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Rockette-Wagner B, Wisnivesky JP, Holguin F, Ankam J, Arora A, Federmann E, Smith V, Federman AD, Conroy MB. The relationships between Physical activity and asthma control and Body Mass Index (BMI) in patients with asthma. J Asthma 2024; 61:194-202. [PMID: 37847059 DOI: 10.1080/02770903.2023.2260868] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/14/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE Asthma is one of the most common chronic conditions in developed countries. We examined whether physical activity (PA) is related to asthma control and body mass index (BMI) in asthma patients. METHODS Cross-sectional data collected on PA (ActiGraph GT3X-BT), asthma control (the Asthma Control Questionnaire; ACQ), and BMI were examined in 206 adults (mean[sd] age 47.2[13.8] years; 49.5% had an obese BMI) with clinically diagnosed asthma. Relationships between PA and continuous BMI and asthma control were assessed using linear regression. Differences in PA across obesity (non-obese: <30 Kg/m2/obese: ≥30 Kg/m2) and asthma control categories (controlled: ≤0.75/uncontrolled: >0.75 ACQ score) were also examined. RESULTS Median (p25, p75) steps counts and peak cadence were 6035 (4248, 8461) steps/day and 123 (115, 133) steps in a minute, respectively. There were nearly 2000 fewer steps/day among those with uncontrolled asthma versus controlled and among those with obese BMI versus nonobese, respectively (both p < 0.05). In regression models adjusted for relevant covariates each 1-unit increase in ACQ score was associated with -686 [95%CI -997, -13] (p ≤ 0.05) average steps/day. The statistical significance of these findings was attenuated (p ≥ 0.05) when BMI was added to the model. However, the point estimate was not reduced (-766 [95%CI -1060, 34]. CONCLUSIONS Overall step counts were low in this population despite peak cadence values suggesting that most participants could perform moderate intensity activity. Increasing step counts should be considered an important lifestyle intervention goal in obese and non-obese asthma patients with low PA levels.
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Affiliation(s)
| | - Juan P Wisnivesky
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Fernando Holguin
- Anschutz School of Medicine, University of Colorado, Denver, CO, USA
| | - Jyoti Ankam
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Arushi Arora
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Emily Federmann
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Vongphone Smith
- Anschutz School of Medicine, University of Colorado, Denver, CO, USA
| | - Alex D Federman
- Icahn School of Medicine, Mount Sinai Beth Israel Hospital, New York, NY, USA
| | - Molly B Conroy
- School of Medicine, University of Utah, Salt Lake City, UT, USA
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Federman AD, O’Conor R, Nnemnbeng J, Ankam J, McDermott D, Lindenauer PK, Wolf MS, Wisnivesky JP. Feasibility Trial of a Comprehensive, Highly Patient-Centered COPD Self-Management Support Program. Chronic Obstr Pulm Dis 2024; 11:13-25. [PMID: 37813826 PMCID: PMC10913921 DOI: 10.15326/jcopdf.2023.0419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 10/11/2023]
Abstract
Purpose To test the feasibility of a novel self-management support intervention for people with chronic obstructive pulmonary disease (COPD). Methods We conducted a feasibility randomized controlled trial involving patients ≥40 years with severe or very severe COPD in New York, New York (n=59). Community health workers screened patients and addressed barriers to COPD self-management. Patients were also offered home-based pulmonary rehabilitation (HBPR) and an antibiotic and steroid rescue pack. Control patients received general COPD education. Clinical outcomes for intervention and control were compared by difference-in-differences (DiD) at baseline and 6 months. The study was not powered for statistically significant differences for any measure. Feasibility measures were collected at 6 months. Results There were high rates of completion of intervention activities, including 75% of patients undergoing evaluation for and participating in HBPR. Most (92%) intervention patients said the program was very or extremely helpful and 96% said they would participate again. Clinical outcomes generally favored the intervention: COPD assessment test, DiD -1.1 (95% confidence interval [CI] -5.9 to 3.6); 6-minute walk test distance, DiD 7.4 meters (95% CI -45.1 to 59.8); self-reported hospitalizations, DiD -9.8% (95% CI -42.3% to 22.8%); medication adherence, DiD 7.7% (-29.6%, 45.0%), and Physical Activity Adult Questionnaire, DiD 86 (95% CI -283 to 455). Intervention patients reported more emergency department visits, DiD 10.6% (95% CI 17.7% to 38.8%). Conclusions A highly patient-centered, self-management support intervention for people with COPD was well received by patients and associated with potential improvements in clinical and self-management outcomes. A fully powered study of the intervention is warranted.
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Affiliation(s)
- Alex D. Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Rachel O’Conor
- Department of Medicine, Feinberg School of Medicine, Northwestern University, New York, New York, United States
| | - Jeannys Nnemnbeng
- Graduate School of Biomedical Sciences, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Jyoti Ankam
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | | | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, Chan Medical School-Baystate, University of Massachusetts, Springfield, Massachusetts, United States
| | - Michael S. Wolf
- Department of Medicine, Feinberg School of Medicine, Northwestern University, New York, New York, United States
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
- Division of Pulmonary and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States
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3
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Federman AD, Becker J, Carnavali F, Rivera Mindt M, Cho D, Pandey G, Chan L, Curtis L, Wolf MS, Wisnivesky JP. Relationship Between Cognitive Impairment and Depression Among Middle Aged and Older Adults in Primary Care. Gerontol Geriatr Med 2024; 10:23337214231214217. [PMID: 38476882 PMCID: PMC10929046 DOI: 10.1177/23337214231214217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 03/14/2024] Open
Abstract
Objectives: To determine rates of previously undetected cognitive impairment among patients with depression in primary care. Methods: Patients ages 55 and older with no documented history of dementia or mild cognitive impairment were recruited from primary care practices in New York City, NY and Chicago, IL (n = 855). Cognitive function was assessed with the Montreal Cognitive Assessment (MoCA) and depression with the Patient Health Questionnaire-8. Results: The mean age was 66.8 (8.0) years, 45.3% were male, 32.7% Black, and 29.2% Latinx. Cognitive impairment increased with severity of depression: 22.9% in persons with mild depression, 27.4% in moderate depression and 41.8% in severe depression (p = .0002). Severe depression was significantly associated with cognitive impairment in multivariable analysis (standardized β = -.11, SE = 0.33, p < .0001). Discussion: Depression was strongly associated with previously undetected cognitive impairment. Primary care clinicians should consider screening, or expand their screening, for both conditions.
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Affiliation(s)
| | | | | | - Monica Rivera Mindt
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Fordham University, New York, NY, USA
| | - Dayeon Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gaurav Pandey
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lili Chan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Federman AD, Becker JH, Mindt MR, Cho D, Curtis L, Wisnivesky J. Rates of Undiagnosed Cognitive Impairment and Performance on the Montreal Cognitive Assessment Among Older Adults in Primary Care. J Gen Intern Med 2023; 38:2511-2518. [PMID: 36814049 PMCID: PMC10465418 DOI: 10.1007/s11606-023-08102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The number of adults in the USA with cognitive impairment is increasing; however, few studies report prevalence rates of undiagnosed cognitive impairment among older adults in primary care. OBJECTIVE To determine the prevalence of undiagnosed cognitive impairment among adults ages 55 years and older in primary care settings and provide normative data for the Montreal Cognitive Assessment in this context. DESIGN Single interview, observational study. PARTICIPANTS English-speaking adults ages 55 years and older without diagnoses of cognitive impairment recruited from primary care practices in New York City, NY, and Chicago, IL (n = 872). MAIN MEASURES Montreal Cognitive Assessment (MoCA). Undiagnosed cognitive impairment was defined by age and education adjusted z-scores more than 1.0 and 1.5 standard deviations below published norms, corresponding to mild or moderate to severe cognitive impairment, respectively. KEY RESULTS The mean age was 66.8 (8.0) years, 44.7% were male, 32.9% were Black or African-American, and 29.1% were Latinx. Undiagnosed cognitive impairment was identified in 20.8% of subjects (mild impairment, 10.5%; moderate-severe impairment, 10.3%). Impairment at any level of severity was associated in bivariate analyses with several patient characteristics, most notably for race and ethnicity (White, non-Latinx, 6.9% vs. Black, non-Latinx, 26.8%, Latinx, 28.2%, other race, 21.9%; p < 0.0001), place of birth (US 17.5% vs. non-US 30.7%, p < 0.0001), depression (33.1% vs. no depression, 18.1%; p < 0.0001), and impairment in activities of daily living (≥ 1 ADL impairment, 34.0% vs. no ADL impairment, 18.2%; p < 0.0001). CONCLUSIONS Undiagnosed cognitive impairment is common among urban dwelling older adults attending primary care practices, and was associated with several patient characteristics, including non-White race and ethnicity and depression. Normative data for the MoCA from this study may serve as a useful resource for studies of similar patient populations.
