Developing a new metric for ADLs

Risk of hospitalization associated with different constellations of home & community based services

BACKGROUND

Identify the association between specific combinations of home and community-based services (HCBS) and risk of acute hospitalization.

METHODS

Data for this study came from Pennsylvania Medicaid claims and Medicare records. This was a retrospective, observational cohort study that examined hospitalization, HCBS service use and patient characteristics between July, 2014 and December, 2016. This analysis compared risk of inpatient hospitalization risk for community dwelling disabled older adults using a range of Medicaid financed HCBS. Twelve constellations of HCBS were identified representing different combinations of common services (personal assistive services [PAS], delivered meals, and adult day care). Since HCBS users are not randomly assigned to different combinations of services, we used logistic regression to estimate the predicted probability of experiencing hospitalization conditional on the constellation of services, and adjusting for demographics, health and level of disability.

RESULTS

The most common constellation was people who used under four hours of PAS per person per day. This group experienced a hospitalization rate of 13.7%. however, those individuals receiving more than 4 h per person per day experienced only a 10.2% hospitalization rate. Similar trends were seen for people who used PAS in combination with home delivered meals. However, those who used adult day care experienced higher hospitalization rates as the number of hours of personal assistive service increased: increasing from 6.8% among those with under 4 h, to 8.6% among those with 8 or more hours per person per day.

CONCLUSION

Using medium and high levels of PAS was associated with lower hospitalization risk for people who PAS alone or in combination with delivered meals. By contrast, higher levels of PAS was associated with increased hospitalization for adult day users (both alone or in combination). Policy makers should consider offering higher levels of PAS to offset potential risk of hospitalization. Future research is needed to explain the association between adult day care and risk.

Technology-based support for stroke caregiving: A rapid review of evidence

AIM

This rapid review examines the technology-based interventions for caregivers of stroke proposed in the literature while also identifying the acceptance, effectiveness and satisfaction of the implemented approaches.

BACKGROUND

The increasing burden of supporting stroke survivors has resulted in caregivers searching for innovative solutions, such as technology-based interventions, to provide better care. Hence, its potential to support caregivers throughout the disease trajectory needs to be assessed.

EVALUATION

Five electronic databases were systematically searched for articles related to stroke caregiving technologies based on well-defined inclusion and exclusion criteria.

KEY ISSUE(S)

Fifteen articles met the inclusion criteria that focused on supporting caregivers through functionalities such as education, therapy and support, remote consultations, health assessments and logs and reminders using different devices. The majority of interventions demonstrated positive conclusions for caregiving impact, acceptance, effectiveness and satisfaction.

CONCLUSION

Findings highlight the influences of technology in improving stroke caregiving and the need to include user-centred design principles to create a meaningful, actionable and feasible system for caregivers.

IMPLICATIONS FOR NURSING MANAGEMENT

Technology can educate and support stroke caregivers, thereby minimizing uncertainty and ensuring better care for the survivor.

Patterns of Home and Community Based Service Use by Beneficiaries Enrolled in the Pennsylvania Medicaid Aging Waiver

BACKGROUND

This study examines multiple services are used across a population and the association between type and amount of services use with level of disability and living arrangement.

METHODS

This is a descriptive cross-sectional analysis examining HCBS use among older Pennsylvanians from 2014 to 2016 enrolled in Pennsylvania's 1915(c) waiver program. Data were derived from Medicaid claims. Logistic regression and OLS regression were used to examine the association between service use and level of disability, controlling for age, gender, race, and other covariates.

RESULTS

People with Alzheimer's or a related dementia were more likely to use adult day care. People with higher ADL and IADL limitations were more likely to use higher amounts of PAS and less likely to have delivered meals.

CONCLUSIONS

These findings demonstrate HCBS is a complex package of services that are allocated regarding the level of need and resources available to individual program participants.

Functional Effects of Intervening Illnesses and Injuries After Hospitalization for Major Surgery in Community-living Older Persons

OBJECTIVE

To evaluate the functional effects of intervening illnesses and injuries, that is, events, in the year after major surgery.

BACKGROUND

Intervening events have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after major surgery.

METHODS

From a cohort of 754 community-living persons, aged 70+ years, 317 admissions for major surgery were identified from 244 participants who were discharged from the hospital. Functional status (13 activities) and exposure to intervening hospitalizations, emergency department (ED) visits, and restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months.

RESULTS

In the year after major surgery, exposure rates (95% CI) per 100-person months to hospitalizations, ED visits, and restricted activity were 10.0 (8.0-12.5), 3.9 (2.8-5.4), and 12.3 (10.2-14.8) for functional recovery and 7.2 (6.1-8.5), 2.5 (1.9-3.2), 11.2 (9.8-12.9) for functional decline. Each of the 3 intervening events were independently associated with reduced recovery, with adjusted hazard ratios (95% CI) of 0.20 (0.09-0.47), 0.35 (0.15-0.81), and 0.57 (0.36-0.90) for hospitalizations, ED visits, and restricted activity. For functional decline, the corresponding odds ratios (95% CI) were 5.68 (3.87-8.33), 1.90 (1.13-3.20), and 1.30 (0.96-1.75). The effect sizes for hospitalizations and ED visits were larger than those for the covariates.

CONCLUSIONS

Intervening illnesses/injuries are common in the year after major surgery, and those leading to hospitalization and ED visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors.

Functional Effects of Intervening Illnesses and Injuries After Critical Illness in Older Persons

OBJECTIVES

Intervening illnesses and injuries have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after critical illness. We set out to evaluate the functional effects of intervening illnesses and injuries in the year after critical illness.

DESIGN

Prospective longitudinal study of 754 nondisabled community-living persons, 70 years old or older.

SETTING

Greater New Haven, CT, from March 1998 to December 2018.

PATIENTS

The analytic sample included 250 ICU admissions from 209 community-living participants who were discharged from the hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Functional status (13 activities) and exposure to intervening illnesses and injuries leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months. In the year after critical illness, recovery of premorbid function was observed for 169 of the ICU admissions (67.6%), and the mean (sd) number of episodes of functional decline (from 1 mo to the next) was 2.2 (1.6). The adjusted hazard ratios (95% CI) for recovery were 0.18 (0.09-0.39), 0.46 (0.17-1.26), and 0.75 (0.48-1.18) for intervening hospitalizations, emergency department visits, and restricted activity, respectively. For functional decline, the corresponding odds ratios (95% CI) were 2.06 (1.56-2.73), 1.78 (1.12-2.83), and 1.25 (0.92-1.69). The effect sizes for hospitalization and emergency department visit were larger than those for any of the covariates.

