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Heart failure (HF) is one of the leading causes of rehospitalization in the United States. Due to the complex nature of HF, the provision of Medicare-certified home healthcare services has increased. Medicare-certified home healthcare agencies measure and report patients' outcomes such as functional status, activities of daily living (ADL), and instrumental activities of daily living to the Centers for Medicare and Medicaid Services. These metrics are assessed using the Outcome and Assessment Information Set (OASIS). As a large data set, OASIS has been used to advance care quality in multiple ways including identifying risk factors for negative patient outcomes. However, there is a lack of OASIS analyses to assess the relationship between functional status and the role of other factors, such as pain, in impeding recovery after hospitalization among HF patients. Therefore, the purpose of this study is to identify the relationship between functional status and pain using the OASIS database. Among 489 HF patients admitted to home healthcare, 83% were White, 57% were female, and the median age was 80. Patients who reported daily but not constant activity-interfering pain at discharge demonstrated the least improvement in functional performance as measured by ADLs, whereas patients without activity-interfering pain demonstrated the greatest improvement in ADL performance (p value = 0.0284). Tracking individual patient ADL scores, particularly the frequency of activity-interfering pain, could be a key indicator for clinical focus for patients with HF in the home healthcare setting.

Aging is associated with comorbidities and increased utilization of healthcare services, which results in a large amount of personal health information (PHI) to manage. Older adults often have difficulty managing this increased load of health information. Although many home healthcare nurses (HCNs) provide assistance to older adults after discharge from medical facilities, little is known about HCNs’ experiences with older adults regarding the management and transfer of PHI in their homes. The purpose of this qualitative study was to 1) determine how HCNs obtain and provide health information, 2) describe the perspective of HCNs regarding older adult PHI and 3) identify the potential role of technology in older adult health information transfer. We conducted and analyzed semi-structured phone interviews with 17 HCNs from two home healthcare agencies. Five thematic areas emerged from interviews with HCNs: 1) common practices of obtaining health information; 2) barriers to obtaining health information; 3) ideal ways to obtain and provide health information; 4) use of patient portals; and 5) HCNs’ use of technology for health information exchange. Most HCNs reported that it would be difficult for older adult patients to update their personal health information without assistance, but HCNS lack the time and resources to assist older adults in PHI management activities.

Frequent rehospitalizations among patients with heart failure (HF) result in patient burden and cost. Homebound patients with HF qualify for home healthcare after hospital discharge. Whether nonhomebound ambulatory patients with HF could also benefit from home healthcare nursing (HHN) visits to improve the transition from hospital to home has not been tested. The purpose of our quality-improvement pilot study was to assess the impact of HHN visits provided to ambulatory patients after hospital discharge on the 30-day rehospitalization rate. We included patients with HF ineligible for home healthcare services at hospital discharge due to their nonhomebound status. Home healthcare nurses followed a modified version of the Discharge Checklist from the American Heart Association’s Rise Above Heart Failure materials. Home healthcare nurses provided education as appropriate based on patients’ responses. We enrolled 68 patients in the study. The mean age was 60 years; 61% were male and 80% were White. Based on patient responses to the Checklist, key areas addressed during HHN visits were medication management, self-care, and adherence to HF behaviors. The 30-day rehospitalization rate of the study patients was 15%, compared with 23% among 540 patients discharged in the same time frame who met the inclusion criteria but were not enrolled in the study (p = .12). Our pilot data show that HHNs in ambulatory patients are feasible and result in a numerically lower 30-day rehospitalization rate after discharge. Further study is needed to confirm the clinical efficacy of this approach.