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Affiliation(s)
- Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1087, New York, NY, 10029, USA
| | - Jacqueline H Becker
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1087, New York, NY, 10029, USA
| | - Monica Rivera Mindt
- Department of Psychology, Latin American and Latino Studies Institute, and African and African American Studies, Fordham University, New York, NY, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dayeon Cho
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1087, New York, NY, 10029, USA
| | - Laura Curtis
- Department of Medicine, Feinberg School of Medicine, Northwestern University, New York, NY, USA
| | - Juan Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1087, New York, NY, 10029, USA
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Muellers KA, O'Conor R, Russell AM, Wismer G, Griffith JW, Wolf MS, Wisnivesky JP, Federman AD. Barriers and facilitators of self-management behaviors among patients with chronic obstructive pulmonary disease and chronic comorbidities: A mixed-methods investigation. Chronic Illn 2023:17423953231187172. [PMID: 37415379 DOI: 10.1177/17423953231187172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
OBJECTIVES We investigated how individuals with chronic obstructive pulmonary disease (COPD) and multi-morbidity (MM) navigate barriers and facilitators to their health management. METHODS We conducted a mixed-methods study using semi-structured interviews and survey assessments of adults with COPD, hypertension, and/or diabetes. We recruited 18 participants with an average age of 65, with 39% being male, 50% Black, and 22% Hispanic/Latino/a. Five investigators used an iterative, hybrid-coding process combining a priori and emergent codes to analyze transcripts and compare quantitative and qualitative data for themes. RESULTS Participants reported a generalized approach to their health rather than managing MMs separately. Individuals with good or mixed adherence found daily routines facilitated regular medication use, while those with poor adherence experienced complex prescriptions and life stressors as barriers. Walking was viewed as beneficial but challenging due to limited mobility. Most participants viewed diet as important to their MMs, but only two reported high diet quality and many held inaccurate beliefs about healthy diet choices. DISCUSSION Participants with MM were highly motivated to engage in self-management activities, but some individuals experienced barriers to maintaining them. Emphasizing an individualized clinical approach to assessing and solving patient barriers may improve self-management outcomes in this complex population.
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Affiliation(s)
- Kimberly A Muellers
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Psychology, Pace University, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrea M Russell
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Guisselle Wismer
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - James W Griffith
- Department of Medical Social Sciences, Northwestern University, Chicago, IL, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Pulmonary and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Feldman JM, Arcoleo K, Greenfield N, Styke S, Becker J, Jariwala S, Federman AD, Wisnivesky JP. Under-perception of airflow limitation, self-efficacy, and beliefs in older adults with asthma. J Psychosom Res 2023; 170:111353. [PMID: 37178474 DOI: 10.1016/j.jpsychores.2023.111353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Under-perception of airflow limitation is more common in older adults with asthma and may lead to under-reporting of asthma symptoms. Asthma management self-efficacy is linked with better asthma control and quality of life (QoL). We sought to examine asthma and medication beliefs as a mediator in the relationship between both under-perception and self-efficacy with asthma outcomes. METHODS This cross-sectional study recruited participants with asthma ≥60 years from hospital-affiliated practices in East Harlem and the Bronx, New York. Perception of airflow limitation was measured for 6 weeks by having participants enter peak expiratory flow (PEF) estimates into an electronic peak flow meter followed by PEF blows. We used validated instruments to assess asthma and medication beliefs, asthma management self-efficacy, asthma control, and QoL. Asthma self-management behaviors (SMB) were quantified by electronic and self-report measures of inhaled corticosteroid (ICS) adherence and observation of inhaler technique. RESULTS The sample comprised 331 participants (51% Hispanic, 27% Black, 84% female). Beliefs mediated the relationship between greater under-perception and better self-reported asthma control (β = -0.08, p = .02) and better asthma QoL (β =0.12, p = .02). Higher self-efficacy was also associated with better reported asthma control (β = -0.10, p = .006) and better asthma QoL (β =0.13, p = .01) in this indirect effect through beliefs. Accurate perception of airflow limitation was associated with higher adherence to SMB (β = 0.29, p = .003). CONCLUSIONS Less threatening asthma beliefs may be maladaptive in under-perception of airflow limitation by contributing to under-reporting of asthma symptoms, but adaptive in the context of higher self-efficacy and better asthma control.
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Affiliation(s)
- Jonathan M Feldman
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States of America; Albert Einstein College of Medicine, Children's Hospital at Montefiore, Department of Pediatrics and Department of Psychiatry and Behavioral Sciences, Division of Academic General Pediatrics, Bronx, NY, United States of America.
| | - Kimberly Arcoleo
- The University of Rhode Island, College of Nursing, Kingston, RI, United States of America
| | - Naomi Greenfield
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States of America
| | - Sarah Styke
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States of America
| | - Jacqueline Becker
- Icahn School of Medicine at Mount Sinai, Division of General Internal Medicine, New York, NY, United States of America
| | - Sunit Jariwala
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine, Division of Allergy/Immunology, Bronx, NY, United States of America
| | - Alex D Federman
- Icahn School of Medicine at Mount Sinai, Division of General Internal Medicine, New York, NY, United States of America
| | - Juan P Wisnivesky
- Icahn School of Medicine at Mount Sinai, Division of General Internal Medicine, New York, NY, United States of America; Icahn School of Medicine at Mount Sinai, Division of Pulmonary, Critical Care and Sleep Medicine, New York, NY, United States of America
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7
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Panjwani AA, Erblich J, Revenson TA, Badr HJ, Federman AD, Wisnivesky JP. The indirect influence of 'invisible' support on pulmonary function among adults with chronic obstructive pulmonary disease. PSYCHOL HEALTH MED 2023; 28:831-842. [PMID: 35373659 PMCID: PMC9527261 DOI: 10.1080/13548506.2022.2061720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
Individuals living with chronic obstructive pulmonary disease (COPD) often require support from family or friends. We examined whether invisible support - support that is provided but goes unnoticed - is related to pulmonary function, and whether this association is mediated by depressive symptoms and illness perceptions. Sixty-six dyads of individuals with COPD and their informal caregivers reported on receipt and provision of support, respectively. Those with COPD completed measures of depressive symptoms, illness perceptions and pulmonary function. Although invisible support was not directly related to pulmonary function, mediation analyses revealed a combined indirect effect through lower depressive symptoms and less negative illness perceptions. Interventions teaching skillful delivery of support to caregivers may reduce depressive symptoms and threatening illness cognitions, which may contribute to improvements in symptom burden among patients with COPD.
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Affiliation(s)
- Aliza A. Panjwani
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON
| | - Joel Erblich
- Department of Psychology, Hunter College & the Graduate Center, City University of New York, New York, NY
| | - Tracey A. Revenson
- Department of Psychology, Hunter College & the Graduate Center, City University of New York, New York, NY
| | - Hoda J. Badr
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Alex D. Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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8
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Feldman JM, Ankam J, Barry M, Fruchter N, Becker J, Jariwala S, Shim C, Wisnivesky JP, Federman AD. A Pilot Randomized Controlled Trial of an Intervention to Improve Perception of Lung Function in Older Adults with Asthma. Am J Respir Crit Care Med 2023; 207:487-490. [PMID: 36343280 PMCID: PMC9940152 DOI: 10.1164/rccm.202206-1132le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jonathan M. Feldman
- Yeshiva University/Ferkauf Graduate School of PsychologyBronx, New York
- Albert Einstein College of Medicine/Children’s Hospital at MontefioreBronx, New York
| | - Jyoti Ankam
- Icahn School of Medicine at Mount SinaiNew York, New York
| | - Michele Barry
- Icahn School of Medicine at Mount SinaiNew York, New York
| | - Natalie Fruchter
- Yeshiva University/Ferkauf Graduate School of PsychologyBronx, New York
| | | | - Sunit Jariwala
- Albert Einstein College of Medicine/Montefiore Medical CenterBronx, New York
| | - Chang Shim
- Jacobi Medical CenterBronx, New York
- Albert Einstein College of MedicineBronx, New York
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9
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Federman AD, Brody A, Ritchie CS, Egorova N, Arora A, Lubetsky S, Goswami R, Peralta M, Reckrey JM, Boockvar K, Shah S, Ornstein KA, Leff B, DeCherrie L, Siu AL. Outcomes of home-based primary care for homebound older adults: A randomized clinical trial. J Am Geriatr Soc 2023; 71:443-454. [PMID: 36054295 PMCID: PMC9939556 DOI: 10.1111/jgs.17999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 07/13/2022] [Accepted: 07/24/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited. METHODS We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients. RESULTS The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46-3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (-17.9%, 95% CI -31.0% to -1.0%; p = 0.001; number needed to treat 6, 95% CI 3-100). There were no significant differences in quality of life (1.25, 95% CI -0.39-2.89, p = 0.13), symptom burden (-1.92, 95% CI -5.22-1.37, p = 0.25) or ED visits (1.2%, 95% CI -10.5%-12.4%; p = 0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001). CONCLUSION HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination.
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Affiliation(s)
- Alex D. Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abraham Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, NY, USA
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, NY, USA
| | - Christine S. Ritchie
- The Mongan Institute and Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Arushi Arora
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Lubetsky
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruchir Goswami
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria Peralta
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jenny M. Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kenneth Boockvar
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
- The New Jewish Home, New York, NY, USA
| | - Shivani Shah
- Visiting Nurse Service of New York, New York, NY, USA
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Linda DeCherrie
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Albert L. Siu
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
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10
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Franzosa E, Kim P, Reckrey JM, Zhang M, Xu E, Aldridge MD, Federman AD, Ornstein KA. Care Disruptions and End-Of-Life Care Experiences Among Home-Based Primary Care Patients During the COVID-19 Pandemic in New York City: A Retrospective Chart Review. Am J Hosp Palliat Care 2023; 40:225-234. [PMID: 35775300 PMCID: PMC9253522 DOI: 10.1177/10499091221104732] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Research on deaths during COVID-19 has largely focused on hospitals and nursing homes. Less is known about medically complex patients receiving care in the community. We examined care disruptions and end-of-life experiences of homebound patients receiving home-based primary care (HBPC) in New York City during the initial 2020 COVID-19 surge. Methods: We conducted a retrospective chart review of patients enrolled in Mount Sinai Visiting Doctors who died between March 1-June 30, 2020. We collected patient sociodemographic and clinical data and analyzed care disruptions and end-of-life experiences using clinical notes, informed by thematic and narrative analysis. Results: Among 1300 homebound patients, 112 (9%) died during the study period. Patients who died were more likely to be older, non-Hispanic white, and have dementia than those who survived. Thirty percent of decedents had confirmed or probable COVID-19. Fifty-eight (52%) were referred to hospice and 50 enrolled. Seventy-three percent died at home. We identified multiple intersecting disruptions in family caregiving, paid caregiving, medical supplies and services, and hospice care, as well as hospital avoidance, complicating EOL experiences. The HBPC team responded by providing clinical, logistical and emotional support to patients and families. Conclusion: Despite substantial care disruptions, the majority of patients in our study died at home with support from their HBPC team as the practice worked to manage care disruptions. Our findings suggest HBPC's multi-disciplinary, team-based model may be uniquely suited to meet the needs of the most medically and socially vulnerable older adults at end of life during public health emergencies.