CONCLUSIONS

In the year after critical illness, intervening illnesses and injuries leading to hospitalization and emergency department visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors. To improve functional outcomes, more aggressive efforts will be needed to prevent and manage intervening illnesses and injuries after critical illness.

Change in Functional Status After Prostate Cancer Treatment Among Medicare Advantage Beneficiaries

OBJECTIVE

To examine the relationship between treatment and subsequent functional status among prostate cancer patients.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data, we identified men 65 years or older diagnosed with prostate cancer between 1998 and 2009 (follow-up through 2010) who were treated with conservative management, surgery, or radiation. Our primary outcome was functional status as measured by activities of daily living. Secondary outcomes included physical component summary and mental component summary scores, which are both calculated from the Short Form 36 (SF-36) and the Veterans RAND 12-item health survey (VR-12) questionnaires. We included patients who completed 2 surveys and performed propensity score analyses to match patients 1:5 with noncancer controls. We used generalized linear mixed effects models, accounting for clustering due to insurance plan.

RESULTS

We identified 408 patients of whom 143 (35%) underwent conservative management, 59 (14%) underwent surgery, and 206 (51%) underwent radiation. Among conservative management and radiation patients, changes in functional status mirrored that of their noncancer controls (all P > .05). Among surgery patients, changes in activities of daily living scores were not significant, but physical component summary (mean difference = 4.5, P < .001) and mental component summary (mean difference = 3.3, P = .01) scores declined slightly more than for their noncancer peers.

CONCLUSION

Surgery patients had a slight decline in their general functional status whereas conservative management and radiation patients had no differences in functional status compared with their noncancer peers. Although the functional status of surgery patients declined more than that of their noncancer peers, this difference may not be clinically significant.

Validity of questions about activities of daily living to screen for dependency in older adults

OBJECTIVE

To determine the criterion validity of the activities of daily living present in functionality questionnaires in older adults for population surveys and to identify which activities are valid to quantify the real daily need for help of this population.

METHODS

This is a population sample of older adults stratified by levels of functionality, according to self-perception of dependency in the activities of daily living. Self-perception was compared with the gold standard – direct observation of these activities in the household of older adults by a trained professional, blinded to the answers in the questionnaire. At the visit, it was decided if the older adult needed help to perform any of the activities of daily living for the research. The sensitivity of each activity of daily living was greater when the self-assessment that there was no need for help coincided with the assessment of the professional. Specificity indicates coincidence regarding the need for help in the activities of daily living – coefficients of sensitivity and specificity above 70% were considered as indicative of good validity.

RESULTS

Self-assessments showed better sensitivity than specificity – older adults and observers agreed more on daily independency than on dependency. All activities showed sensitivity above 70%. Some activities had low (go shopping: 55%) or very low specificity (brush the hair: 33%). The best specificities were to take a shower and dress up (95.8% for both), among the personal ones, and to use transportation and perform banking transactions (78% for both), among the instrumental ones.

CONCLUSIONS

Activities of daily living can be valid indicators of functional dependence. The best coefficients of validity were generally obtained for personal activities. Some activities with good sensitivities and specificities – walk 100 meters, take a shower, and lie down in and get out of the bed – can be used to classify older adults into low, average, and high need for help depending on the affected activities and, therefore, can help in the planning of health services aimed at them.

Effects of Posthospital Informal Care on Nursing Home Discharge

This study examines the effect of family caregiving on the probability that nursing home residents would be discharged to the community. The effect of the number of hours of informal care on the probability of nursing home discharge was estimated using a logistic regression of a 6-week postadmission location (home or institution) on the number of hours of informal care in the first 2 weeks in the nursing home, of caregiver visits, and other patient factors. The odds of being discharged to their home were higher for those who received more care that is informal. Informal care may increase the quality and the amount of care that residents receive, thus, influencing rehabilitation outcomes and returns to home. Caregiving families may advocate for residents and signal to nursing home staff that the resident has a well-functioning support system.

Functional Decline in Residents Living in Nursing Homes: A Systematic Review of the Literature

OBJECTIVES

To describe the functional dependence progression over time in older people living in nursing homes (NHs).

DESIGN

A systematic review of the literature was performed. Studies involving individuals 65 years and older living in NHs, describing their functional decline, improvement or stability in activities of daily living (ADLs), were eligible. The search strategy was applied in MedLine, Cochrane, CINAHL, and SCOPUS databases; aimed at identifying an unbiased and complete list of studies, searching by hand was also performed. The methodological quality of the 27 studies included was assessed.

RESULTS

Functional trajectories were documented mainly through multicenter study design including sample size ranging from 2 to 9336 NHs, from 1983 to 2011 throughout a single or multiple follow-ups (>20). The average rate of decline was expressed in different metrics and periods of time: from 3 months with a decline of -0.13 points of 28, to 6 months (-1.78 points of 2829) to 1.85 years (-0.5 points of 6). Eating and toileting were the most documented ADLs and the decline is approximately 0.4 points and 0.2 to 0.4 points of 5 a year, respectively. Among the covariates, individual factors, such as cognitive status, were mainly considered, whereas only 13 studies considered facility-level factors.

CONCLUSIONS

Findings report the slow functional decline mainly in women living in US NHs, in years when residents were admitted with a low or medium degree of functional dependence. Considering that in recent years residents have been admitted to NHs with higher-level functional dependence, studies measuring each single ADL, using standardized instruments capable of capturing the signs of decline, stability, or improvement are strongly recommended. Among the covariates, evaluation of both individual and facility-level factors, which may affect functional decline, is also suggested.

Prevalence of Advance Directives Among Older Adults Admitted to Intensive Care Units and Requiring Mechanical Ventilation

Because older adults are at high risk for hospitalization and potential decisional incapacity, advance directives are important components of pre-hospital advanced care planning, as they document individual preferences for future medical care. The prevalence of pre-hospital advance directive completion in 450 critically ill older adults requiring mechanical ventilation from two Mid-Atlantic hospitals is described, and demographic and clinical predictors of pre-hospital advance directive completion are explored. The overall advance directive completion rate was 42.4%, with those in older age groups (75 to 84 years and 85 and older) having approximately two times the odds of completion. No significant differences in the likelihood of advance directive completion were noted by sex, race, or admitting diagnosis. The relatively low prevalence of advance directive completion among older adults with critical illness and high mortality rate (24%) suggest a need for greater awareness and education.

Do Technology-Based Support Groups Reduce Care Burden Among Dementia Caregivers? A Review

Technology-based support groups for caregivers are often more accessible and convenient than attending face-to-face support groups. In this review the author examines the effectiveness of technology-based social support groups on reducing care burden among caregivers of individuals with dementia. Studies were identified through 10 online bibliographic databases.

