Browsing by Author "Chumbler, Neale R."

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    Aging in Urban Communities, Neighborhood Senior Attachment and Youth Offending: New Roles and New Goals
    (2012-03-16) Hobson-Prater, Tara L.; Leech, Tamara G. J.; Pike, Lynn M.; Chumbler, Neale R.
    Relationships among neighbors contribute to the well-being and outcomes of all who live within a neighborhood. Existing literature provides us with a wealth of information on individual seniors’ isolation but does not seem to consider how neighborhood factors add to the attachment of seniors. Given the increasing number of seniors in our society who have the ability to remain living in their neighborhoods as they age, this study focuses on understanding neighborhood attachment to seniors living in the community. Furthermore, emphasis was placed on the potential impact that senior attachment could have on youth as one subset life stage who reside in a neighborhood. This thesis describes the characteristics of neighborhoods that foster low, normal, and high levels of senior attachment in urban areas and explores the relationship this attachment has to neighborhood youth outcomes. This research opens the door for other scholars to begin to place greater emphasis on the understanding of neighborhood dynamics, intergenerational ties to seniors, and the well being of residents across the life course.
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    Care Trajectories of Veterans in the Twelve Months following Hospitalization for Acute Ischemic Stroke
    (AHA, 2015-10) Arling, Greg; Ofner, Susan; Reeves, Mathew J.; Myers, Laura J.; Williams, Linda S.; Daggy, Joanne K.; Phipps, Michael S.; Chumbler, Neale R.; Bravata, Dawn M.; Department of Neurology, IU School of Medicine
    Background—Recovery after a stroke varies greatly between individuals and is reflected by wide variation in the use of institutional and home care services. This study sought to classify veterans according to their care trajectories in the 12 months after hospitalization for ischemic stroke. Methods and Results—The sample consisted of 3811 veterans hospitalized for ischemic stroke in Veterans Health Administration facilities in 2007. Three outcomes—nursing home care, home care, and mortality—were modeled jointly >12 months using latent class growth analysis. Data on Veterans’ care use and cost came from the Veterans Administration and Medicare. Covariates included stroke severity (National Institutes of Health Stroke Scale), functional status (functional independence measure score), age, marital status, chronic conditions, and prestroke ambulation. Five care trajectories were identified: 49% of Veterans had Rapid Recovery with little or no use of care; 15% had a Steady Recovery with initially high nursing home or home care that tapered off; 9% had Long-Term Home Care; 13% had Long-Term Nursing Home Care; and 14% had an Unstable trajectory with multiple transitions between long-term and acute care settings. Care use was greatest for individuals with more severe strokes, lower functioning at hospital discharge, and older age. Average annual costs were highest for individuals with the Long-Term Nursing Home trajectory ($63 082), closely followed by individuals with the Unstable trajectory ($58 720). Individual with the Rapid Recovery trajectory had the lowest costs ($9271). Conclusions—Care trajectories after stroke were associated with stroke severity and functional dependency and they had a dramatic impact on subsequent costs.
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    Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: Nursing admission screening tool versus National Institutes of Health Stroke Scale
    (2009) Bravata, Dawn M.; Daggett, Virginia S; Woodward-Hagg, Heather; Damush, Teresa M.; Plue, Laurie; Russell, Scott; Allen, George; Williams, Linda S.; Harezlak, Jaroslaw; Chumbler, Neale R.
    This study assessed the positive and negative predictive values and the sensitivity and specificity of a nursing dysphagia screening tool and the National Institutes of Health Stroke Scale (NIHSS) for the identification of dysphagia for veterans hospitalized with ischemic stroke. A secondary objective of this study was to evaluate the speech-language pathology consult rate before and after the nursing admission dysphagia screening tool. This retrospective cohort study evaluated veterans admitted to one Department of Veterans Affairs medical center with ischemic stroke during the 6 months both before and after the implementation of a nursing dysphagia screening tool, which was part of the admission nursing template. Stroke severity was measured with the use of the retrospective NIHSS. Dysphagia diagnosis was based on speech-language pathology evaluations. Dysphagia was present in 38 of 101 patients (38%) with ischemic stroke. The nursing dysphagia screening tool had a positive predictive value of 50% and a negative predictive value of 68%, with a sensitivity of 29% and specificity of 84%. The use of the NIHSS to identify dysphagia risk had a positive predictive value of 60% and a negative predictive value of 84%. The NIHSS had better test characteristics in predicting dysphagia than the nursing dysphagia screening tool. Future research should evaluate the use of the NIHSS as a screening tool for dysphagia.
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    Estimating and Reporting on the Quality of Inpatient Stroke Care by Veterans Health Administration Medical Centers
    (2012-01) Arling, Greg; Reeves, Mathew; Ross, Joseph S.; Williams, Linda S.; Keyhani, Salomeh; Chumbler, Neale R.; Phipps, Michael S.; Roumie, Christianne L; Myers, Laura J.; Salanitro, Amanda H; Ordin, Diana L.; Myers, Jennifer; Bravata, Dawn M.