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Affiliation(s)
- Emily Franzosa
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
- Geriatric Research, Education, and
Clinical Center (GRECC), James J. Peters
VA Medical Center, Bronx, NY, USA
| | - Patricia Kim
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Jennifer M. Reckrey
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Meng Zhang
- Department of Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Emily Xu
- Department of Medical Education,
Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Melissa D. Aldridge
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Alex D. Federman
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics
and Palliative Medicine, Icahn School of Medicine at Mount
Sinai, New York, NY, USA
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11
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Althoff MD, Jimenez G, Peterson R, Jin Y, Grasemann H, Sharma S, Federman AD, Wisnivesky JP, Holguin F. Differences in L-arginine metabolism and asthma morbidity among asthma patients with and without obstructive sleep apnea. Respir Res 2022; 23:230. [PMID: 36064404 PMCID: PMC9442950 DOI: 10.1186/s12931-022-02157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Imbalance in L-arginine and nitric oxide (NO) metabolism has been implicated in the pathophysiology of asthma and obstructive sleep apnea (OSA), and both diseases impact the other's morbidity. We sought to determine whether L-arginine/NO metabolism differs between adults with asthma with or without comorbid OSA, and its association with asthma morbidity. METHODS This is a cross-sectional study of 322 adults with asthma recruited in Denver, CO and New York City, NY. Data were collected on OSA status, spirometry, and metrics of asthma control and morbidity. L-Arginine metabolites were quantified in patient serum. Bivariate analyses and multiple regression were performed to determine differences between L-arginine metabolism, OSA and association with asthma morbidity. RESULTS Among the 322 participants, 92 (28.5%) had OSA. The cohort was 81.6% female, 23.4% identified as Black and 30.6% as Latino. Patients with asthma and OSA had significantly higher serum concentrations of NO synthase inhibitor asymmetric dimethylarginine (ADMA) (p-value = 0.019), lower L-arginine to ornithine ratios (p-value = 0.003), and increased ornithine (p-value = 0.001) and proline levels (p-value < 0.001) compared to those without OSA. In adjusted models, OSA was associated with worse asthma control, adjusted mean difference in asthma control questionnaire of 0.36 (95% confidence interval [CI]: 0.06 to 0.65), and asthma quality of life questionnaire, adjusted mean difference: - 0.53 (95% CI: - 0.85 to - 0.21), after adjusting for relevant covariates including body mass index and L-arginine metabolites. CONCLUSIONS Adults with asthma and OSA had increased ADMA, an inhibitor of nitric oxide synthase, and greater metabolism of L-arginine via the arginase pathway compared to those with asthma alone, indicating a possible shared pathophysiological mechanism of these diseases.
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Affiliation(s)
- Meghan D Althoff
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz School of Medicine, 12700 East 19th Avenue, 9C03, Aurora, CO, 80045, USA
| | - Guillermo Jimenez
- Department of Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Ying Jin
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Hartmut Grasemann
- Division of Respiratory Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Sunita Sharma
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz School of Medicine, 12700 East 19th Avenue, 9C03, Aurora, CO, 80045, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Juan P Wisnivesky
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz School of Medicine, 12700 East 19th Avenue, 9C03, Aurora, CO, 80045, USA.
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12
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Mindlis I, Wisnivesky JP, Wolf MS, O’Conor R, Federman AD. Comorbidities and depressive symptoms among older adults with asthma. J Asthma 2022; 59:910-916. [PMID: 33556292 PMCID: PMC11009969 DOI: 10.1080/02770903.2021.1887890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/25/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Depression is associated with poor outcomes among older adults with asthma, and the presence of multiple comorbidities may magnify this relationship. We sought to determine the association of comorbidities with depressive symptoms among older adults with asthma. METHODS Secondary analysis of data from a randomized controlled trial of older adults with poorly controlled asthma and comorbidities. Comorbidities were measured in two ways: (1) as a count of all the patient's chronic diseases, and (2) as a count of chronic illnesses with self-management intensive needs (diabetes, hypertension, congestive heart failure). Depressive symptoms were measured using the PROMIS SF8a scale. Multiple regression analyses tested the relationship between comorbidities and depressive symptoms, adjusting for sociodemographic factors. RESULTS Overall, 25% of participants had moderate-severe levels of depressive symptoms, 87% had ≥ two comorbidities, and 41% had ≥ one comorbidity with self-management intensive needs. The count of all comorbidities was significantly associated with depressive symptoms (F (8, 330) = 7.7, p < 0.0001, R2 = 0.158) in adjusted models, whereas the count of self-management intensive conditions was not significantly associated with depressive symptoms in adjusted analyses. CONCLUSIONS In older adults with asthma and multiple comorbidities, depressive symptoms increased with the overall count of comorbidities but not with the count of comorbidities with self-management intensive needs. Given the impact of depression on asthma outcomes for older adults, the mechanisms by which comorbid illness contributes to depressive symptoms in older asthmatics warrants further evaluation.
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Affiliation(s)
- Irina Mindlis
- The Graduate Center, City University of New York, NY, USA
| | - Juan P. Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael S. Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Rachel O’Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex D. Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Siu AL, Zhao D, Bollens-Lund E, Lubetsky S, Schiller G, Saenger P, Ornstein KA, Federman AD, DeCherrie LV, Leff B. Health equity in Hospital at Home: Outcomes for economically disadvantaged and non-disadvantaged patients. J Am Geriatr Soc 2022; 70:2153-2156. [PMID: 35363372 DOI: 10.1111/jgs.17759] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Duzhi Zhao
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gabrielle Schiller
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Saenger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Medically Home, Boston, Massachusetts, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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14
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Becker JH, Feldman JM, Arora A, Busse PJ, Wisnivesky JP, Federman AD. Cognition, symptom perception, and medication non-adherence in older adults with asthma. J Asthma 2022; 59:607-615. [PMID: 33249956 PMCID: PMC8180526 DOI: 10.1080/02770903.2020.1856867] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cognitive impairment (CI) is highly prevalent in elderly asthmatics and is associated with worse asthma self-management (SM) and outcomes. CI may also explain why older adults may under-perceive asthma symptoms. We hypothesized that CI would be associated with low medication adherence and asthma symptom under-perception (ASP). We also hypothesized that ASP would mediate the relationship between CI and medication adherence. METHODS Participants of this longitudinal cohort study were asthmatics (N = 334) ≥60 years (51% Hispanic, 25% Black). Cognitive measures assessed general cognition, attention, processing speed, executive functioning, memory, and language. Measures of SM were self-reported and electronically measured adherence to controller medications. ASP was assessed for 6 weeks by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter, followed by PEF blows. Participants were blinded to actual PEF values. Percentage of time that participants were in the over-perception zone was calculated as an average. RESULTS In regression analyses, those with impairments in memory and general cognition had lower odds ratios (OR) for self-reported non-adherence (OR: 0.96, 95% CI 0.93 - 0.98 & OR: 0.90, 95% CI 0.83 - 0.96, respectively). CI was not associated with electronically measured non-adherence or ASP. In structural equation modeling, while CI was associated with adherence (β = 0.04, SE = 0.021, p = 0.04), ASP did not mediate this relationship. CONCLUSIONS While results confirmed the importance of cognition in asthma SM, these findings were not linked to ASP. Future analyses are needed to understand the role of confounding factors.