INCLUSION CRITERIA

(a) published before June 2013, (b) rigorous study design, (c) English language, (d) peer-reviewed journals, (e) home-based care, (f) telephone and/or Internet support group utilized at home, and (g) outcome measure of care burden or caregiver stress. Technology-based social support groups enjoy a modest level of positive outcomes, appear to be low cost, and pose little risk of harmful effects while reducing care burden in caregivers. Based on the five studies reviewed, technology-based support group services have demonstrated a positive impact on reducing care burden among dementia caregivers; and improve support networks similarly to the way face-to-face support groups connect participants.

The Effect of Transitions in Caregiving Status and Intensity on Perceived Stress Among 992 Female Caregivers and Noncaregivers

BACKGROUND

Informal caregiving, a chronic stressor, is also a dynamic experience, as caregivers may repeatedly enter and exit the role and alter the amount of care they provide. Changes in caregiving status and intensity influence stress, but few studies have evaluated the simultaneous impact of these changes on perceived stress.

METHODS

A total of 1,027 female caregivers and noncaregivers (mean age = 81.7), of which 992 were included in the final sample, were followed for at least two consecutive annual interviews (ie, one interval) and up to five interviews over a 9-year period. Caregiving status was measured by self-report of whether the respondent assisted someone with at least one basic or instrumental activity of daily living; caregiving intensity was dichotomized at the median number of basic or instrumental activity of daily living tasks caregivers performed. The associations between changes in caregiving status and intensity level with Perceived Stress Scale (PSS) score at the end of an interval were estimated using mixed-effects regression models.

RESULTS

Respondents contributed 2,832 intervals. High-intensity caregivers reported the highest stress at the end of an interval, whereas noncaregivers reported the lowest (mean PSS = 18.97 vs 15.73, p < .01). Low-intensity caregivers, whose intensity increased, had higher stress than continuing high-intensity caregivers. Those who stopped caregiving, regardless of intensity level, reported the same amount of stress as noncaregivers.

CONCLUSIONS

Transitions in caregiving status and intensity affect caregiver perceived stress. Continuing high-intensity caregivers and those who transition from low- to high-intensity caregiving report the highest stress of all transition groups, suggesting that stress-reduction interventions should target high-intensity caregivers.

How Older Persons Structure Information in the Decision to Seek Medical Care

Typical models of the decision to seek care consider information as a single conceptual object. This paper presents an alternative that allows multiple objects. For older persons seeking care, results support this alternative. Older decision-makers that segregate information into multiple conceptual objects assessed separately are characterized by socio-demographic (younger age, racial category, non-Hispanic, higher education, higher income, and not married), health status (better general health for men and worse general health for women, fewer known illnesses), and neuropsychological (less memory loss for men, trouble concentrating and trouble making decisions for men) factors. Results of this study support the conclusion that older persons are more likely to integrate information, and individuals with identifiable characteristics are more likely to do so than others. The theory tested in this study implies a potential explanation for misutilization of care (either over or under-utilization).

Activity of daily living trajectories surrounding acute hospitalization of long-stay nursing home residents

OBJECTIVES

To explore patterns of change in nursing home (NH) residents' activities of daily living (ADLs), particularly surrounding acute hospital stays.

DESIGN

Longitudinal study using Medicare and Minimum Data Set (MDS) assessments.

SETTING

National sample of long-stay NH residents.

PARTICIPANTS

NH residents who were hospitalized for the seven most-common inpatient diagnoses (N = 40,128). Each hospital admission was at least 90 days after any prior hospitalization and had at least two preceding MDS assessments.

MEASUREMENTS

The MDS ADL long-form score, a simple sum of seven self-care variables coded from 0 (independent) to 4 (totally dependent) was used to indicate resident ADL function. Scores ranged from 0 to 28, with higher scores indicating greater impairment. A linear mixed model describing ADL trajectories was jointly estimated with time-to-event models for mortality and hospital readmission.

RESULTS

Before hospitalization, the most common trajectory was stable (53.7%), with 27.5% of residents worsening and 18.8% improving. ADL function after hospital discharge was most often characterized as stable (43.1%) or worsening (39.2%). Mortality (20.3%) was higher for those with worsening prehospital ADL function (28.9%) than for those with stable (19.1%) or improving (11.3%) trajectories. Hospital diagnosis was associated with amount of ADL worsening and rate of subsequent ADL change. Most residents with the best initial function continued to worsen after hospital discharge. Cognitive impairment was associated with poorer ADL function and accelerated worsening of ADLs.

CONCLUSION

For many long-stay NH residents, substantial and sustained ADL worsening accompanies acute hospitalization, so acute hospitalization presents an opportunity to revisit care goals; the results of the current study can help inform decision-making.

Are IADLs comparable across countries? Sociodemographic associates of harmonized IADL measures

BACKGROUND AND AIMS

Independence in Instrumental Activities of Daily Living (IADLs) is determined not only by physical ability but also by the environmental and cultural surroundings of the individual. The present study describes the harmonization of data on IADL functioning of the Comparison of Longitudinal European Studies on Aging (CLESA) Project. The focus of this report is to examine the comparability of IADLs across countries and to study the association of IADLs with age, gender and socioeconomic status, and the scalability of the measure.

METHODS

The study base includes data from five European countries (Finland, Italy, The Netherlands, Spain, Sweden) and Israel, for older people aged 65-89 living both in the community and in institutions, for a total of 11,557 subjects. In this report, only community-dwelling respondents were included (N=8420). The common IADL items in all six countries were: preparing meals, shopping, and doing housework. The analyses include how these items are distributed by age group and gender, and the associations between independence in these items and socioeconomic status (SES) with logistic regression modeling. The scale properties of these three items are also examined.

RESULTS

Independence in IADLs decreases steadily with age in all countries. Associations with gender and SES follow largely similar patterns across countries. The reliability of the 3-item scale is satisfactory in most countries, and Cronbach's alpha-coefficient for the complete CLESA sample was 0.75.

CONCLUSIONS

The associations between sociodemographic variables and independence in preparing meals, shopping, and doing housework are similar across countries. Results suggest that the predictors of IADLs in different countries are comparable.

Patient-reported physical activity questionnaires: a systematic review of content and format

Background

Many patients with chronic illness are limited in their physical activities. This systematic review evaluates the content and format of patient-reported outcome (PRO) questionnaires that measure physical activity in elderly and chronically ill populations.

Methods

Questionnaires were identified by a systematic literature search of electronic databases (Medline, Embase, PsychINFO & CINAHL), hand searches (reference sections and PROQOLID database) and expert input. A qualitative analysis was conducted to assess the content and format of the questionnaires and a Venn diagram was produced to illustrate this. Each stage of the review process was conducted by at least two independent reviewers.