Cardiopulmonary rehabilitation (CR) improves physical function and quality of life (QoL) in chronic obstructive pulmonary disease (COPD) and heart failure (HF), but it is unknown if CR improves outcomes in very severe disease. This study’s purpose was to describe functional capacity (6-min walk distance [6MWD], steps/day), symptoms (dyspnea, depression), QoL (Short-Form Health Survey–Veterans [SF-36 V]) and cardiopulmonary function ( N-terminal pro-brain natriuretic peptide [NT-proBNP], forced expiratory volume in 1 s [FEV1]), and derive predictors of mortality among patients with severe COPD and HF who participated in CR.Methods and Results:In this secondary analysis of a randomized controlled trial comparing two CR methods in severe COPD and HF, 90 (COPD = 63, HF = 27) male veterans, mean age 66 ± 9.24 years, 79% Caucasian, and body mass index 31 kg/m2, were followed for 12 months after CR. The COPD group had greater functional decline than the HF group (6MWD, p = .006). Dyspnea was lower ( p = .001) and QoL higher ( p = .006) in the HF group. Mean NT-proBNP was higher in the HF group at all time points. FEV1improved over 12 months in both groups ( p = .01). Mortality was 8.9%, 16.7%, and 37.8% at 12, 24, and 60 months, respectively. One-year predictors of mortality were baseline total steps (2,000 mg/pg).Conclusions:In very severe COPD and HF, risks of mortality over 12 months can predict patients unlikely to benefit from CR and should be considered at initial referral.

Background Standardized pain-intensity measurement across different tools would enable practitioners to have confidence in clinical decision making for pain management. Objectives The purpose was to examine the degree of agreement among unidimensional pain scales and to determine the accuracy of the multidimensional pain scales in the diagnosis of severe pain. Methods A secondary analysis was performed. The sample included a convenience sample of 480 cancer patients recruited from both the Internet and community settings. Cancer pain was measured using the Verbal Descriptor Scale (VDS), the visual analog scale (VAS), the Faces Pain Scale (FPS), the McGill Pain Questionnaire-Short Form (MPQ-SF), and the Brief Pain Inventory-Short Form (BPI-SF). Data were analyzed using a multivariate analysis of variance and a receiver operating characteristic curve. Results The agreement between the VDS and VAS was 77.25%, whereas the agreement was 71.88% and 71.60% between the VDS and FPS, and VAS and FPS, respectively. The MPQ-SF and BPI-SF yielded high accuracy in the diagnosis of severe pain. Cutoff points for severe pain were more than 8 for the MPQ-SF and more than 14 for the BPI-SF, which exhibited high sensitivity and relatively low specificity. Conclusion The study found substantial agreement between the unidimensional pain scales and high accuracy of the MPQ-SF and the BPI-SF in the diagnosis of severe pain. Implications for practice Use of 1 or more pain screening tools that have validated diagnostic accuracy and consistency will help classify pain effectively and subsequently promote optimal pain control in multiethnic groups of cancer patients.

Objective: To identify potential risk factors associated with rehospitalization among Medicare recipients with heart failure (HF) receiving telehomecare. Materials and Methods: This study is a nonexperimental, cross-sectional secondary data analysis of the Centers for Medicare and Medicaid (CMS) mandated assessment called the Outcome and Assessment Information Set (OASIS)–C, provided by a large home care company. A total of 526 patients who received telehomecare from January 1, 2011 to August 31, 2013 were included in the analyses, which used multiple logistic regression. Results: The overall rate of rehospitalization was 36% while patients were receiving telehomecare. Moderately frail health status (p = 0.01), the presence of severe pain (p = 0.01), the presence of dermatologic problems (p = 0.03), and independence in dressing one's lower body (compared to slightly dependent [p = 0.01] or mostly dependent patient groups [p = 0.02]) were identified as risk factors for rehospitalization. Conclusions: The risk factors identified from this study may be used to drive more effective telehomecare placements, and referrals for additional services among telehomecare patients with HF.

Background Pain is common in older adults, but it is often underreported or undertreated partly because many consider pain to be a normal consequence of ageing. Among the plethora of available self-report pain assessment tools, there is no synthetised evidence which tools are indicated for use among cognitively intact older adults. Purpose of the study To understand documented self-report pain assessment tools that have been used among cognitively intact older adults, and to describe their characteristics including overall performance as well as studies demonstrating their use. Methods A systematic search of the indexed databases PubMed, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus) was conducted to identify documented self-report pain assessment tools through peer-reviewed papers, including citations from January 1990 to December 2015. Thirty-five percentage of abstracts were independently evaluated by two raters according to specific criteria. Results Among identified tools, the Iowa Pain Thermometer, the 6-point Verbal Descriptor Scale, the Numeric Rating Scale, the short form Brief Pain Inventory (BPI) and the Geriatric Pain Measure (GPM) may be suitable tools for self-reported pain by cognitively intact older adults based on the statement of the literature. Only two self-report tools (the GPM and the Geriatric Painful Events Inventory) were designed specifically for older adults. Conclusions More studies are needed to evaluate pain measures' psychometric performance across different settings, racial/ethnic groups and disease categories. Since 80% of older adults have at least one chronic disease, multidimensional tools such as the GPM may need to be used more often for accurate self-report of pain. Implications for practice Examining the psychometric properties of comprehensive self-report pain assessment tools informs recommendations for the selection of tools to be used in clinical practice.