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Affiliation(s)
- Jacqueline H. Becker
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan M. Feldman
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA;,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arushi Arora
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paula J. Busse
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Juan P. Wisnivesky
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex D. Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA;,Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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15
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Saenger PM, Ornstein KA, Garrido MM, Lubetsky S, Bollens-Lund E, DeCherrie LV, Leff B, Siu AL, Federman AD. Cost of home hospitalization versus inpatient hospitalization inclusive of a 30-day post-acute period. J Am Geriatr Soc 2022; 70:1374-1383. [PMID: 35212391 DOI: 10.1111/jgs.17706] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/20/2021] [Accepted: 01/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies have demonstrated that hospital at home (HaH) care is associated with lower costs than traditional hospital care. Most prior studies were small, not U.S.-focused, or did not include post-acute costs in their analyses. Our objective was to determine if combined acute and 30-day post-acute costs of care were lower for HaH patients compared to inpatient comparisons in a Center for Medicare and Medicaid Innovation Center demonstration of HaH. METHODS A single-center New York City retrospective observational cohort study of patients admitted to either HaH or inpatient care from September 1, 2014 through August 31, 2017. Eligible patients were 18 years or older, required inpatient admission, lived in Manhattan, and met home safety requirements. Comparison individuals met the same criteria and were included if they refused HaH care or were admitted when HaH was not available. HaH care was substitutive hospital-level care and 30-days of post-acute transitional care. Main outcomes were costs of care of the acute and post-acute 30-day episodes. We matched subjects on age, sex, and insurance and conducted regression analyses using an unadjusted model and one adjusted for several patient characteristics. RESULTS Of 523 Medicare admission episodes, data were available for 201 episodes in the HaH arm and 101 episodes of usual care. HaH patients were older (81.6 [SD = 12.3] years vs. 74.6 [SD = 14.0], p < 0.0001) and more likely to have activities of daily living (ADL) impairments (75.4% vs. 46.5%, p < 0.0001). Unadjusted mean costs were $5054 lower for HaH episodes compared to inpatient episodes. Regression analysis with matching showed HaH costs were $5116 (95% CI -$10,262 to $30, p = 0.05) lower, and when adjusted for age, sex, insurance, diagnosis, and ADL impairments, $5977 (95% CI -$10,758 to -$1196, p = 0.01) lower. CONCLUSIONS HaH combined with 30-day post-acute transition care was less costly than inpatient care.
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Affiliation(s)
- Pamela M Saenger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health and Partnered Evidence-based Policy Resource Center (PEPReC), Boston VA Healthcare System, Boston, Massachusetts, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Evan Bollens-Lund
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research, Education, and Clinical Center, James J Peters Veterans Affairs Medical Center, Bronx, New York, USA
| | - Alex D Federman
- Department of Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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16
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Federman AD, Barry M, Moas E, Davenport C, McGeough C, Tejeda M, Rivera L, Gutierrez S, Mejias H, Belton D, Mathew C, Lindenauer PK, McDermott D, O'Conor R, Wolf MS, Wisnivesky JP. Protocol for a feasibility randomized trial of self-management support for people with chronic obstructive pulmonary disease using lay health coaches. Contemp Clin Trials 2021; 110:106570. [PMID: 34560265 DOI: 10.1016/j.cct.2021.106570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
Challenges with self-management are a major contributor to poor outcomes among adults with chronic obstructive pulmonary disease (COPD). The causes of poor self-management in COPD are manifold, and they arise from physical, cognitive, socioeconomic, environmental and societal sources. To address this complexity, we developed the Supporting self-Management Behaviors in Adults with COPD (SaMBA-COPD) model, which uses lay health coaches to identify a patient's barriers to effective COPD self-management and provide tailored support to help them overcome those barriers, reduce their symptoms and need for urgent care and improve their quality of life. The 6-month intervention includes referral of patients to a pharmacist for prescription of antibiotic and oral steroid "rescue packs" and support for a structured home exercise routine. All interactions of coaches and patients will take place by telephone or video call. We will test the feasibility and preliminary efficacy of SaMBA-COPD in a trial of 58 patients randomized 1:1 to the intervention or a COPD education control. Outcomes will be assessed at 6 and 9 months. Data from the trial will be used to inform the design of a fully powered, multi-site randomized trial of the intervention.
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Affiliation(s)
- Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Michele Barry
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Esther Moas
- Mount Sinai Health System, New York, NY, United States of America
| | - Claire Davenport
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | | | | | - Leny Rivera
- City Health Works, New York, NY, United States of America
| | | | - Hilda Mejias
- City Health Works, New York, NY, United States of America
| | - Destini Belton
- City Health Works, New York, NY, United States of America
| | - Cathleen Mathew
- Mount Sinai Hospital, New York, NY, United States of America
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Sciences, University of Massachusetts Medical School-Baystate, Springfield, MA, United States of America
| | | | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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17
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Augustine MR, Siu AL, Boockvar KS, DeCherrie LV, Leff BA, Federman AD. Outcomes of Hospital at Home for Older Adults with and without High Levels of Social Support. Home Healthc Now 2021; 39:261-270. [PMID: 34473114 PMCID: PMC8425599 DOI: 10.1097/nhh.0000000000000980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The evaluation of social support within hospital at home (HaH) programs has been limited. We performed a secondary analysis of a prospective cohort evaluation of 295 participants receiving HaH care and 212 patients undergoing traditional hospitalization from November of 2014 to August of 2017. We examined the confounding and moderating effects of instrumental and informational social support upon length of stay and 30-day rehospitalization, emergency department (ED) visit, and skilled nursing facility admission. Instrumental social support attenuated the effects of HaH upon any ED visit (base model: OR 0.61, p = 0.037; controlling for social support: OR 0.71, p = 0.15). The association of HaH with other outcomes remained unchanged. Interactions between HaH and informational or instrumental social support for all outcomes were not significant. Lack of high levels of social support had little effect on the positive outcomes of HaH care, suggesting similar benefits of HaH services for patients with lower levels of social support.
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18
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Feldman JM, Becker J, Arora A, DeLeon J, Torres-Hernandez T, Greenfield N, Wiviott A, Jariwala S, Shim C, Federman AD, Wisnivesky JP. Depressive Symptoms and Overperception of Airflow Obstruction in Older Adults With Asthma. Psychosom Med 2021; 83:787-794. [PMID: 33938504 PMCID: PMC8419010 DOI: 10.1097/psy.0000000000000951] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Older adults are at increased risk for depression and poor asthma outcomes. We examined whether depressive symptoms are associated with overperception of airflow obstruction and a pattern of worse asthma control, but not pulmonary function. METHODS We recruited a cohort of adults with asthma 60 years and older in East Harlem and the Bronx, New York. Baseline measures included the Geriatric Depression Scale, Asthma Control Questionnaire, and Mini Asthma Quality of Life Questionnaire. Spirometry was conducted at baseline to assess pulmonary function. Perception of airflow obstruction was assessed for 6 weeks following baseline by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter followed by PEF blows. Participants were blinded to actual PEF values. The percentage of time that participants were in the overperception zone was calculated as an average. RESULTS Among the 334 participants (51% Hispanic, 25% Black), depressive symptoms were associated with overperception of airflow obstruction (β = 0.14, p = .029), worse self-reported asthma control (β = 0.17, p = .003), and lower asthma-related quality of life (β = -0.33, p < .001), but not with lung function (β = -0.01, p = .82). Overperception was also associated with worse self-reported asthma control (β = 0.14, p = .021), but not lung function (β = -0.05, p = .41). CONCLUSIONS Depressive symptoms were associated with greater perceived impairment from asthma, but not pulmonary function. Overperception of asthma symptoms may play a key role in the relationship between depression and asthma outcomes in older adults.
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Affiliation(s)
- Jonathan M Feldman
- From the Ferkauf Graduate School of Psychology (Feldman, Greenfield, Wiviott), Yeshiva University; Division of Academic General Pediatrics, Department of Pediatrics (Feldman, DeLeon, Torres-Hernandez), Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx; Division of General Internal Medicine (Becker, Arora, Federman, Wisnivesky), Icahn School of Medicine at Mount Sinai, New York; Division of Allergy/Immunology, Department of Medicine (Jariwala), Albert Einstein College of Medicine/Montefiore Medical Center; Division of Pulmonary Medicine, Department of Medicine (Shim), Jacobi Medical Center/Albert Einstein College of Medicine, Bronx; and Division of Pulmonary, Critical Care and Sleep Medicine (Wisnivesky), Icahn School of Medicine at Mount Sinai, New York, New York
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19
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Federman AD, O’Conor R, Wolf MS, Wisnivesky JP. Associations of Medication Regimen Complexity with COPD Medication Adherence and Control. Int J Chron Obstruct Pulmon Dis 2021; 16:2385-2392. [PMID: 34434045 PMCID: PMC8382307 DOI: 10.2147/copd.s310630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/04/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Medication adherence is often low among people with chronic obstructive pulmonary disease (COPD) and medication regimen complexity may be a contributing factor. In this study, we sought to examine the role of medication regimen complexity in COPD medication adherence among patients with multimorbidity. Methods We performed cross-sectional analysis of data on COPD patients in primary care and pulmonary practices in New York City and Chicago (n=400). Regimen complexity was represented by the medication regimen complexity index (MRCI) and simple medication count. Adherence was measured by self-report and inhaler dose counts. Disease control measures included the COPD severity score (COPDSS) and the Medical Research Council (MRC) severity index. Results Mean age of study participants was 69 years, 66% had MRC grades 4 or 5, and 45% had low medication adherence. MRCI scores did not differ significantly between those with and without adequate medication adherence. Patients with higher MRCI scores were more likely to have severe COPD (OR 5.00, 95% CI 1.46-17.1, p=0.01) and dyspnea grades 3 or 4 (OR 2.27, 95% CI 1.03-5.03, p=0.04). Significant associations of medication count with COPD severity were also observed. Discussion These findings demonstrate that among patients with COPD and comorbid hypertension and diabetes, higher medication regimen complexity is associated with worse COPD control but not with COPD medication adherence.