Results

104 questionnaires fulfilled our criteria. From these, 182 physical activity domains and 1965 items were extracted. Initial qualitative analysis of the domains found 11 categories. Further synthesis of the domains found 4 broad categories: 'physical activity related to general activities and mobility', 'physical activity related to activities of daily living', 'physical activity related to work, social or leisure time activities', and '(disease-specific) symptoms related to physical activity'. The Venn diagram showed that no questionnaires covered all 4 categories and that the '(disease-specific) symptoms related to physical activity' category was often not combined with the other categories.

Conclusions

A large number of questionnaires with a broad range of physical activity content were identified. Although the content could be broadly organised, there was no consensus on the content and format of physical activity PRO questionnaires in elderly and chronically ill populations. Nevertheless, this systematic review will help investigators to select a physical activity PRO questionnaire that best serves their research question and context.

A comprehensive systematic review of the development process of 104 patient-reported outcomes (PROs) for physical activity in chronically ill and elderly people

BACKGROUND

Capturing dimensions of physical activity relevant to patients may provide a unique perspective for clinical studies of chronically ill patients. However, the quality of the development of existing instruments is uncertain. The aim of this systematic review was to assess the development process of patient-reported outcome (PRO) instruments including their initial validation to measure physical activity in chronically ill or elderly patient populations.

METHODS

We conducted a systematic literature search of electronic databases (Medline, Embase, Psychinfo, Cinahl) and hand searches. We included studies describing the original development of fully structured instruments measuring dimensions of physical activity or related constructs in chronically ills or elderly. We broadened the population to elderly because they are likely to share physical activity limitations. At least two reviewers independently conducted title and abstract screening and full text assessment. We evaluated instruments in terms of their aim, items identification and selection, domain development, test-retest reliability, internal consistency, validity and responsiveness.

RESULTS

Of the 2542 references from the database search and 89 from the hand search, 103 full texts which covered 104 instruments met our inclusion criteria. For almost half of the instruments the authors clearly described the aim of the instruments before the scales were developed. For item identification, patient input was used in 38% of the instruments and in 32% adaptation of existing scales and/or unsystematic literature searches were the only sources for the generation of items. For item reduction, in 56% of the instruments patient input was used and in 33% the item reduction process was not clearly described. Test-retest reliability was assessed for 61%, validity for 85% and responsiveness to change for 19% of the instruments.

CONCLUSIONS

Many PRO instruments exist to measure dimensions of physical activity in chronically ill and elderly patient populations, which reflects the relevance of this outcome. However, the development processes often lacked definitions of the instruments' aims and patient input. If PROs for physical activity were to be used in clinical trials more attention needs to be paid to the establishment of content validity through patient input and to the assessment of their evaluative measurement properties.

Item response theory: how Mokken scaling can be used in clinical practice

AIMS

To demonstrate the principles and application of Mokken scaling.

BACKGROUND

The history and development of Mokken scaling is described, some examples of applications are given, and some recent development of the method are summarised.

DESIGN

Secondary analysis of data obtained by cross-sectional survey methods, including self-report and observation.

METHODS

Data from the Edinburgh Feeding Evaluation in Dementia scale and the Townsend Functional Ability Scale were analysed using the Mokken scaling procedure within the 'R' statistical package. Specifically, invariant item ordering (the extent to which the order of the items in terms of difficulty was the same for all respondents whatever their total scale score) was studied.

RESULTS

The Edinburgh Feeding Evaluation in Dementia scale and the Townsend Functional Ability Scale showed no violations of invariant item ordering, although only the Townsend Functional Ability Scale showed a medium accuracy.

CONCLUSION

Mokken scaling is an established method for item response theory analysis with wide application in the social sciences. It provides psychometricians with an additional tool in the development of questionnaires and in the study of individuals and their responses to latent traits. Specifically, with regard to the analyses conducted in this study, the Edinburgh Feeding Evaluation in Dementia scale requires further development and study across different levels of severity of dementia and feeding difficulty.

RELEVANCE TO CLINICAL PRACTICE

Good scales are required for assessment in clinical practice and the present paper shows how a relatively recently developed method for analysing Mokken scales can contribute to this. The two scales used as examples for analysis are highly clinically relevant.

Disability among elderly survivors of mechanical ventilation

RATIONALE

Studies of long-term functional outcomes of elderly survivors of mechanical ventilation (MV) are limited to local samples and biased retrospective, proxy-reported preadmission functional status.

OBJECTIVES

To assess the impact on disability of hospitalization with MV, compared with hospitalization without MV, accounting for prospectively assessed prior functional status.

METHODS

Retrospective population-based longitudinal cohort study of Medicare beneficiaries age 65 and older enrolled in the Medicare Current Beneficiary Survey, 1996-2003.

MEASUREMENTS AND MAIN RESULTS

Premeasures and postmeasures of disability included mobility difficulty and weighted activities of daily living disability scores ranging from 0 (not disabled) to 100 (completely disabled) based on self-reported health and functional status collected 1 year apart. Among 54,771 person-years (PY) of observation over 7 calendar years of data, 42,890 PY involved no hospitalization, 11,347 PY involved a hospitalization without MV, and 534 PY included a hospitalization with MV. Mortality at 1 year was 8.9%, 23.9%, and 72.5%, respectively. The level of disability at the postassessment was substantially higher for a prototypical patient who survived after hospitalization with MV (adjusted activities of daily living disability score [95% confidence interval] 14.9 [12.2-17.7]; adjusted mobility difficulty score [95% confidence interval] 25.4 [22.4-28.4]) compared with an otherwise identical patient who survived hospitalization without MV (11.5 [11.1-11.9] and 22.3 [21.8-22.9]) or who was not hospitalized (8.0 [7.9-8.1] and 13.4 [13.3-13.6]).

CONCLUSIONS

The greater marginal increase in disability among survivors of MV compared with survivors of hospitalization without MV is larger than would be predicted from prior functional status.

Measuring care of the elderly: psychometric testing and modification of the Time in Care instrument for measurement of care needs in nursing homes

Background

Aging entails not only a decrease in the ability to be active, but also a trend toward increased dependence to sustain basic life functions. An important aspect for appropriately elucidating the individual's care needs is the ability to measure them both simply and reliably. Since 2006 a new version of the Time in Care needs (TIC-n) instrument (19-item version) has been explored and used in one additional municipality with the same structure as the one described in an earlier study.

Methods

The TIC-n assessment was conducted on a total of 1282 care recipients. Factor analysis (principal component) was applied to explore the construct validity of the TIC-n. Cronbach's alpha was calculated to test reliability and for each of the items remaining in the instrument after factor analysis, an inter-rater comparison was carried out on all recipients in both municipalities. Independently of each other, a weighted Kappa (K_w) was calculated. Results. The mean of each weighted Kappa (K_w) for the dimensions in the two municipalities was 0.75 and 0.76, respectively. Factor analysis showed that all 19 items had a factor loading of ≥ 0.40. Three factors (General Care, Medical Care and Cognitive Care) were created.

