Functional outcomes of posthospital care for stroke and hip fracture patients under medicare

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge. METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988-1989. These diagnosis-related groups were chosen because patients were discharged to all three major types of Medicare-supported posthospital care. Patients were interviewed in-person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment. The impacts of discharge locations on the functional outcomes were examined by one-way analyses of variance (ANOVA). RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P<.01). Stroke patients discharged to home health had the lowest rehospitalization rates (P<.05). Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P<.05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement. CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.     

Astrocytes in the aged rat spinal cord fail to increase GFAP mRNA following sciatic nerve axotomy

We have expanded the original Glucocorticoid Receptor Resource (GRR) database to include several individual resources as part of a larger project called the Nuclear Receptor Resource (NRR). In addition to the GRR, the NRR currently features the Thyroid Hormone Receptor Resource, the Androgen Receptor Resource, the Mineralocorticoid Receptor Resource, the Vitamin D Receptor Resource, and the Steroid Receptor Associated Proteins Resource. The goal of the NRR project is to provide a comprehensive resource for information on the nuclear receptor superfamily, and to provide a forum for the dissemination and discussion of both published and unpublished material on these proteins. Although the individual resources are managed from different servers, all the files are integrated and can be accessed through the project's Home Page, housed at http://nrr. georgetown.edu/nrr.html. In the near future, we hope to expand the project to contain information on other nuclear receptors and to better our electronic publication system. To accomplish this, we encourage the involvement of nuclear receptor investigators in the NRR.     

An emerging role for the national laboratories in materials research

The mission of the Department of Energy National Laboratories should be expanded to include as an item of high priority collaborative research in support of high technology industry, including the materials industry. There are numerous reasons for doing this. The original missions of the laboratories, other than those of the weapons laboratories, have been deemphasized or disappeared. The laboratories have superior facilities, often unique, and high quality staffs experienced in the interdisciplinary approach to problem solving. Perhaps most important, domestic industry, especially high technology industry, should have this resource available if it is to meet the challenge of remaining competitive.     

Clinical applications of composite and realtime megavoltage imaging

The versatility of electronic portal imaging devices (EPIDs) is best demonstrated by their ability to perform novel megavoltage imaging protocols, which are still pertinent to good radiotherapy practice. This paper examines two such techniques: composite and realtime imaging. Our EPID can be programmed to acquire and manipulate images very easily, allowing images from segmented treatment protocols to be mixed and displayed, giving a composite image of the effective treatment result. Its use for verifying the efficacy of spinal shielding using a segmented, offset collimator technique is described. By acquiring images very quickly, realtime imaging sequences can be obtained and used to analyse anatomical movement within a single treatment field. The technique is employed here to investigate movement in radical lung, breast, abdomen, pelvis and thyroid treatments. Our results show that the protocol is vital for treatment sites involving the lungs; changes up to 5 mm have been observed in the maximum lung depth for breast treatments, and displacements up to 16 mm for radical lung treatments. It is also useful in other anatomical sites for ensuring that no movement occurs.     

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