCCT intervention appears to be broadly acceptable among participants. Benefits of HBCCT were identified in terms of access, confidentiality, and strengthening the relationship. Fears of negative consequences from knowing one's HIV status, including stigma, blame, physical abuse, or divorce, remain a concern and a potential barrier to the successful provision of the intervention. Lessons for implementation highlighted the importance of appointments for home visits, building relationships of confidence and trust between counselors and clients, and assessing and responding to a couple's readiness to undergo HIV testing. HBCCT should addresses HIV stigma, emphasize confidentiality, and improve communication skills for disclosure and decision-making among couples.Item Open Access Performance of accredited social health activists to provide home-based newborn care: a situational analysis.(Indian pediatrics, 2014-02) Das, Emily; Panwar, Dharmendra Singh; Fischer, Elizabeth A; Bora, Girdhari; Carlough, Martha CObjective
To assess Accredited social health activists' (ASHAs) ability to recognize illness in infants aged less than 2 months.Methods
Investigators observed 25 ASHAs conducting 47 visits.Results
ASHA-investigator agreement on the need to further assess infants was intermediate (kappa 0.48, P<0.001). Using IMNCI's color codes, ASHAs misclassified 80% of infants. ASHAs did not follow home-based newborn care formats and skipped critical signs. Overall ASHA-investigator agreement on diagnosis was poor (kappa=0.23, P=0.01).Conclusion
There is a need for improved training, tools, and supportive supervision.Item Open Access Randomized controlled trial of universal postnatal nurse home visiting: impact on emergency care.(Pediatrics, 2013-11) Dodge, Kenneth A; Goodman, W Benjamin; Murphy, Robert A; O'Donnell, Karen; Sato, JeannineBACKGROUND AND OBJECTIVES: Although nurse home visiting has proven efficacious with small samples, scaling up to community populations with diverse families has not yet proven effective. The Durham Connects program was developed in collaboration with community leaders as a brief, universal, postnatal nurse home visiting intervention designed to screen for risk, provide brief intervention, and connect families with more intensive evidence-based services as needed. This study tested program effectiveness in reducing infant emergency medical care between birth and age 12 months. METHODS: All 4777 resident births in Durham, North Carolina across 18 months were randomly assigned, with even birth date families to intervention and odd birth date families to control. Intervention families were offered 3 to 7 contacts between 3 and 12 weeks after birth to assess family needs and connect parents with community resources to improve infant health and well-being. Hospital records were analyzed by using an intent-to-treat design to evaluate impact among a representative subset of 549 families. RESULTS: After demographic factors (ie, birth risk, Medicaid status, ethnicity, and single parenthood) were covaried, relative to control families, families assigned to intervention had 50% less total emergency medical care use (mean [M] emergency department visits and hospital overnights) (M(intervention) = 0.78 and M(control) = 1.57; P < .001, effect size = 0.28) across the first 12 months of life. CONCLUSIONS: This brief, universal, postnatal nurse home visiting program improves population-level infant health care outcomes for the first 12 months of life. Nurse home visiting can be implemented universally at high fidelity with positive impacts on infant emergency health care that are similar to those of longer, more intensive home visiting programs. This approach offers a novel solution to the paradox of targeting by offering individually tailored intervention while achieving population-level impact.Item Open Access Reframing Hospital to Home Discharge from "Should We?" to "How Can We?": COVID-19 and Beyond.(Journal of the American Geriatrics Society, 2021-03) Gustavson, Allison M; Toonstra, Amy; Johnson, Joshua K; Ensrud, Kristine EItem Open Access The impact of frequency of patient self-testing of prothrombin time on time in target range within VA Cooperative Study #481: The Home INR Study (THINRS), a randomized, controlled trial.(Journal of thrombosis and thrombolysis, 2015-07) Matchar, David B; Love, Sean R; Jacobson, Alan K; Edson, Robert; Uyeda, Lauren; Phibbs, Ciaran S; Dolor, Rowena JAnticoagulation (AC) is effective in reducing thromboembolic events for individuals with atrial fibrillation (AF) or mechanical heart valve (MHV), but maintaining patients in target range for international normalized ratio (INR) can be difficult. Evidence suggests increasing INR testing frequency can improve time in target range (TTR), but this can be impractical with in-clinic testing. The objective of this study was to test the hypothesis that more frequent patient-self testing (PST) via home monitoring increases TTR. This planned substudy was conducted as part of The Home INR Study, a randomized controlled trial of in-clinic INR testing every 4 weeks versus PST at three different intervals. The setting for this study was 6 VA centers across the United States. 1,029 candidates with AF or MHV were trained and tested for competency using ProTime INR meters; 787 patients were deemed competent and, after second consent, randomized across four arms: high quality AC management (HQACM) in a dedicated clinic, with venous INR testing once every 4 weeks; and telephone monitored PST once every 4 weeks; weekly; and twice weekly. The primary endpoint was TTR at 1-year follow-up. The secondary endpoints were: major bleed, stroke and death, and quality of life. Results showed that TTR increased as testing frequency increased (59.9 ± 16.7 %, 63.3 ± 14.3 %, and 66.8 ± 13.2 % [mean ± SD] for the groups that underwent PST every 4 weeks, weekly and twice weekly, respectively). The proportion of poorly managed patients (i.e., TTR <50 %) was significantly lower for groups that underwent PST versus HQACM, and the proportion decreased as testing frequency increased. Patients and their care providers were unblinded given the nature of PST and HQACM. In conclusion, more frequent PST improved TTR and reduced the proportion of poorly managed patients.