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Affiliation(s)
- Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O’Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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20
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Bendayan R, Zhu Y, Federman AD, Dobson RJB. Multimorbidity Patterns and Memory Trajectories in Older Adults: Evidence From the English Longitudinal Study of Aging. J Gerontol A Biol Sci Med Sci 2021; 76:867-875. [PMID: 33449072 PMCID: PMC8087269 DOI: 10.1093/gerona/glab009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We aimed to examine the multimorbidity patterns within a representative sample of UK older adults and their association with concurrent and subsequent memory. METHODS Our sample consisted of 11 449 respondents (mean age at baseline was 65.02) from the English Longitudinal Study of Aging (ELSA). We used 14 health conditions and immediate and delayed recall scores (IMRC and DLRC) over 7 waves (14 years of follow-up). Latent class analyses were performed to identify the multimorbidity patterns and linear mixed models were estimated to explore their association with their memory trajectories. Models were adjusted by sociodemographics, body mass index (BMI), and health behaviors. RESULTS Results showed 8 classes: Class 1: Heart Disease/Stroke (26%), Class 2: Asthma/Lung Disease (16%), Class 3: Arthritis/Hypertension (13%), Class 4: Depression/Arthritis (12%), Class 5: Hypertension/Cataracts/Diabetes (10%), Class 6: Psychiatric Problems/Depression (10%), Class 7: Cancer (7%), and Class 8: Arthritis/Cataracts (6%). At baseline, Class 4 was found to have lower IMRC and DLRC scores and Class 5 in DLRC, compared to the no multimorbidity group (n = 6380, 55.72% of total cohort). For both tasks, in unadjusted models, we found an accelerated decline in Classes 1, 3, and 8; and, for DLRC, also in Classes 2 and 5. However, it was fully attenuated after adjustments. CONCLUSIONS These findings suggest that individuals with certain combinations of health conditions are more likely to have lower levels of memory compared to those with no multimorbidity and their memory scores tend to differ between combinations. Sociodemographics and health behaviors have a key role to understand who is more likely to be at risk of an accelerated decline.
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Affiliation(s)
- Rebecca Bendayan
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.,NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, UK
| | - Yajing Zhu
- Personalized Healthcare, Product Development, F.Hoffmann - La Roche Ltd, Cambridge, UK.,MRC Biostatistics Unit, University of Cambridge, UK
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Richard J B Dobson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.,NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, UK
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21
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Gorbenko K, Franzosa E, Masse S, Brody AA, Sheehan O, Kinosian B, Ritchie CS, Leff B, Ripp J, Ornstein KA, Federman AD. "I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York. Home Health Care Serv Q 2021; 40:1-15. [PMID: 34301160 PMCID: PMC8783921 DOI: 10.1080/01621424.2021.1935383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.
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Affiliation(s)
- Ksenia Gorbenko
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Institute of Health Care Delivery Science, Mount Sinai Health System, New York, New York, USA
| | - Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, New York, USA
| | - Sybil Masse
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute of Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Orla Sheehan
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatrics, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Ripp
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Katherine A. Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D. Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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22
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Federman AD, Leff B, Brody AA, Lubetsky S, Siu AL, Ritchie CS, Ornstein KA. Disruptions in Care and Support for Homebound Adults in Home-Based Primary Care in New York City During the COVID-19 Pandemic. Home Healthc Now 2021; 39:211-214. [PMID: 34190705 PMCID: PMC8345896 DOI: 10.1097/nhh.0000000000000983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Homebound older adults are a highly vulnerable population, yet little is known about their experiences with healthcare during the COVID-19 pandemic. We interviewed patients in home-based primary care (HBPC) in New York City by telephone in May and June of 2020. Interviews covered social supports, household activities, self-care, and medical care, and asked participants to compare current with prepandemic experiences. Among 70 participants, 37% were Black and 32% were Hispanic. Disruptions in the home included greater difficulty accessing paid caregivers (13.9%) and food (35.3%) than before the pandemic, and unaddressed household chores (laundry, 81.4%; food preparation, 11.4%). Black study participants were more likely than White and Hispanic participants to report disruptions in accessing medical care (13 [50.0%] vs. 3 [14.3%] vs. 6 [27.3%], respectively, p = 0.02), as well as food preparation and medication taking. Black patients in HBPC are at risk of disparities in healthcare and social support during the COVID-19 pandemic.
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23
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Franzosa E, Gorbenko K, Brody AA, Leff B, Ritchie CS, Kinosian B, Sheehan OC, Federman AD, Ornstein KA. "There Is Something Very Personal About Seeing Someone's Face": Provider Perceptions of Video Visits in Home-Based Primary Care During COVID-19. J Appl Gerontol 2021; 40:1417-1424. [PMID: 34210200 DOI: 10.1177/07334648211028393] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The rapid deployment of video visits during COVID-19 may have posed unique challenges for home-based primary care (HBPC) practices due to their hands-on model of care and older adult population. This qualitative study examined provider perceptions of video visits during the first wave of the COVID-19 crisis in New York City (NYC) through interviews with HBPC clinical/medical directors, program managers, nurse practitioners/nurse managers, and social work managers (n = 13) at six NYC-area practices. Providers reported a combination of commercial (health system-supported) and consumer (e.g., FaceTime) technological platforms was essential. Video visit benefits included triaging patient needs, collecting patient information, and increasing scheduling capacity. Barriers included cognitive and sensory abilities, technology access, reliance on caregivers and aides, addressing sensitive topics, and incomplete exams. Effectively integrating video visits requires considering how technology can be proactively integrated into practice. A policy that promotes platform flexibility will be crucial in fostering video integration.
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Affiliation(s)
- Emily Franzosa
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters VA Medical Center, Bronx, NY, USA
| | | | | | - Bruce Leff
- Johns Hopkins University, Baltimore, MD, USA
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24
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Kee D, O'Conor R, Wisnivesky JP, Wolf MS, Federman AD. Patient characteristics associated with retention in an asthma self-management trial for older adults. J Asthma 2021; 59:1652-1660. [PMID: 34112032 DOI: 10.1080/02770903.2021.1941090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE New self-management interventions are being developed for older adults who suffer from worse asthma morbidity than their younger counterparts, but high rates of study drop out have hampered these efforts and there is limited literature on what factors may influence retention in behavioral intervention studies with older adults. This study analyzed illness beliefs and patient characteristics that may contribute to retention in an asthma self-management trial for older adults. METHODS This is a secondary analysis of data from a randomized controlled trial of a self-management support intervention for adults 60 years and older with persistent, uncontrolled asthma. Multivariable logistic regression was used to evaluate the association of medication and illness beliefs, and other subject characteristics with study retention, which was defined as completion of the research study interview at 6 and 12 months. RESULTS The randomized trial enrolled 388 individuals; 261 (67.3%) completed the 12-month interview. Higher perceived threat of chronic diseases relative to asthma was associated with higher study retention (OR = 1.11, 95% CI = 1.00-1.24) at 12 months. Other variables including asthma beliefs, age, cognitive function, health literacy, and asthma symptoms were not significantly associated with retention. CONCLUSIONS Concern about non-asthma chronic conditions, but no other illness beliefs, or patient characteristics, were associated with retention in an asthma self-management support intervention. Further research, including qualitative studies, is needed to better understand why patients drop out of asthma behavioral intervention studies.
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Affiliation(s)
- Dustin Kee
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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25
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O’Conor R, Opsasnick L, Pack A, Yoshino Benavente J, Curtis LM, Lovett RM, Luu H, Wismer G, Kwasny MJ, Federman AD, Bailey SC, Wolf MS. Perceived Adequacy of Tangible Support during Stay-at-Home Orders in Chicago and New York. J Prim Care Community Health 2021; 12:21501327211024411. [PMID: 34109874 PMCID: PMC8202264 DOI: 10.1177/21501327211024411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: Physical distancing precautions during the COVID-19 pandemic may challenge the provision of tangible support many middle age and older adults receive in managing their health. We examined the association between unmet tangible support needs and self-management behaviors and mental health status during the stay-at-home orders in Chicago and New York. Methods: We used data from the COVID-19 & Chronic Conditions study collected between May 1st and May 22nd, 2020. A total of 801 middle age and older adults with ≥1 chronic condition in Chicago and New York City completed the telephone interview. Adequacy of tangible social support was measured using a brief, validated scale that determined whether an individual needed assistance managing his or her health, and if yes, whether this need was met. Participants reported their level of difficulty engaging in self-management behaviors using 2 discrete items; they also self-reported medication adherence using the ASK-12 medication adherence scale. Mental health status was measured using the depression and anxiety PROMIS short-form instruments. Results: Participants’ mean age was 63 years; 30% identified as Black, 26% identified as Latino, and 12% identified unmet support needs. Inadequacy of tangible support was associated with greater difficulty managing one’s health and accessing medications due to COVID-19, as well as poorer medication adherence, increased anxiety and depressive symptoms, and poorer overall well-being (P’s < .05). Conclusions: Perceived unmet support needs during stay-at-home orders were associated with greater difficulty engaging in self-management behaviors and poorer overall well-being. Two brief items quickly identified individuals with unmet support needs.
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Affiliation(s)
- Rachel O’Conor
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Rachel O’Conor, Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Dr, 10th Floor, Chicago, IL 60611, USA.
| | - Lauren Opsasnick
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allison Pack
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Julia Yoshino Benavente
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Laura M. Curtis
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Rebecca M. Lovett
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Han Luu
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Guisselle Wismer
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mary J. Kwasny
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Stacy C. Bailey
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael S. Wolf
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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26
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Ritchie CS, Gallopyn N, Sheehan OC, Sharieff SA, Franzosa E, Gorbenko K, Ornstein KA, Federman AD, Brody AA, Leff B. COVID Challenges and Adaptations Among Home-Based Primary Care Practices: Lessons for an Ongoing Pandemic from a National Survey. J Am Med Dir Assoc 2021; 22:1338-1344. [PMID: 34111388 PMCID: PMC8184288 DOI: 10.1016/j.jamda.2021.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/13/2021] [Accepted: 05/16/2021] [Indexed: 12/02/2022]
Abstract
Objectives Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. Design Mixed-methods national survey. Setting and Participants HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. Methods Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions. Results Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%). Conclusions and Implications HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.