    Background—Reporting of quality indicators (QIs) in Veterans Health Administration Medical Centers is complicated by estimation error caused by small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation in addressing this issue in performance reporting of stroke care quality in the Medical Centers. Methods and Results—We studied a retrospective cohort of 3812 veterans admitted to 106 Medical Centers with ischemic stroke during fiscal year 2007. The median number of study patients per facility was 34 (range, 12–105). Inpatient stroke care quality was measured with 13 evidence-based QIs. Eligible patients could either pass or fail each indicator. Multilevel modeling of a patient's pass/fail on individual QIs was used to produce facility-level EB-estimated QI pass rates and confidence intervals. The EB estimation reduced interfacility variation in QI rates. Small facilities and those with exceptionally high or low rates were most affected. We recommended 8 of the 13 QIs for performance reporting: dysphagia screening, National Institutes of Health Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining 5 QIs were not recommended because of too few eligible patients or high pass rates with little variation. Conclusions—Considerations of statistical uncertainty should inform the choice of QIs and their application to performance reporting.
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    Implementation of a Journal Prototype for Pregnant and Parenting Adolescents
    (2014-10) Bute, Jennifer J.; Comer, Karen; Lauten, Kathryn M.; Sanematsu, Helen; Moore, Courtney M.; Lynch, Dustin; Chumbler, Neale R.
    Teenage pregnancy and childbearing remain pressing public health issues that have garnered attention from public health officials and social services agencies. This paper reports on the initial implementation and formative evaluation of a journaling program used as a means of communicating health information to pregnant and parenting adolescents (young women age 15-19) while also providing participants with a means of self-expression. The journaling prototype was implemented in a community-based agency in the Midwest by Family Support Specialists (FSSs) who made home visits on a monthly basis to assist pregnant and parenting adolescents (n = 52) with successful family planning and public health education. A mixed method approach of qualitative (analysis of journals, field notes, and responses of semi-structured interviews with FSSs) and quantitative (questionnaires from pregnant and parenting adolescent respondents) data with purposive sampling was employed to evaluate the implementation of the journaling intervention. Twenty of the 52 study participants were pregnant when the journaling intervention was implemented, while 32 were not pregnant, but recently had a child and were currently parenting. Two core themes emerged from analysis of the data after the implementation of the journals: (1) usefulness of the journal and responsiveness to participants' information needs and (2) functionality challenges. The results offer practical starting points to tailor the implementation of journaling in other contexts. Further, areas for improvement emerged regarding the distribution timeline for the journal and the content of the journal itself. As such, we discuss the lessons learned through this collaborative project and suggest opportunities for future phases of the journal intervention.
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    Inpatient stroke care quality for Veterans: Are there differences between VA medical centers in the stroke belt and other areas?
    (Wiley, 2015-01) Jia, Huanguang; Phipps, Michael S.; Bravata, Dawn M.; Castro, Jaime; Li, Xinli; Ordin, Diana L.; Myers, Jennifer; Vogel, W. Bruce; Williams, Linda S.; Chumbler, Neale R.; Department of Medicine, IU School of Medicine
    Background Stroke mortality has been found to be much higher among residents in the stroke belt region than in the rest of United States, but it is not known whether differences exist in the quality of stroke care provided in Department of Veterans Affairs medical centers in states inside and outside this region. Objective We compared mortality and inpatient stroke care quality between Veterans Affairs medical centers inside and outside the stroke belt region. Methods Study patients were veterans hospitalized for ischemic stroke at 129 Veterans Affairs medical centers. Inpatient stroke care quality was assessed by 14 quality indicators. Multivariable logistic regression models were fit to examine differences in quality between facilities inside and outside the stroke belt, adjusting for patient characteristics and Veterans Affairs medical centers clustering effect. Results Among the 3909 patients, 28·1% received inpatient ischemic stroke care in 28 stroke belt Veterans Affairs medical centers, and 71·9% obtained care in 101 non-stroke belt Veterans Affairs medical centers. Patients cared for in stroke belt Veterans Affairs medical centers were more likely to be younger, Black, married, have a higher stroke severity, and less likely to be ambulatory pre-stroke. We found no statistically significant differences in short- and long-term post-admission mortality and inpatient care quality indicators between the patients cared for in stroke belt and non-stroke belt Veterans Affairs medical centers after risk adjustment. Conclusions These data suggest that a stroke belt does not exist within the Veterans Affairs health care system in terms of either post-admission mortality or inpatient care quality.
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    Perceptions of Partners' Wealth and Partnership Decisions among Young Adults
    (2011-07-08) Zimmerman, Amanda Nicole; Leech, Tamara G. J.; Chumbler, Neale R.; Haas, Linda
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    Postdischarge quality of care: Do age disparities exist among Department of Veterans Affairs ischemic stroke patients?
    (2013) Chumbler, Neale R.; Jia, Huanguang; Phipps, Michael S.; Li, Xinli; Ordin, Diana L.; Williams, Linda S.; Myers, Laura J.