Conclusion

The TIC-n instrument has now been tested for validity and reliability in two municipalities with satisfactory results. However, TIC-n can not yet be used as a golden standard, but it can be recommended for use of measurement of individual care needs in municipal elderly care.

Simple counts of ADL dependencies do not adequately reflect older adults' preferences toward states of functional impairment

OBJECTIVE

To use unweighted counts of dependencies in activities of daily living (ADLs) to assess the impact of functional impairment requires an assumption of equal preferences for each ADL dependency. To test this assumption, we analyzed standard gamble (SG) utilities of single and combination ADL dependencies among older adults.

STUDY DESIGN AND SETTING

Four hundred older adults used multimedia software (FLAIR1) to report SG utilities for their current health and hypothetical health states of dependency in each of 7 ADLs and 8 of 30 combinations of ADL dependencies.

RESULTS

Utilities for health states of multiple ADL dependencies were often greater than for states of single ADL dependencies. Dependence in eating, which is the ADL dependency with the lowest utility rating of the single ADL dependencies, ranked lower than 7 combination states. Similarly, some combination states with fewer ADL dependencies had lower utilities than those with more ADL dependencies. These findings were consistent across groups by gender, age, and education.

CONCLUSION

Our results suggest that the count of ADL dependencies does not adequately represent the utility for a health state. Cost-effectiveness analyses and other evaluations of programs that prevent or treat functional dependency should apply utility weights rather than relying on simple ADL counts.

The association between low vision and function

OBJECTIVE

This study considers the relationship between low vision and function, specifically exploring whether vision loss is differentially associated with activities of daily living (ADL) versus instrumental activities of daily living (IADL) disability.

METHODS

Guided by the World Health Organization's International Classification of Functioning, Disability, and Health framework, multinomial logistic regression analyses were performed for IADL and ADL on a sample of 9,115 adults aged 65 years and above from the 1998 Health and Retirement study.

RESULTS

The data supports the fact that ADL and IADL disabilities are associated with vision loss, and there is a differential relationship among functions, with IADLs being more challenging and requiring better visual abilities.

DISCUSSION

The findings provide evidence that ADL and IADLs require different skills and are associated differently depending on numerous variables. As the incidence of people living with vision loss is increasing to epidemic proportions due to an aging population, understanding the relationship between vision and participation in meaningful activities has important implications.

Cost-utility analysis of high- vs. low-intensity home- and community-based service interventions

Home- and community-based services (HCBS) have been advocated as a mechanism to delay institutionalization and reduce health care costs for the growing senior population. Studies of costs to date have found little evidence of cost savings from HCBS. However, HCBS can be thought to have two main benefits: delaying institutionalization and improving quality of life. Since cost and quality of life can be considered simultaneously in a cost-effectiveness analysis, an exploratory study was conducted to examine the relative cost-effectiveness of a high-dosage (i.e., high-intensity) HCBS intervention (i.e., 1915c Medicaid waiver) compared to a lower-dosage HCBS intervention (i.e., in-home aide service) using quality-adjusted life years as the measure of effectiveness. Findings indicated that high-dosage HCBS is not a cost-effective alternative. The low-dosage alternative allows for greater equity through provision of service to a larger pool of individuals in need.

Associations of physical activity and body mass index with activities of daily living in older adults

Research reports about the associations of leisure-time physical activity (LPA) and Body Mass Index (BMI) with activities of daily living (ADL)- or instrumental activities of daily living (IADL)-dependent disability in older adults are inconclusive. Data were obtained from the 2000 Missouri Older Adult Needs Assessment Survey. Logistic regression was used to examine the associations of LPA and BMI with ADL- or IADL-dependent disability, while controlling for factors known to be associated with LPA, BMI, ADL and IADL. ADL- or IADL-dependency decreased with LPA and increased with BMI regardless of each other's level, presence of functional limitation, education, gender, race-ethnicity, and health care coverage. Physically active individuals were less likely than inactive ones to be ADL- or IADL-dependent. BMI was modestly associated with ADL- or IADL-dependency and this relationship was confounded by LPA. If confirmed by well designed longitudinal studies, LPA and BMI independent associations with ADL- or IADL-dependent disability lends supports to a strategy for improving older adult quality of life through improved physical activity. Etiological studies on the associations between risk factors and quality of life outcomes in older adults should consider the joint confounding effect of LPA and BMI.

Caring for others: Internet video-conferencing group intervention for family caregivers of older adults with neurodegenerative disease

PURPOSE

The aim of this pilot feasibility study was to evaluate the effects of an innovative, Internet-based psychosocial intervention for family caregivers of older adults with neurodegenerative disease.

DESIGN AND METHODS

After receiving signed informed consent from each participant, we randomly assigned 66 caregivers to an Internet-based intervention or to a no-intervention control group. The intervention group received computers and training in order to access a password-protected Web site with links to information, e-mail, and threaded discussion. Unique to the Web site was a video-conferencing link that supported caregivers' participation in a 10-session, manual-guided psychosocial support group, followed by 12 additional online sessions facilitated by a group member. Participants completed health-status and stress-response measures at baseline and 6-month follow-up.

RESULTS

Content analysis of archived video sessions showed (a) reliable adherence to the manual-guided support-group intervention and (b) online group discussion themes similar to those in face-to-face caregiver support groups. Analyses of stress-response outcome data showed significant between-group differences, with the intervention group experiencing a decline in stress compared with an escalation in stress for the control group.

IMPLICATIONS

Despite the limitations of this pilot study in terms of limited sample size and 54% dropout of control participants at 6-month follow-up, the results provide preliminary supportive evidence for a technology-based psychosocial intervention for family caregivers of individuals with neurodegenerative disease.

Creating Needs-Based Tiered Models for Assisted Living Reimbursement

PURPOSE

This research provides state policy makers and others interested in developing needs-based reimbursement models for Medicaid-funded assisted living with an evaluation of different methodologies that affect the structure and outcomes of these models.

DESIGN AND METHODS

We used assessment data from Medicaid-enrolled assisted living residents and waiver-eligible community-dwelling individuals (N = 726) in order to evaluate five methodologies in the design of these tiered needs-based models. We used ordinary least squares regression analyses in order to evaluate each model's ability to predict the time needed to care for individuals with varying needs (e.g., activities of daily living limitations, dementia, special services.)

RESULTS

These models varied in fit from .127 to a high of .357 using the adjusted R2 statistic. Both count and weighted models adequately predicted service needs and discriminated individuals into their appropriate tiers well. Weighted models with the largest score range worked best and provided more flexibility.

