Wheelchair Breakdowns Becoming More Common, Reports AJPM&R

Main Category: Rehabilitation / Physical Therapy
Also Included In: Rehabilitation / Physical Therapy;  Medicare / Medicaid / SCHIP
Article Date: 04 May 2012 – 1:00 PDT

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Wheelchair users with spinal cord injury (SCI) report very high rates of wheelchair breakdowns – and the problem is getting worse, suggests a study in American Journal of Physical Medicine Rehabilitation (AJPMR), the official journal of the Association of Academic Physiatrists, AJPMR is published by Lippincott Williams Wilkins, a part of Wolters Kluwer Health.

The study found that over 50 percent of wheelchair users experienced a breakdown in a six-month period, up from a previous report. “It is possible that this increase in the number of repairs is the result of a decrease in wheelchair quality resulting from changes in reimbursement policies and a lack of enforcement of standards testing,” write the researchers, led by Dr Michael Boninger of University of Pittsburgh’s Department of Physical Medicine and Rehabilitation. They also found a significant increase in wheelchair breakdowns causing health and safety consequences.


For People with SCI, Wheelchair Breakdowns Becoming More Frequent

Dr Boninger and colleagues analyzed data from an ongoing survey study of more than 700 individuals with SCI who used wheelchairs at least 40 hours per week. The participants provided routine data on wheelchair breakdowns requiring repairs, along with any consequences of breakdowns – for example, being stranded, missing a medical appointment, or being injured.

The data suggested that the rate of wheelchair breakdowns has increased in recent years. From 2006 to 2011, about 53 percent of wheelchair users reported one or more breakdowns requiring repair per six-month period – a significant increase over the 45 percent rate from 2004 to 2006. The average number of repairs per person also increased: 1.42 in 2006-11, compared to 1.03 in 2004-06.

The rate of adverse consequences of breakdowns increased as well: 30.5 percent in 2006-11, compared to 22 percent in 2004-06. The total number of consequences per participant in 2006-11 was more than twice as high as in 2004-06.

Power wheelchairs had more problems than manual wheelchairs – nearly two-thirds of all consequences were reported by power wheelchair users. These rates were especially high in wheelchairs equipped with power seat functions.


Differences by Race/Ethnicity and Funding Source

Rates of breakdowns and repairs appeared higher for individuals from a racial/ethnic minority background. These same individuals were also less likely to have a backup wheelchair available.

Individuals whose wheelchairs were funded by Medicare or Medicaid had higher rates of breakdowns and consequences, compared to those covered by private insurance or other sources (such as the Veterans Administration or workers compensation).

More than 2.8 million Americans use a wheelchair for mobility, allowing greater independence in daily functioning, home life, and vocational settings. Wheelchair users are at risk when breakdowns occur, with consequences ranging from minor inconveniences to significant injuries.

The new data raise concerns that wheelchair users with SCI are experiencing higher rates of wheelchair breakdowns. The higher risk among people whose wheelchairs are funded by Medicare/Medicaid may be at least partly related to recent changes in insurance reimbursement policy. In addition, the lax requirements for testing don’t ensure that wheelchairs meet established standards for performance and safety.

“This paper should serve as a call to reevaluate and revise current policies and standards testing for wheelchair prescription in the United States,” Dr Boninger and coauthors conclude. They also suggest that educating wheelchair users on the importance of routine maintenance – such as replacing cushions, caster wheels, and batteries at recommended times – might help to reduce the rates and consequences of breakdowns.

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Medical Equipment and Its Need with Innovations in Medical Technology

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Bacterial Infection Rates Higher In Children With Juvenile Arthritis

Main Category: Arthritis / Rheumatology
Also Included In: Pediatrics / Children’s Health;  Infectious Diseases / Bacteria / Viruses
Article Date: 03 May 2012 – 0:00 PDT

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Children with juvenile idiopathic arthritis (JIA) have higher rates of hospitalized bacterial infection than children without JIA according to an observational study appearing in Arthritis Rheumatism, a journal published by Wiley-Blackwell on behalf of the American College of Rheumatology (ACR). The findings show that the risk of infection among JIA patients was significantly increased with use of high-dose glucocorticoids (steroids). Methotrexate (MTX) and tumor necrosis factor alpha (TNF) inhibitors were not found to increase infection risk in this pediatric population.

Arthritis is an inflammation of the joints that causes pain, swelling, stiffness and can lead to disability. JIA refers to chronic arthritis diseases that attack young patients and the ACR estimates close to 300,000 children in the U.S are affected. While immunosuppressant therapies such as steroids, MTX, and TNF inhibitors are used to treat JIA, it is unclear how they impact infection risk.