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Affiliation(s)
- Christine S Ritchie
- Massachusetts General Hospital Department of Medicine, Division of Palliative Care and Geriatric Medicine, Boston, MA, USA; Massachusetts General Hospital Mongan Institute, Boston, MA, USA; Harvard Medical School Center for Palliative Care, Boston, MA, USA.
| | - Naomi Gallopyn
- Massachusetts General Hospital Department of Medicine, Division of Palliative Care and Geriatric Medicine, Boston, MA, USA; Massachusetts General Hospital Mongan Institute, Boston, MA, USA
| | - Orla C Sheehan
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shanaz Ahmed Sharieff
- Massachusetts General Hospital Department of Medicine, Division of Palliative Care and Geriatric Medicine, Boston, MA, USA; Massachusetts General Hospital Mongan Institute, Boston, MA, USA
| | - Emily Franzosa
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - Bruce Leff
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Agarwal P, Lin J, Muellers K, O'Conor R, Wolf M, Federman AD, Wisnivesky JP. A structural equation model of relationships of health literacy, illness and medication beliefs with medication adherence among patients with chronic obstructive pulmonary disease. Patient Educ Couns 2021; 104:1445-1450. [PMID: 33308880 PMCID: PMC8144232 DOI: 10.1016/j.pec.2020.11.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To determine the relative contributions of health literacy (HL) and illness and medication beliefs to medication adherence among older COPD patients and determine the pathways through which they operate. METHODS The study was conducted using data from a prospective cohort of COPD patients in New York City and Chicago. We used structural equation modeling to examine the pathways linking HL, through medications and illness beliefs, with COPD medication adherence. RESULTS Out of 393 older adults with COPD, 123 (31%) had limited HL and 208 (53%) reported low adherence to daily COPD medications. Those with limited HL were more likely to have low medication adherence (p < 0.0001). Medications concerns (p = 0.001) and medication necessity (p = 0.003) demonstrated a mediational role between HL and adherence. However, in the final multivariate model, HL did not have direct effect on medication adherence (p = 0.12) and illness beliefs (p = 0.16) did not demonstrate a mediational role between HL and adherence. CONCLUSION Our findings suggest that low HL is not a direct predictor of poor medication adherence among COPD patients. PRACTICE IMPLICATIONS Addressing medication concerns and reinforcing the need for daily COPD medications may be a more effective strategy for increasing adherence in this population.
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Affiliation(s)
- Parul Agarwal
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine, New York, NY, USA.
| | - Jenny Lin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Kimberly Muellers
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Rachel O'Conor
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Michael Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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28
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Curtis LM, Kwasny MJ, Opsasnick L, O'Conor RM, Yoshino-Benavente J, Eifler M, Federman AD, Altschul D, Wolf MS. Change in Health Literacy over a Decade in a Prospective Cohort of Community-Dwelling Older Adults. J Gen Intern Med 2021; 36:916-922. [PMID: 33559068 PMCID: PMC8042084 DOI: 10.1007/s11606-020-06423-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Health literacy is often viewed as a static trait in longitudinal studies, which may over or underestimate an individual's ability to manage one's health. OBJECTIVES We sought to examine health literacy over time among older adults using three widely used measures. DESIGN A prospective cohort study. PARTICIPANTS Community-dwelling adults ages 55 to 74 at baseline with at least one follow-up visit (N = 656) recruited from one academic internal medicine clinic and six community health centers in Chicago, IL. MEASURES Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA), Newest Vital Sign (NVS), and Rapid Estimate of Adult Literacy in Medicine (REALM) at baseline and up to three follow-up time points. RESULTS In unadjusted analyses, significant changes since baseline were found beginning at the second follow-up (mean (M) = 6.0 years, SD = 0.6) for the TOFHLA (M = - 0.9, SD = 0.95, p = 0.049) and the REALM (M = 0.3, SD = 2.5, p = 0.004) and at the last follow-up (M = 8.6 years, SD = 0.5) for the NVS (M = - 0.2, SD = 1.4, p = 0.02). There were non-linear effects of baseline age on TOFHLA and NVS scores over time (piecewise cubic spline p = 0.01 and p < 0.001, respectively) and no effect on REALM scores (B = 0.02, 95% CI - 0.01 to 0.04, p = 0.17) using multivariable mixed-effects linear regression models, controlling for race, education, income, and comorbidity. CONCLUSION We found a negative relationship between age and health literacy over time as measured by the TOFHLA and NVS. Health literacy barriers appear to be more prevalent among individuals in later life, when self-care demands are similarly increasing. Clinicians might consider strategies to assess and respond to limited health literacy, particularly among patients 70 and older. REALM performance remained stable over 10 years of follow-up. This questions whether health literacy tools measure the same attribute. Prospective health literacy studies should carefully consider what measures to use, depending on their objective.
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Affiliation(s)
- Laura M Curtis
- Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA.
| | - Mary J Kwasny
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N Lake Shore Drive, Suite 1400, Chicago, IL, 60611, USA
| | - Lauren Opsasnick
- Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Rachel M O'Conor
- Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Julia Yoshino-Benavente
- Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Morgan Eifler
- Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mt. Sinai, 17 East 102nd Street, 7th Floor, New York, NY, 10029, USA
| | - Drew Altschul
- Department of Psychology, School of Philosophy, Psychology and Language Sciences, University of Edinburgh, Room F2, Psychology Building, 7 George Square, Edinburgh, EH8 9JZ, UK
| | - Michael S Wolf
- Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA
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29
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Pollevick ME, Xu KY, Mhango G, Federmann EG, Vedanthan R, Busse P, Holguin F, Federman AD, Wisnivesky JP. The Relationship Between Asthma and Cardiovascular Disease: An Examination of the Framingham Offspring Study. Chest 2021; 159:1338-1345. [PMID: 33316236 PMCID: PMC8501004 DOI: 10.1016/j.chest.2020.11.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 10/13/2020] [Accepted: 11/16/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although asthma has been suggested as a risk factor for cardiovascular disease (CVD), robust longitudinal evidence of this relationship is limited. RESEARCH QUESTION Using Framingham Offspring Cohort data, the goal of this study was to longitudinally examine the association between asthma and lifetime risk of CVD while controlling for cardiovascular risk factors included in the Framingham Risk Score. STUDY DESIGN AND METHODS Data were analyzed from a prospective population-based cohort of 3,612 individuals, ages 17 to 77 years, who participated in Framingham Offspring Study examinations from 1979 to 2014. Asthma was defined based on physician diagnosis during study interviews. Incident CVD included myocardial infarction, angina, coronary insufficiency, stroke, transient ischemic attack, and heart failure. Time-dependent Cox regression models were used to evaluate the relationship between asthma and CVD incidence. RESULTS Overall, 533 (15%) participants had a diagnosis of asthma and 897 (25%) developed CVD during the course of the study. Unadjusted analyses revealed that asthma was associated with increased CVD incidence (hazard ratio, 1.40; 95% CI, 1.17-1.68). Cox regression also showed an adjusted association between asthma and CVD incidence (hazard ratio, 1.28; 95% CI, 1.07-1.54) after controlling for established cardiovascular risk factors. INTERPRETATION This prospective analysis with > 35 years of follow-up shows that asthma is a risk factor for CVD after adjusting for potential confounders. When assessing risk of cardiovascular disease, asthma should be evaluated and managed as a risk factor contributing to morbidity and mortality.
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Affiliation(s)
- Matias E Pollevick
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Feinberg School of Medicine at Northwestern University, Chicago, IL
| | - Kevin Y Xu
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Grace Mhango
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Emily G Federmann
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rajesh Vedanthan
- Department of Population Health, New York University School of Medicine, New York, NY; Department of Medicine, New York University School of Medicine, New York, NY
| | - Paula Busse
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Allergy and Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Fernando Holguin
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Colorado, Denver, CO
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
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Perez-Benzo GM, Muellers K, Chen S, Liu B, Bagiella E, O'Conor R, Wolf MS, Wisnivesky JP, Federman AD. Identifying Behavioral Phenotypes in Chronic Illness: Self-Management of COPD and Comorbid Hypertension. Patient Educ Couns 2021; 104:627-633. [PMID: 32921518 PMCID: PMC7914263 DOI: 10.1016/j.pec.2020.08.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/27/2020] [Accepted: 08/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To identify and characterize the constellation, or clusters, of self-management behaviors in patients with chronic obstructive pulmonary disease (COPD) and comorbid hypertension. METHODS Cluster analysis (n = 204) was performed with standardized scores for medication adherence to COPD and hypertension medications, inhaler technique, and diet as well as self-reported information on physical activity, appointment keeping, smoking status, and yearly influenza vaccination for a total of eight variables. Classification and regression tree analysis (CART) was performed to further characterize the resulting clusters. RESULTS Patients were divided into three clusters based on eight self-management behaviors, which included 95 patients in cluster 1, 42 in cluster 2, and 67 in cluster 3. All behaviors except for inhaler technique differed significantly among the three clusters (P's<0.005). CART indicated physical activity was the first differentiating variable. CONCLUSIONS Patients with COPD and hypertensioncan be separated into those with adequate and inadequate adherence. The group with inadequate adherence can further be divided into those with poor adherence to medical behaviors compared to those with poor adherence to lifestyle behaviors. PRACTICE IMPLICATIONS Once validated in other populations, the identification of patient clusters using patient self-management behaviors could be used to inform interventions for patients with multimorbidity.