IMPLICATIONS

Policy makers can tailor the generic tiered models developed with these methods to a state's population. Any state considering adoption of a needs-based tiered model will need to refine its model based on its assisted living population characteristics, its resources, and how the model fits its long-term care system. For the industry, these models can serve to identify levels of care needed in planning for staff time and skill mix required for assisted living as well as other long-term care populations.

Predicting nursing facility residents' quality of life using external indicators

PURPOSE

A newly developed brief measure of nursing facility (NF) resident self-reported quality of life (QOL) has been proposed for inclusion in a modified version of the minimum data set (MDS). There is considerable interest in determining whether it is possible to develop indicators of QOL that are more convenient and less expensive than direct, in-person interviews with residents.

DESIGN AND METHODS

QOL interview data from 2,829 residents living in 101 NFs using a 14-item version of a longer instrument were merged with data from the MDS and the Online Survey and Certification Automated Record (OSCAR). Bivariate and multivariate hierarchical linear modeling were used to assess the association of QOL with potential resident and facility level indicators.

RESULTS

Resident and facility level indicators were associated with self-reported QOL in the expected direction. At the individual resident level, QOL is negatively associated with physical function, visual acuity, continence, being bedfast, depression, conflict in relationships, and positively associated with social engagement. At the facility level, QOL is negatively associated with citations for failing to accommodate resident needs or providing a clean, safe environment. The ratio of activities staff to residents is positively associated with QOL. This study did not find an association between QOL and either use of restraints or nurse staff levels. Approximately 9 percent of the total variance in self-reported QOL can be attributed to differences among facilities; 91 percent can be attributed to differences among residents. Resident level indicators explained about 4 percent of the variance attributable to differences among residents, and facility factors explained 49 percent of the variance attributable to differences among NFs. However, the different variables explained only 10 percent of the variance in self-reported QOL.

IMPLICATIONS

A brief self-report measure of NF resident QOL is consistently associated with measures that can be constructed from extant data sources. However, the level of prediction possible from these data sources does not justify reliance on external indicators of resident QOL for policy purposes.

Improving risk adjustment for Medicare capitated reimbursement using nonlinear models

OBJECTIVES

This article compares a linear risk-adjusted model of medical expenditures for Medicare patients with a model that explicitly account for skewness in distribution of expenditures.

METHODS

A model of expenditures and a model of the square root of expenditures, each expressed as linear combinations of risk adjusters, are estimated using data from the 1992 through 1994 Medicare Current Beneficiary Surveys. Five sets of risk adjusters are considered. Each combination of model and set of risk adjusters is tested for linearity, heteroscedasticity, in-sample fit (R2), forecast performance (forecast bias and forecast mean squared error), and overfitting the data. We analyze forecast performance (1)based on forecasts in same year used for estimation, and (2)based on forecasts in the year following that used for estimation.

RESULTS

In the first analysis, the model using a square root transformation of expenditures as the dependent variable and the more parsimonious specification of risk adjusters performs best in terms of forecast squared error and overfitting. The untransformed model performs best in terms of forecast bias in each group based on severity of disability, with the exception of the severely disabled for whom the square root model is best. In the second analysis, the square root model performs better than the untransformed model in terms of forecast squared error, but neither model is statistically distinguishable from zero in terms of bias.

CONCLUSIONS

Accounting for skewness in expenditures tends to improve precision but not necessarily bias, except among the severely disabled. Adjusting for health status improves risk adjustment.

Measuring disability in Medicare home care patients: application of Rasch modeling to the outcome and assessment information set

BACKGROUND

The Outcome and Assessment Information Set (OASIS) is the universal clinical assessment tool for adult nonmaternity patients receiving skilled care at home from Medicare-certified home health agencies in the United States. Anticipating increased use of OASIS data for research purposes, this article explored the usefulness of Rasch modeling to address disability measurement challenges presented by the unique response category structure of the seven activities of daily living (ADL) and eight instrumental ADL (IADL) items in the OASIS.

OBJECTIVES

To illustrate how Rasch model statistics can be used to evaluate OASIS ADL and IADL item unidimensionality and model fit; to illustrate how Rasch modeling simultaneously estimates ADL and IADL item difficulty, thresholds between item response categories, and person disability; and to compare Rasch estimates of item difficulty and person disability scores to estimates based on more conventional Likert scoring techniques.

SUBJECTS

Medicare-eligible home health care patients (n = 583) served by one of 12 home care agencies in Ohio between November 1999 and September 2000.

MEASURES

ADL and IADL items were measured three ways: according to the original OASIS scoring (raw Likert); transformed raw Likert scores accounting for the nonuniform item structure (corrected Likert); and Rasch Partial Credit model scores.

RESULTS

The items bathing and telephone use showed evidence of unexpected response patterns; recoding of these items was necessary for good Rasch model fit. Partial Credit model results revealed that interval distances between response categories varied widely across the 15 ADL and IADL items. When ADL and IADL items were ranked by level of difficulty, results were similar between Rasch and corrected Likert measurement approaches; however, corrected Likert person scores were found to be nonlinear at highest and lowest disability levels when plotted against Rasch person scores.

CONCLUSIONS

Rasch modeling can help improve the precision of disability measurement in Medicare home care patients when using ADL and IADL items from the OASIS instrument.

Nursing home residents covered by Medicare risk contracts: early findings from the EverCare evaluation project

OBJECTIVES

To compare the characteristics of a sample of EverCare nursing home residents with two control groups: one composed of other residents in the same homes and another made up of residents in matched nursing homes. To compare levels of unmet need, satisfaction with medical care, and the use of advance directives.

DESIGN

Quasi-experimental design using two control groups to minimize selection effects. Information collected by in-person surveys of nursing home residents and telephone surveys of proxies and family members.

SETTING

Nursing homes affiliated with EverCare and matched control homes.

PARTICIPANTS

Nursing home residents and their family members.

MEASUREMENTS

Questionnaire addressing function (activities of daily living (ADLs)), unmet care needs, pain, use of advance directives, satisfaction, and caregiver burden.

RESULTS

In general, the experimental and control groups were similar, but the EverCare sample had more dementia and less ADL disability. Family members in the EverCare sample expressed greater satisfaction with several aspects of the medical care they received than did controls. Satisfaction of residents in the EverCare sample was more comparable with that of controls. There was no difference in experience with advance directives between EverCare and control groups.

CONCLUSIONS

EverCare appears to be a model of managed care worth tracking. It is producing care that is at least comparable with what is available in the fee-for-service environment, with evidence that families seem to appreciate the added attention. There is some suggestion that it has enrolled a less disabled but more demented population. Pending results on the effects of this care on hospitalization and emergency care should shed useful light.