To compare bacterial infection incidence in children with and without JIA, a research team led by Dr. Timothy Beukelman from the University of Alabama at Birmingham used U.S. Medicaid data from 2000 to 2005. The team identified 8,479 JIA patients with 13,003 person-years of follow-up and a group of 360,489 children with attention-deficit hyperactivity disorder (ADHD) for comparison. Pharmacy claims were used to determine exposure to MTX, TNF inhibitors, and oral steroid medications. Infections were identified using hospital discharge diagnoses.

Researchers determined that 42% of JIA patients used MTX and 17% used TNF inhibitors to manage their disease. JIA patients without current exposure to MTX or TNF inhibitors had an increased rate of bacterial infection compared to patients with ADHD, even after adjusting for steroid use. “Patients with JIA who were not currently treated with MTX or TNF inhibitors had a 2-fold increase in hospitalized bacterial infection rates compared to children without arthritis,” explains Dr. Beukelman, “This finding suggests the inflammatory or autoimmune process may predispose children to infection regardless of therapy.”

Among children with JIA, the rate of infection associated with MTX or TNF inhibitor use was similar. After adjusting for MTX and TNF inhibitor use among children with JIA, high-dose steroid use -10 mg or more of prednisone daily – more than doubled the rate of subsequent infection compared to patients not taking steroids. Dr. Beukelman concludes, “A steroid-sparing treatment strategy may reduce the risk of serious infection in children with JIA.”

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This research was supported by grants from the Agency for Healthcare Research and Quality (AHRQ), the Food and Drug Administration (FDA) U.S. Department of Health and Human Services (DHHS), and the National Institutes of Health (NIH).

Full citation: “Rates of Hospitalized Bacterial Infection Associated with Juvenile Idiopathic Arthritis and Its Treatment.” Timothy Beukelman, Fenglong Xie, Lang Chen, John W Baddley, Elizabeth Delzell, Carlos G Grijalva, James D Lewis, Rita Ouellet-Hellstrom, Nivedita M Patkar, Kenneth G Saag, Kevin L Winthrop and Jeffrey R Curtis on behalf of the Safety Assessment of Biological ThERapeutics (SABER) Collaboration. Arthritis Rheumatism; Published Online: May 1, 2012 (DOI: 10.1002/art.34458).
Wiley-Blackwell

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Hospital Infection Prevention Efforts Driven By Medicare Penalty

Main Category: Infectious Diseases / Bacteria / Viruses
Also Included In: Medicare / Medicaid / SCHIP;  Preventive Medicine
Article Date: 03 May 2012 – 1:00 PDT

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The 2008 decision by the Centers for Medicare Medicaid Services (CMS) to cease additional reimbursement to hospitals for certain healthcare-associated infections (HAIs) has led to enhanced focus on infection prevention and changes in practice by front-line staff, according to a national survey of infection preventionists published in the May issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC).

A team of researchers and public health policymakers led by Grace M. Lee, MD, MPH, from Harvard Pilgrim Health Care Institute and Harvard Medical School, surveyed head infection preventionists (IPs) at 317 acute care hospitals that were directly impacted by the policy change, which was enacted to motivate hospitals to eliminate preventable infections. According to the survey results, 81 percent of IPs reported increased focus on those HAIs targeted by the policy, namely catheter-associated urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs).

A majority of IPs reported an increase in surveillance, education, and prevention efforts for HAIs targeted by the CMS policy, particularly for CAUTIs. IPs felt that front-line staff removed urinary (71 percent) and central venous catheters (50 percent) more quickly than before, and increased use of antiseptic-containing dressings for central venous catheters (56 percent) for CLABSI prevention.

Although the policy did not appear to have a major impact on funding to support infection prevention departments (77 percent), a closer working relationship between infection prevention and quality improvement departments (57 percent) and greater collaboration by interdisciplinary teams to prevent HAIs (65 percent) was noted in response to the CMS policy.

While most of the findings were positive, the survey did identify some unintended consequences of the policy. One-third of respondents said their hospitals needed to shift resources away from non-targeted infections in order to focus on targeted infections. IPs also expressed concern that hospitals focused greater effort on improving physician documentation and coding practices to avoid negative financial penalties, rather than enhancing infection prevention efforts to improve patient outcomes. Finally, a quarter of respondents reported that their hospitals performed unnecessary diagnostic testing upon admission to avoid potential financial penalties.

“The CMS policy of eliminating additional payment for certain HAIs appears to have had a positive impact on hospital infection prevention efforts, yet careful consideration of the potential for unintended consequences is warranted,” say the study authors. “As CMS expands the list of complications for which it will adjust payment and continues to modify its requirements for reporting, it is critical to ensure that policy changes lead to measureable improvements in patient outcomes while minimizing potential unintended consequences.”