Purpose Renal impairment is highly prevalent among patients with cancer, and many patients have undiagnosed chronic kidney disease (CKD) from underlying disease, treatment, or both. African American individuals have disproportionate risk factors (diabetes, hypertension) predisposing them to CKD. We investigated whether African American patients are more likely than white patients to receive morphine with 3- and 6-glucuronide metabolites, which are known to be neurotoxic and accumulate in CKD; whether insurance type mediates the relationship between race and the prescriber's opioid selection; and whether the chosen opioid has a resultant negative effect according to race. Patients and Methods Patients (N = 182) were recruited from oncology clinics within the University of Pennsylvania Health System. Inclusion was based on self-identified African American or white race, age older than 18 years, and the presence of cancer-related pain plus a prescription for morphine or oxycodone. Kidney function was estimated using the abbreviated Modification of Diet in Renal Disease formula. Results Patients with CKD who received morphine reported a greater severity of analgesic-related adverse effects than patients with CKD who received oxycodone (P = .010). Controlling for health insurance type, African American patients had 71% lower odds of receiving a prescription of oxycodone than white patients (P < .001). Limiting analysis to those with CKD, the effect of private insurance became insignificant. However, race still remained a significant predictor of the prescribed opioid selection. Race was a strong predictor of adverse effect severity in the presence of CKD, and the type of opioid selection partially mediated this relationship. Conclusion Reducing racial disparities in the type of opioid prescription and understanding mechanisms of disproportionate opioid-related adverse effects in African American patients might decrease the clinical disparities in cancer pain outcomes.

The energy intake goal is important to achieving energy intake in critically ill patients, yet clinical outcomes associated with energy goals have not been reported.This secondary analysis used the Improving Nutrition Practices in the Critically III International Nutrition Surveys database from 2007-2009 to evaluate whether mortality or time to discharge alive is related to use of complex energy prediction equations vs weight only. The sample size was 5672 patients in the intensive care unit (ICU) ≥ 4 days and a subset of 3356 in the ICU ≥ 12 days. Mortality and time to discharge alive were compared between groups by regression, controlling for age, sex, admission type, Acute Physiology and Chronic Health Evaluation II score, ICU geographic region, actual energy intake, and obesity.There was no difference in mortality between the use of complex and weight-only equations (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.86-1.15), but obesity (OR, 0.83; 95% CI, 0.71-0.96) and higher energy intake (OR, 0.65; 95% CI, 0.56-0.76) had lower odds of mortality. Time to discharge alive was shorter in patients fed using weight-only equations (hazard ratio [HR], 1.11; 95% CI, 1.01-1.23) in patients staying ≥ 4 days and with greater energy intake (HR, 1.19; 95% CI, 1.06-1.34) in patients in the ICU ≥ 12 days.These data suggest that higher energy intake is important to survival and time to discharge alive. However, the analysis was limited by actual energy intake70% of goal. Delivery of full goal intake will be needed to determine the relationship between the method of determining energy goal and clinical outcomes.

Clinicians working with patients who undergo bariatric surgery have found loss to follow-up challenging; however, the impact of this factor on postsurgical weight loss has not been adequately examined. The purpose of this study was to determine whether patients who returned for office visits after their gastric bypass (GBP) lost more weight than those who did not. All patients treated with GBP by a single surgeon during 2003 were eligible. Measured weights were obtained from surgical and local physician records over 24 months after GBP. Attender status was defined by whether patients attended the 12-month post-GBP visit, and number of visits attended was recorded. When measured weights were not available at 1.5, 6, 12, or 24 months, the previous measured weight was carried forward. Weight loss over time was compared by attender group and by visit number using mixed models and ≥50% excess weight loss (EWL) by logistic regression. Weight loss was greater in attenders and men (both p