Consumer responses to the Wisconsin Partnership Program for Elderly Persons: a variation on the PACE Model

BACKGROUND

The Wisconsin Partnership Program (WPP) is a variation on the Program for All-inclusive Care of the Elderly (PACE) model that is designed to be more flexible by allowing frail elderly dual-eligible (for both Medicare and Medicaid) clients to use their regular primary care physicians instead of relying on the physician hired by PACE. Case management is provided by a team of nurse, social worker, and nurse practitioner. The latter is charged with communicating with the client's primary physician.

METHODS

We compared the functional status and satisfaction of WPP elderly enrollees with those of two sets of dually eligible controls drawn from the Medicaid waiver rosters. One set of controls came from persons in the same county who opted not to enroll in WPP. The second came from matched counties that did not have access to the WPP. Enrollees were interviewed in person. Family members were interviewed by telephone.

RESULTS

The prevalence of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) dependency was lower for the WPP sample than that for the controls. The pattern of unmet needs was generally comparable. About half of each sample had a written advance directive. Overall, there were few areas of significant difference in beneficiaries' satisfaction. The WPP families were more satisfied than either control group that services were provided when needed and were better coordinated. There were no significant differences in the prevalence of any aspect of care burden.

CONCLUSIONS

The impact of WPP seems limited. There is some evidence that families perceive better coordinated care. A more complete evaluation will await the analysis of the differences in utilization patterns between WPP and the controls.

The Minnesota Senior Health Options program: an early effort at integrating care for the dually eligible

BACKGROUND

Duplication of funding and resultant inefficiencies have prompted active consideration of pooling the funding for persons covered by both Medicare and Medicaid into a single managed care program. This study reports the initial results of the first such program.

METHODS

A sample of enrollees in Minnesota Senior Health Options (MSHO) and two sets of controls (within the same catchment area and outside it) as well as their families were interviewed to assess their functional status and satisfaction with their medical care. Respondents included those living in the community and those living in nursing homes.

RESULTS

The MSHO and control samples were generally alike in terms of demographics and illness patterns. The differences that were found reflected those attributable to geographic location more than program. The groups were also similar with regard to functional status. There were few satisfaction differences among the community-dwelling samples, but the MSHO nursing residents and especially their families expressed more satisfaction with several aspects of care.

CONCLUSIONS

Whereas no causal conclusions about outcomes can be drawn from a cross-sectional sample, there is no indication that managed care for the dually eligible population has profound impacts on care. However, the system of care provided to nursing home residents is appreciated over traditional care.

Effects of using consumer and expert ratings of an activities of daily living scale on predicting functional outcomes of postacute care

To test the effects of using preference weights for activities of daily living (ADL) outcome measures derived from different sources, data from a large study of the outcomes of postacute care (PAC study) were analyzed using two different weightings for the ADL measures. Both were developed using the same magnitude estimation technique; one from a panel of long-term care experts (the expert rating system); the other from a group of elderly Medicare beneficiaries (the consumer rating system). Neither group was directly involved in the PAC study. Although ADL scores generated by both rating systems were highly correlated prior to hospitalization and at hospital discharge, the consumer and expert rating systems generated significantly different functional outcomes measured by the change of ADL scores with a few exceptions. Compared to the consumer rating system, the expert rating system generated a greater change in functional outcomes at each of three follow-up time points after hospital discharge. This study suggests that the choice of weights for ADL items is important.

Posthospitalization home health care use and changes in functional status in a Medicare population

OBJECTIVE

The objective of this work was to estimate the effect of Medicare beneficiaries' use of home health care (HHC) for 6 months after hospital discharge on the change in functional status over a 1-year period beginning before hospitalization.

DATA SOURCES AND STUDY SETTING

Data came from the Medicare Current Beneficiary Survey, which is a nationally representative sample of Medicare beneficiaries, in-person interview data, and Medicare claims for 1991 through 1994 for 2,127 nondisabled, community-dwelling, elderly Medicare beneficiaries who were hospitalized within 6 months of their annual in-person interviews.

STUDY DESIGN

Econometric estimation with the instrumental variable method was used to correct for observational data bias, ie, the nonrandom allocation of discharged beneficiaries to the use of posthospitalization HHC. The analysis estimates a first-stage model of HHC use from which an instrumental variable estimate is constructed to estimate the effect on change in functional status.

PRINCIPAL FINDINGS

The instrumental variable estimates suggest that HHC users experienced greater improvements in functional status than nonusers as measured by the change in a continuous scale based on the number and mix of activities of daily living and instrumental activities of daily living before and after hospitalization. The estimated improvement in functional status could be as large as 13% for a 10% increase in HHC use. In contrast, estimation with the observational data on HHC use implies that HHC users had poorer health outcomes.

CONCLUSIONS

Adjusting for potential observational data bias is critical to obtaining estimates of the relationship between the use of posthospitalization HHC and the change in health before and after hospitalization. After adjustment, the results suggest that efforts to constrain Medicare's spending for HHC, as required by the Balanced Budget Act of 1997, may lead to poorer health outcomes for some beneficiaries.

Development of multi-disciplinary team I-ADL assessment in community health care: an interrater reliability study of the measure of instrumental daily activity

This paper describes a development process concerning the active involvement of staff of different professions in developing and implementing methods for assessment of activities of daily living (ADL) in home-based geriatric rehabilitation. Although a variety of established ADL instruments exist, at the time for this study no I-ADL (Instrumental Activities of Daily Living) instrument suitable for communication among staff members of different professions was available. The specific aim was to test a new I-ADL instrument for interrater reliability. The developmental process resulting in the Measure of Instrumental Daily Activity (MIDA) is described. The instrument comprises 12 I-ADL items, defined on the basis of practical home rehabilitation experience. The study involved 36 clients with impairments, aged 65+ years. Multi-disciplinary interrater reliability was tested by 67 parallel independent assessments during a 3-month period, performed by pairs of raters of different professions. Overall agreement was very good (mean weighted kappa=0.89). The MIDA fulfils the basic requirements necessary for valid I-ADL assessment of elderly clients in community health care. An important quality is the active involvement of all staff in the assessment procedure, facilitating and stimulating the implementation of a general rehabilitative attitude in everyday practice.

Activities of daily living. Old-fashioned or still useful?

1 The Index of Activities of Daily Living (ADL) is used by many nurses to assess function in older adults, but there is debate regarding the scoring, wording of questions, and validity in diverse populations. 2 Older adults may give inaccurate answers to ADL questions because they misunderstand the questions, have personal reasons for underreporting or overreporting difficulty in ADL, or fail to recognize difficulty because they have adapted to changes in function. 3 Physical performance tests, especially of the lower extremities, may be an alternative method of assessing function, especially in high-functioning older adults who report no difficulty in ADL.