This study is one of the first to assess perceived impact of the CMS payment policy on hospital infection prevention efforts as reported by infection preventionists. Infection preventionists were chosen for the study because of their organizational knowledge of infection prevention surveillance, practices, and documentation.

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Low Cost, Lifesaving Services Missing From Most Older Patients’ Health Care: National Poll

Main Category: Seniors / Aging
Also Included In: Primary Care / General Practice;  Medicare / Medicaid / SCHIP
Article Date: 02 May 2012 – 5:00 PDT

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Large majorities of older Americans experience significant and troubling gaps in their primary care, according to a new national survey, “How Does It Feel? The Older Adult Health Care Experience,” released by the John A. Hartford Foundation, a champion for improved geriatric care and longtime partner of the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing.

The poll focuses exclusively on Americans age 65 and older and assesses whether, in the past 12 months, patients received seven important medical services to support healthy aging, including:

  • an annual medication review,
  • a falls risk assessment and history,
  • depression screening,
  • referral to community-based health resources, and
  • discussion of their ability to perform routine daily tasks and activities without help.

This type of low-cost, low-tech geriatric care supports a health aging process by managing and lowering patients’ risk of a number of preventable health problems that can be serious enough to erode quality of life, increase health care costs, cause disability, and even kill. Yet only a tiny number (7%) of older adults surveyed received all seven recommended services, which represent critical elements of a geriatric assessment. Fifty-two percent report receiving none or only one, and large majorities (76%) received fewer than half.

“Primary care providers must recognize the uniqueness of care for older adults. The need to keep people at their highest potential for cognitive and physical function must be a priority,” said Tara Cortes, PhD, RN, FAAN, executive director of the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing. “The Hartford Institute recognizes that addressing health needs and providing preventative healthcare is imperative in order for an older adult to age gracefully. Identifying functional decline and other health conditions before it begins or deteriorates, will assure that older adults are healthier and will need less intervention in the future.”

“We feel this survey highlights why expert geriatric care is needed,” said Christopher Langston, PhD, Program Director of the John A. Hartford Foundation, which commissioned the poll. “One of the central truths of geriatrics is that older adults are not just older 40 year olds, any more than children are just small 40 year olds. Older people need different care, and when they don’t receive these kinds of evidence-based interventions, as many don’t, the result is a lot of preventable disability and suffering.”

Falls: One of the important and recommended services that large numbers of older adults are not receiving is counseling about falls prevention, and discussion of any history of falling. Falling is the leading cause of injury and injury-related death in older people and the cause of 90 percent of all hip fractures. A considerable body of evidence exists about risk factors and how, by controlling risks, older people can cut their risk of falling by about 30 percent.

Yet, even among people at elevated risk, the Hartford poll reveals a troubling lack of intervention on falls. For example, advanced age is a known risk factor for falling, yet 75 percent of adults 80 and older say their doctor has not talked to them in the past 12 months about how to avoid falling. Taking multiple medications is another known risk factor, yet 71 percent of people taking 5+ medications regularly say they were never counseled on avoiding falls. Even people receiving large amounts of care were likely not to receive this important intervention: among older adults who made 10 or more doctor visits in the last year, 57 percent said their doctor had not talked with them about how to avoid falling down.


Medicare’s Annual Wellness Visit: The benefit nobody knows

Since January 2011, Medicare has offered a benefit specifically designed to promote these healthy aging interventions, the Annual Wellness Visit (AWV), which is free for patients (no co-pays or deductibles) and pays doctors nearly three times as much as an average office visit. Unfortunately, 68 percent of older adults surveyed had not heard of the benefit or were not sure if they had heard of it, and only 17 percent said that they had received their Annual Wellness visit. (In fact, the self-reported number may be overstated, as Medicare’s records suggest that uptake is only 6.5 percent.)

“Older adults need to be made aware of this benefit, the opportunity it provides and the importance of wellness to ensure a good quality of life,” said Tara Cortes, PhD., RN, FAAN, executive director of the Hartford Institute.


Strong support for geriatrics education:

Older adults in the survey also expressed strong support (93%) for requiring all medical and nursing students to take classes and training in caring for older people (which most are not presently required to do). Sixty-seven percent also said they believed they would “get better care” if their doctors, nurses, social workers, and other health professionals had more geriatrics training.

“We couldn’t agree more,” said Chris Langston of the Hartford Foundation. “One of the goals of the Hartford Foundation’s grantmaking is to ensure that everyone who cares for older adults, specialists and non-specialists alike, receives the training required to understand and meet their unique health needs.”

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