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Affiliation(s)
| | - Kimberly Muellers
- Department of Psychology, Pace University, New York, NY, United States
| | - Shiqi Chen
- ISO, Verisk Analytics, Jersey City, NJ, United States
| | - Bian Liu
- Institute for Translational Epidemiology, Department of Population Health Science and Policy, The Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Emilia Bagiella
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Juan P Wisnivesky
- Division of Pulmonary and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
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Franzosa E, Gorbenko K, Brody AA, Leff B, Ritchie CS, Kinosian B, Ornstein KA, Federman AD. "At Home, with Care": Lessons from New York City Home-based Primary Care Practices Managing COVID-19. J Am Geriatr Soc 2021; 69:300-306. [PMID: 33179761 PMCID: PMC8285037 DOI: 10.1111/jgs.16952] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/09/2020] [Accepted: 11/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES COVID-19 required rapid innovation throughout the healthcare system. Home-based primary care (HBPC) practices faced unique challenges maintaining services for medically complex older populations for whom they needed to adapt a traditionally hands-on, model of care to accommodate restrictions on in-person contact. Our aim was to determine strategies used by New York City (NYC)-area HBPC practices to provide patient care during the first wave of the COVID-19 pandemic with the goal of informing planning and preparation for home-based practices nationwide. DESIGN Cross-sectional qualitative design using semi-structured interviews. SETTING HBPC practices in the NYC metro area during spring 2020. PARTICIPANTS HBPC leadership including clinical/medical directors, program managers, nurse practitioners/nursing coordinators, and social workers/social work coordinators (n = 13) at 6 NYC-area practices. MEASUREMENTS Semi-structured interviews explored HBPC practices' COVID-19 care delivery challenges, adaptations, and advice for providers. Interviewers probed patient care, end-of-life care, telehealth, community-based services and staffing. Interviews were recorded and transcribed. Data were analyzed through a combined inductive and deductive thematic approach. RESULTS Participants described care delivery and operational adaptations similar to those universally adopted across healthcare settings during COVID-19, such as patient outreach and telehealth. HBPC-specific adaptations included mental health services for patients experiencing depression and isolation, using multiple modalities of patient interactions to balance virtual care with necessary in-person contact, strategies to maintain patient trust, and supporting team connection of staff through daily huddles and emotional support during the surge of deaths among long-standing patients. CONCLUSION NYC-area HBPC providers adapted care delivery and operations rapidly during the height of the COVID-19 pandemic. Keeping older, medically complex patients safe in their homes required considerable flexibility, transparency, teamwork, and partnerships with outside providers. As the pandemic continues to surge around the United States, HBPC providers may apply these lessons and consider resources needed to prepare for future challenges.
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Affiliation(s)
- Emily Franzosa
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Geriatrics Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, New York, USA
| | - Ksenia Gorbenko
- Department of Population Health Science and Policy, Institute of Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Abraham A Brody
- Hartford Institute of Geriatric Nursing, Rory Meyers College of Nursing, New York University, New York, New York, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatrics, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine S Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Kinosian
- Center for Health Equity Research and Promotion, Corporal Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Geriatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Katherine A Ornstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D Federman
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Abstract
Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) defines a subgroup of patients with asthma who have persistent airflow obstruction or patients with COPD who may exhibit variable airflow limitation and/or evidence of type 2 inflammation. Additional investigations are needed to determine whether ACO represents a distinct disorder with unique underlying pathophysiology, whether ACO patients should be managed differently from those with asthma or COPD, and whether the diagnosis affects long-term outcomes. This article presents the data about the clinical features of ACO, the current information regarding the underlying pathophysiology of the syndrome, and current understanding of therapeutic options.
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Affiliation(s)
- Sunita Sharma
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, 12700 East 19th Avenue, MS C272, Aurora, CO 80045-2563, USA.
| | - Sandhya Khurana
- Division of Pulmonary and Critical Care Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mt. Sinai, 1 Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Juan Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mt. Sinai, 1 Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Fernando Holguin
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, 12700 East 19th Avenue, MS C272, Aurora, CO 80045-2563, USA
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Reckrey JM, Tsui EK, Morrison RS, Geduldig ET, Stone RI, Ornstein KA, Federman AD. Beyond Functional Support: The Range Of Health-Related Tasks Performed In The Home By Paid Caregivers In New York. Health Aff (Millwood) 2020; 38:927-933. [PMID: 31158023 DOI: 10.1377/hlthaff.2019.00004] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paid caregivers (for example, home health aides and personal care attendants) are formally tasked with helping older adults with functional impairment meet their basic needs at home. This study used thirty semistructured interviews with dyads of patients or their proxies and their paid caregivers in New York City to understand the range of health-related tasks that paid caregivers perform in the home and determine whether these tasks are taught in the New York State Department of Health's curriculum. We found that patients, proxies, and paid caregivers all reported that paid caregivers performed a wide range of health-related tasks that were often not part of their formal training. Creating clear competencies for paid caregivers that reflect the full breadth of health-related tasks they may perform in the home could help maximize the positive impact of the paid caregiver workforce on the lives of patients living at home with functional impairment.
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Affiliation(s)
- Jennifer M Reckrey
- Jennifer M. Reckrey ( ) is an associate professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City
| | - Emma K Tsui
- Emma K. Tsui is an assistant professor of community health and social sciences at the City University of New York School of Public Health, in New York City
| | - R Sean Morrison
- R. Sean Morrison is a professor in the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai
| | - Emma T Geduldig
- Emma T. Geduldig is a student in the Department of Medical Education, Icahn School of Medicine at Mount Sinai
| | - Robyn I Stone
- Robyn I. Stone is senior vice president for research at LeadingAge, in Washington, D.C
| | - Katherine A Ornstein
- Katherine A. Ornstein is an assistant professor in the Department of Geriatrics and Palliative Medicine and the Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai
| | - Alex D Federman
- Alex D. Federman is a professor in the Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai
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Muellers KA, Chen L, O'Conor R, Wolf MS, Federman AD, Wisnivesky JP. Health Literacy and Medication Adherence in COPD Patients: When Caregiver Presence Is Not Sufficient. COPD 2020; 16:362-367. [PMID: 31755323 DOI: 10.1080/15412555.2019.1665007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Limited health literacy (HL) is associated with a lower medication adherence in patients with chronic obstructive pulmonary disease (COPD). In this study, we examined the potential mitigating role of caregiver support on the relationship between HL and adherence to COPD medications. We conducted a prospective observational study of adults with COPD and their caregivers. HL was assessed using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and COPD medication adherence was evaluated with the Medication Adherence Rating Scale (MARS). We also collected caregiver HL data for a subset of participants. We tested whether having a caregiver impacted the relationship between HL and medication adherence using cross-sectional data collected between 2011 and 2015. Our sample included 388 COPD patients and 97 caregivers. COPD patients with low HL had a lower medication adherence (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.24-0.81) after adjusting for sociodemographic factors. Caregiver presence was not associated with increased patient medication adherence (OR: 1.28, 95% CI: 0.79-2.08). Among the subset of patients with caregivers, low patient HL remained associated with a lower medication adherence (OR: 0.28, 95% CI: 0.09-0.82) when adjusted for caregiver HL and sociodemographic factors. Low HL is associated with lower COPD medication adherence, and this effect is not mitigated by the presence of a caregiver. These findings suggest a need for effective strategies to manage high-risk COPD patients with low HL, even among those with adequate support from caregivers, and to design interventions for both patients and caregivers with low HL.
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Affiliation(s)
- Kimberly A Muellers
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Li Chen
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Division of Pulmonary and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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35
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Federman AD, Thanik E, O'Conor R, Arora A, Wolf MS, Wisnivesky JP. Patient characteristics associated with improvements in asthma control and reduction in emergency department visits for older adults with asthma. J Asthma 2020; 58:1528-1535. [PMID: 32812836 DOI: 10.1080/02770903.2020.1805753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify patient characteristics associated with improvements in asthma control among older adults with asthma. METHODS Secondary analysis of data from a randomized controlled trial of an asthma self-management support intervention for adults ages 60 and older with moderate-severe persistent asthma (n = 391). We tested the association of baseline patient characteristics with reduced emergency department (ED) visits and improvement in asthma control equal to or exceeding the minimal clinically important difference (MCID) in asthma control test (ACT) scores (3.0) 12 months. RESULTS At baseline, the mean age was 68 years, 15.0% were male, 30.3% were black, and 56.5% were Hispanic. Patients with a history of ED visits in the 12 months preceding study enrollment were significantly more likely to experience an ED visit during the study period (adjusted odds ratio [AOR] 6.92, 95% confidence interval [CI] 2.18-21.9, p < .0001). Similarly, those with poorer asthma control (baseline ACT scores <13) had greater odds of achieving improved asthma control (AOR 13.7, 95% CI 5.32-35.1, p < .0001). No other variables had statistically significant associations with the outcomes. CONCLUSIONS Low scores on the asthma control test and prior ED visits for asthma are strong correlates of later clinically meaningful changes in asthma control among older adults. Health systems preparing for population management of patients with asthma ought to consider incorporating serial collection of data on the ACT into the monitoring and management of older asthmatics, a high-risk patient population.