    This study examined whether age disparities existed across postdischarge quality indicators (QIs) for veterans with ischemic stroke who received care at Department of Veterans Affairs medical centers (VAMCs). This retrospective cohort included a national sample of 3,196 veterans who were diagnosed with ischemic stroke and received acute and postdischarge stroke care at 127 VAMCs in fiscal year 2007 (10/1/06 through 9/30/07). Data included an assessment of postdischarge stroke QIs in the outpatient setting during the 6 mo postdischarge. The QIs included measurement of and goal achievement for (1) blood pressure, (2) serum international normalized ratio (INR) for all patients discharged on warfarin, (3) cholesterol (low-density lipoprotein [LDL]) levels, (4) serum glycosylated hemoglobin, and (5) depression treatment. The mean age for the 3,196 veterans included in this study was 67.2 +/– 11.3 yr. Before risk adjustment, there were age differences in (1) depression screening/treatment, (2) blood pressure goals, and (3) LDL levels. After we adjusted for patient sociodemographic, clinical, and facility-level characteristics by using hierarchical linear mixed modeling, none of these differences remained significant but INR goals for patients discharged on warfarin differed significantly by age. After we adjusted for patient and facility characteristics, fewer age differences were found in the postdischarge stroke QIs. Clinical trial registration was not required.
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    Rural-Urban Differences in Inpatient Quality of Care in US Veterans With Ischemic Stroke
    (2014-06) Phipps, Michael S.; Jia, Huanguang; Chumbler, Neale R.; Li, Xinli; Castro, Jaime G; Myers, Jennifer; Williams, Linda S.; Bravata, Dawn M.
    Purpose Differences in stroke care quality for patients in rural and urban locations have been suggested, but whether differences exist across Veteran Administration Medical Centers (VAMCs) is unknown. This study examines whether rural-urban disparities exist in inpatient quality among veterans with acute ischemic stroke. Methods In this retrospective study, inpatient stroke care quality was assessed in a national sample of veterans with acute ischemic stroke using 14 quality indicators (QIs). Rural-Urban Commuting Areas codes defined each VAMC's rural-urban status. A hierarchical linear model assessed the rural-urban differences across the 14 QIs, adjusting for patient and facility characteristics, and clustering within VAMCs. Findings Among 128 VAMCs, 18 (14.1%) were classified as rural VAMCs and admitted 284 (7.3%) of the 3,889 ischemic stroke patients. Rural VAMCs had statistically significantly lower unadjusted rates on 6 QIs: Deep vein thrombosis (DVT) prophylaxis, antithrombotic at discharge, antithrombotic at day 2, lipid management, smoking cessation counseling, and National Institutes of Health Stroke Scale completion, but they had higher rates of stroke education, functional assessment, and fall risk assessment. After adjustment, differences in 2 QIs remained significant—patients treated in rural VAMCs were less likely to receive DVT prophylaxis, but more likely to have documented functional assessment. Conclusions After adjustment for key demographic, clinical, and facility-level characteristics, there does not appear to be a systematic difference in inpatient stroke quality between rural and urban VAMCs. Future research should seek to understand the few differences in care found that could serve as targets for future quality improvement interventions.
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    Study protocol: home-based telehealth stroke care: a randomized trial for veterans
    (BMC, 2010-06-30) Chumbler, Neale R.; Rose, Dorian K.; Griffiths, Patricia; Quigley, Patricia; McGee-Hernandez, Nancy; Carlson, Katherine A.; Vandenberg, Phyllis; Morey, Miriam C.; Sanford, Jon; Hoenig, Helen; Medicine, School of Medicine
    Background Stroke is one of the most disabling and costly impairments of adulthood in the United States. Stroke patients clearly benefit from intensive inpatient care, but due to the high cost, there is considerable interest in implementing interventions to reduce hospital lengths of stay. Early discharge rehabilitation programs require coordinated, well-organized home-based rehabilitation, yet lack of sufficient information about the home setting impedes successful rehabilitation. This trial examines a multifaceted telerehabilitation (TR) intervention that uses telehealth technology to simultaneously evaluate the home environment, assess the patient's mobility skills, initiate rehabilitative treatment, prescribe exercises tailored for stroke patients and provide periodic goal oriented reassessment, feedback and encouragement. Methods We describe an ongoing Phase II, 2-arm, 3-site randomized controlled trial (RCT) that determines primarily the effect of TR on physical function and secondarily the effect on disability, falls-related self-efficacy, and patient satisfaction. Fifty participants with a diagnosis of ischemic or hemorrhagic stroke will be randomly assigned to one of two groups: (a) TR; or (b) Usual Care. The TR intervention uses a combination of three videotaped visits and five telephone calls, an in-home messaging device, and additional telephonic contact as needed over a 3-month study period, to provide a progressive rehabilitative intervention with a treatment goal of safe functional mobility of the individual within an accessible home environment. Dependent variables will be measured at baseline, 3-, and 6-months and analyzed with a linear mixed-effects model across all time points. Discussion For patients recovering from stroke, the use of TR to provide home assessments and follow-up training in prescribed equipment has the potential to effectively supplement existing home health services, assist transition to home and increase efficiency. This may be particularly relevant when patients live in remote locations, as is the case for many veterans. Trial Registration Clinical Trials.gov Identifier: NCT00384748