Patients with Parkinson's disease (PD) and essential tremor (ET) can experience deficits in executive functioning (EF) secondary to abnormalities in fronto-striatal and cerebellar-frontal pathways respectively. The assessment of EF can be confounded in these patients due to motor difficulties and slowed processing speed. Thus, instruments which do not require speeded motor responses are potentially attractive in this population. The Neuropsychological Assessment Battery-Categories Test (NABCAT) is one such instrument. This study evaluated the convergent and divergent validity of this measure as well as its diagnostic accuracy in comparison to other commonly administered tests. Records for 28 patients with PD and/or ET who presented for evaluation pre-deep brain stimulation surgery were analyzed. The NABCAT had modest correlations with other measures of EF, as well as memory. However, it demonstrated relatively poor sensitivity and modest specificity to executive dysfunction. The NABCAT did not demonstrate adequate psychometric properties to replace traditional measures of EF in this population; however, it may have utility as a screening instrument for more significant dysfunction.
Background/Aim: Patient engagement in healthcare is potentially important for moderating risks for adverse events and rehospitalization during hospitalto-home transitions. However, little is known about whether patients' behaviors actually impact outcomes following hospital discharge. The aim of this study was to describe the impact of medication adherence on risk for rehospitalization and ER visits following hospitalization for Medicare beneficiaries enrolled in a Medicare cost contract HMO offered by Scott & White Health Plan. Methods: Claims data from June 2006 to June 2008 were selected for all SeniorCare patients who had at least one hospitalization during 2007. The first hospitalization of the year was considered the index hospitalization. Medication adherence in the six months prior to index hospitalization was estimated using the Medication Possession Ratio (MPR). Time to rehospitalization and time to ER visit were calculated from the index hospitalization date of discharge to the event date or last follow-up date. Results: The analysis included 3,729 members with at least one hospitalization during 2007. Median age was 78 (range 27-105) and 57% of those patients were female. The cumulative incidence of rehospitalization at 6 months was 12.2% (95% confidence interval = 11.1%, 13.4%). The cumulative incidence of ER visits at 6 months was 21.2% (95% Confidence Interval = 19.8%, 22.7%). Median MPR in the six months prior to the index hospitalization was 0.85 (range 0.01-1) with 62% of patients with MPRs representative of "high" adherence to prescribed medications. Medication adherence was not significantly associated with rehospitalization or ER visits following hospitalization. Conclusion: Most guidelines and interventions for care transitions following hospitalization emphasize the important role of patient or family health behaviors, including medication adherence. No evidence was found that supports the hypothesis that history of adherence to medications is associated with a reduced risk for rehospitalization or ER use. Prospective studies of patient health behaviors during hospital transitions are needed to better understand the impact of patient health behaviors during the time following hospitalization.
Background and Objective:
Stroke deficits frequently alter patient medical decision-making capacity (
MDC
) resulting in lost trial recruitment and reducing validity of qualitative outcome measures. Since no standardized tool exists for MDC evaluation in stroke, we tested a validated standardized questionnaire used for medical patients, the Aid to Capacity Evaluation (
ACE
), vs. independent clinician assessment in mild-to-moderate severity stroke patients. We hypothesized that the ACE would show similar agreement with clinicians and therefore be appropriate for rapid bedside screening for MDC.
Methods:
Ischemic or hemorrhagic stroke patients underwent 3 independent capacity assessments by a medical student (ACE), psychiatrist (
PS
) and neuropsychologist (
NP
). Inter-rater reliability was assessed using intraclass correlation (
ICC
) and Cohen’s kappa. Assuming the clinician as the gold-standard, we tested sensitivity and specificity vs. ACE.
Results:
All planned 30 patients (90% ischemic; mean age 67.8; 60% male; median NIHSS = 6) were prospectively enrolled between 7/13- 8/13. The median time from stroke onset to first capacity assessment was 3.3 days. 11 (37%) had aphasia and/or neglect and 38% had left hemispheric stroke (see table). ACE agreed with PS and NP in 59% (kappa 0.293; 95% CI 0.08-0.51) and 76% (kappa 0.494; 95% CI 0.19-0.80) of cases, respectively. Despite low sensitivity and NPV, specificity and PPV of ACE vs. clinicians ranged 88-100%; only classifying 1 patient capable when clinicians scored incapable. ICC among all raters was 0.474 (95% CI 0.25-0.68).
Conclusions:
There was fair overall agreement between a standardized questionnaire and expert clinicians. The ACE was highly specific in identifying mild-to-moderate severity stroke patients who lacked MDC. The ACE might be a useful screening tool to determine
lack
of capacity
in stroke patients, but low sensitivity for identifying
presence
of capacity
warrants caution and further study.
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