The relationship of self-rated vision and hearing to functional status and well-being among seniors 70 years and older

PURPOSE

To describe the relationship between self-reported visual and hearing impairment and an index of global functional status among seniors age 70 years or older.

METHODS

A total of 7,320 United States community-dwelling persons aged 70 years or older participating in the 1993 Assets and Health Dynamics of the Oldest Old Survey (AHEAD) completed detailed questionnaires about their demographic, socioeconomic, and health status. Multivariate analyses of functional status (using a global index of functional status based on self-reported limitations in 11 activities) were conducted, controlling for demographic and socioeconomic status and common medical conditions, as well as independently for hearing and vision.

RESULTS

Of the respondents, 27% rated their vision as fair or poor, whereas 25% rated their hearing as fair or poor. Controlling for demographic factors, socioeconomic status, medical conditions, and general health status, limitations in both vision and hearing correlated independently with worsened functional status. Controlling for income, wealth, and education did not greatly reduce the strength of the association between visual and hearing impairment and function.

CONCLUSIONS

Visual and hearing impairment appear to have a significant relationship to overall functioning in the oldest old, regardless of income or wealth. By confirming these findings across income and household wealth groups, adjusted for medical conditions and general health status, in a nationally representative population of Americans age 70 years or older, this study provides a powerful added impetus to efforts for improving vision and hearing for all other Americans, including the oldest old.

Do hip replacements improve outcomes for hip fracture patients?

BACKGROUND

Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority.

OBJECTIVES

To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation).

DESIGN

Prospective cohort study.

PARTICIPANTS

We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive.

MEASUREMENTS

We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year).

RESULTS

Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02).

CONCLUSIONS

Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.

The associations between self-rated vision and hearing and functional status in middle age

OBJECTIVES

To describe the associations between self-reported visual and hearing impairment and an index of global functional status among community-dwelling, middle-aged Americans.

DESIGN

Cross-sectional.

PARTICIPANTS

A total of 9744 U.S. community-dwelling persons 51 to 61 years of age participated.

METHODS

Multivariate analyses of functional status based on cross-sectional data from Wave I (1992) of the Health and Retirement Study (HRS), controlling for demographic and socioeconomic status, common chronic medical conditions, and general health status, were performed.

MAIN OUTCOME MEASURE

A global index of functional status based on self-reported limitations in 17 activities was measured.

RESULTS

Approximately 3% of respondents in the HRS rated their vision or hearing as poor. Even after controlling for demographic factors, socioeconomic status, medical conditions, and general health status, limitations in both vision and hearing were independently correlated with worse functional status. In addition, controlling for income, wealth, and education reduced the strength of the associations between vision and hearing impairment and function, but did not eliminate them. The magnitude of effect of poor vision exceeded all medical conditions except stroke.

CONCLUSIONS

Visual and hearing impairment appear to have a significant relationship with overall functional status, among even community-dwelling, middle-aged Americans and even after controlling for general health status, medical comorbidities, and socioeconomic status.

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.

Differences in valuation of functional status components among consumers and professionals in Europe and the United States

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor-patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

The relationship between nursing staffing levels and nursing home outcomes

This study examined the effects of selected Minnesota nursing home attributes (size, ownership, noncompliance with a state correction order, and licensed and nonlicensed nursing hours) on specific outcomes (functional ability, discharge home, and death) for residents ages 65 and older, controlling for residents' age and previous functional ability. The functional outcome was operationalized by calculating the resident's Total Dependence Score (TDS), the total score on the assessment of eight activities of daily living (score range: 0-33). Ordinary least squares regression analysis was used to estimate the effects of facility attributes, admission TDS, and age on resident outcomes, and nonlinear probability analyses were used to estimate the effects of facility attributes, admission TDS, and age on the probability of death or discharge home. In the year after admission, licensed (but not nonlicensed) nursing homes were significantly related to improved functional ability, increased probability of discharge home, and decreased probability of death, but when limited to chronic residents, the role of professional nursing hours virtually disappears. Overall, the findings support greater use of licensed nurses in the nursing home setting.

The effect of HMO status on the outcomes of home-care after hospitalization in a Medicare population

OBJECTIVE

The literature suggests that Medicare health maintenance organization (HMO) patients may have poorer outcomes with formal home-health care than do fee-for-service (FFS) patients, but it is unclear whether this is related to case-mix or quality. Our objective was to compare the home-health care outcomes for HMO and FFS Medicare patients after hospitalization for stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement while controlling for site of discharge and other patient characteristics.

DESIGN

Patients were identified before hospital discharge with data collected at that time and then prospectively for 1 year.

SETTING

Nineteen acute general hospitals in Minneapolis/St. Paul, Minnesota.

PATIENTS

All Medicare patients in the above hospitals identified predischarge with stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement.

MEASURES

OUTCOME

weighted ADL scale and hospital readmission. Independent factors: site of discharge, HMO status, comorbidity, severity, and demographic factors.

RESULTS

A total of 970 subjects were studied, 211 of whom were discharged to home-care. HMO patients were more likely to be discharged to a nursing home than to home-care after controlling for other factors (OR = 1.7; P = .015). After controlling for site of discharge and patient characteristics through either propensity scores or regression analysis, there was no statistically significant difference in ADL function at 6 weeks or at 6 months between HMO and FFS patients. Nor was there was a statistically significant difference in hospital readmission rates at 6 weeks and 6 months between HMO and FFS home-care patients.

CONCLUSIONS

The outcomes of Medicare HMO patients discharged to home-care are not worse than those of FFS patients.

Multidimensionality in instrumental and basic activities of daily living

Although the use of self-reported ADL (activity of daily living) scales has a long history, the Katz-based assumptions of unidimensionality and hierarchy are increasingly found lacking, and ADLs alone are found to underestimate dysfunction and disability. Data from nearly 8900 elderly respondents in the community sample of the 1991 Canadian Study of Health and Aging were used to examine the measurement properties of a modified version of the Older Americans Research Survey (OARS) ADL and IADL items combined. A multidimensional factor structure was revealed, with three levels of functional ability possessing internal consistency. We conclude that assumptions regarding ADL/IADL unidimensionality and hierarchy are not always valid, and that ADL and IADL items should be considered in combination to capture a greater range of functional disability prevalence. We also suggest that expectations of precise measurement of functional dependence by (I)ADL scales should perhaps be relaxed to the goal of simply differentiating broad levels of self-reported functioning (such as basic, intermediate, and complex), within which some tasks are roughly equivalent. Because these scales are widely used as screening tools and in shaping policy, we suggest that employing a more empirically grounded measurement standard has the potential to reduce bias due to item complexity and task specificity, facilitate standardization, and more reliably predict outcomes.