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Affiliation(s)
- Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erin Thanik
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Arushi Arora
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Reckrey JM, Geduldig ET, Lindquist LA, Morrison RS, Boerner K, Federman AD, Brody AA. Paid Caregiver Communication With Homebound Older Adults, Their Families, and the Health Care Team. Gerontologist 2020; 60:745-753. [PMID: 31112604 DOI: 10.1093/geront/gnz067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although paid caregivers (e.g., home health aides and home care workers) provide essential care for homebound older adults with serious illness in their homes, little is known about how and to whom paid caregivers communicate about the health needs they encounter. This study explored how paid caregivers (i) communicate when older adults experience symptoms or clinical changes and (ii) interact with the health care team. RESEARCH DESIGN AND METHODS We conducted separate one-on-one, semi-structured interviews (n = 30) lasting 40-60 min with homebound older adults (or their proxies if they had cognitive impairment) and their paid caregivers (provided they had worked with the older adult for ≥8 hr per week for ≥6 months). Interviews were audio-recorded, transcribed, and coded. RESULTS Thematic analysis identified four themes: (i) older adults or their families were the gatekeepers to paid caregiver communication with the health care team; (ii) communication between older adults, their families, and paid caregivers was enhanced when close relationships were present; (iii) paid caregivers responded to health care team inquiries but rarely communicated proactively; and (4) most older adults, families, and paid caregivers were satisfied with existing paid caregiver communication with the health care team. DISCUSSION AND IMPLICATIONS Rather than discuss concerns with the health care team, paid caregivers communicated directly with older adults or their families about the health needs they encounter. Understanding how communication occurs in the home is the first step to maximizing the potentially positive impact of paid caregivers on the health of older adults living at home.
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Affiliation(s)
- Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emma T Geduldig
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lee A Lindquist
- Department of Medicine, Division of General Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts Boston, New York
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Abraham A Brody
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J Peters Bronx VA Geriatric Research Education and Clinical Center, New York, New York.,New York University Rory Meyers College of Nursing
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Saenger P, Federman AD, DeCherrie LV, Lubetsky S, Catalan E, Leff B, Siu AL. Choosing Inpatient vs Home Treatment: Why Patients Accept or Decline Hospital at Home. J Am Geriatr Soc 2020; 68:1579-1583. [PMID: 32374438 DOI: 10.1111/jgs.16486] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 03/12/2020] [Accepted: 03/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Hospital at home (HaH) provides interdisciplinary acute care in the home as a substitute for inpatient hospitalization. Studies have demonstrated that HaH care is associated with better quality care, fewer complications, and better patient and caregiver experience. Still, some patients decline HaH. The objective of the study was to characterize patients who accept vs decline HaH care and describe reasons for their decisions in the context of a Center for Medicare and Medicaid Innovation demonstration of HaH. DESIGN/SETTING/PARTICIPANTS A total of 442 patients with Medicare or other eligible insurance, 18 years or older, who met study eligibility criteria were offered HaH at Mount Sinai Hospitals in New York, NY, between September 1, 2014, and August 31, 2017. MEASUREMENTS Reasons for accepting or declining HaH were recorded. Age, sex, insurance type, and admission diagnoses of HaH acceptors and refusers were compared in univariate analyses. RESULTS Of the 442 patients offered HaH, 66.7% accepted. Main reasons for enrolling in HaH included being more comfortable at home (78.2%) and being near family (40.7%). Specific reasons given for refusing HaH included preferring in-hospital care (15.0%) and concern that HaH would not meet care needs (12.9%). CONCLUSION Two-thirds of patients offered HaH care opted to receive it. The reasons for declining HaH provided by those who chose not to participate should be considered for quality improvement, and reasons for acceptance may be helpful in marketing and other efforts to promote HaH participation. J Am Geriatr Soc 68:1579-1583, 2020.
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Affiliation(s)
- Pamela Saenger
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Elisse Catalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bruce Leff
- Division of Geriatric Medicine, Center for Transformative Geriatric Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peters VA Medical Center, Bronx, New York, USA
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38
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Mindlis I, Livert D, Federman AD, Wisnivesky JP, Revenson TA. Racial/ethnic concordance between patients and researchers as a predictor of study attrition. Soc Sci Med 2020; 255:113009. [PMID: 32371270 DOI: 10.1016/j.socscimed.2020.113009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/31/2020] [Accepted: 04/19/2020] [Indexed: 11/25/2022]
Abstract
RATIONALE The differential attrition of racial/ethnic minority participants in clinical research is a major threat to advancing medical and behavioral science. OBJECTIVE Our aim was to examine the influence of racial/ethnic concordance between participants and research staff on study attrition. METHOD Data were pooled from participants and clinical research coordinators (CRCs) in six longitudinal studies of respiratory illness. Dyads were classified as concordant if the patient and CRC were of the same racial/ethnic group. Multilevel modeling examined the effect of racial/ethnic concordance on attrition at the first and one-year follow-ups. RESULTS Spanish language, lower education, and greater depressive symptoms predicted greater attrition, but these effects disappeared in adjusted models. Race/ethnicity, age, gender and health literacy did not predict attrition. Contrary to hypotheses, attrition was greater among concordant than discordant dyads: Attrition was almost five times greater at first follow-up for Black and Hispanic participants in concordant dyads, and almost four times greater at one year. CONCLUSIONS Racial/ethnic concordance between participant and CRCs was related to greater attrition in a highly diverse sample of adults with respiratory illness. Differential attrition of racial/ethnic minorities is a major threat to advancing public health. Interactions with research staff may be critical to bridging the disparities gap.
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Affiliation(s)
- Irina Mindlis
- Psychology Department, The Graduate Center, City University of New York, NY, USA.
| | - David Livert
- Psychology Department, Penn State Lehigh Valley, PA, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Tracey A Revenson
- Psychology Department, The Graduate Center, City University of New York, NY, USA; Psychology Department, Hunter College, City University of New York, NY, USA
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39
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McInerney GE, Muellers K, O'Conor R, Wolf MS, Leventhal H, Wisnivesky JP, Federman AD. Concordance of patients' beliefs about chronic obstructive pulmonary disease, their comorbidities, and their medications. Patient Educ Couns 2020; 103:677-681. [PMID: 31761528 PMCID: PMC7138702 DOI: 10.1016/j.pec.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/11/2019] [Accepted: 11/15/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To test the association of chronic obstructive pulmonary disease (COPD) illness and medication beliefs with those specific to hypertension or diabetes in patients with COPD and coexisting chronic conditions. METHODS A cross-sectional analysis of data collected from a sample of 282 adults with COPD and comorbid hypertension or diabetes recruited from primary care practices in New York, NY, and Chicago, IL. Beliefs about COPD, hypertension, and diabetes were measured using the Brief Illness Perception Questionnaire. Higher scores indicate a more adaptive view of the illness. Beliefs about medications were measured using the 10-item Beliefs about Medicines Questionnaire; higher scores on the two subscales indicate increased concerns and necessity, respectively. RESULTS In adjusted analyses, scores for COPD and hypertension as well as COPD and diabetes illness beliefs, medication necessity, and medication concern were significantly associated. CONCLUSION Patients with COPD and comorbid hypertension or diabetes have consistent beliefs about their diseases and the medications used to treat them. PRACTICE IMPLICATIONS The consistency of beliefs across conditions may help in the development of a more holistic approach to disease management in patients with COPD who have comorbid illnesses and contribute to a better understanding of the Common-Sense Model of Illness Representation.
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Affiliation(s)
| | - Kimberly Muellers
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Howard Leventhal
- Institute for Health and Department of Psychology, Rutgers University, New Brunswick, NJ, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Division of Pulmonary and Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Tangirala NC, O'Conor R, Wolf MS, Wisnivesky JP, Federman AD. Validity of the Medication Adherence Rating Scale for Adherence to Inhaled Corticosteroids among Older Adults with Asthma or Chronic Obstructive Pulmonary Disease. COPD 2020; 17:74-80. [PMID: 31948266 DOI: 10.1080/15412555.2020.1712688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Regular use of inhaled corticosteroids (ICS) is the standard of care for patients with persistent asthma and chronic obstructive pulmonary disease (COPD). Adherence to ICS is measured using the 10-item Medication Adherence Report Scale (MARS), a self-reported medication adherence assessment. However, data on the validity of this measure are limited. Data were obtained from two cohort studies that examined the association of health literacy with self-management behaviors among adults ages 65 and older with asthma and adults ages 40 and older with COPD. ICS adherence was objectively measured over a 4-week period using electronic monitoring devices. Adequate adherence by MARS assessment was defined as a score ≥4.5, and by electronic monitoring as ≥80% of doses prescribed. We assessed the criterion validity using correlations between self-reported adherence and electronic adherence. Receiver Operating Characteristic (ROC) curve analysis was performed between the two measures. Among patients with asthma, the continuous values for adherence measured by self-report and electronically were weakly correlated (r = 0.33, p < 0.001); similarly, the agreement between the dichotomized measures was weak (kappa 0.30, p=.49). Findings were similar for COPD patients: r = 0.26, p = 0.003; kappa 0.19, p = .60. Area under curve (AUC) values generated from ROC analysis was 0.69 and 0.61, for asthma and COPD patients, respectively. Commonly used measure for adherence performed weakly compared to electronic monitoring in separate populations of patients with asthma and COPD. Investigators measuring self-reported medication adherence among patients with these pulmonary diseases should consider using alternative instruments or using objective measures exclusively.
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Affiliation(s)
- Neelima C Tangirala
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Bailey SC, Opsasnick LA, Curtis LM, Federman AD, Benavente JY, O'Conor R, Wolf MS. Longitudinal Investigation of Older Adults' Ability to Self-Manage Complex Drug Regimens. J Am Geriatr Soc 2019; 68:569-575. [PMID: 31765007 DOI: 10.1111/jgs.16255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES We sought to investigate older patients' ability to correctly and efficiently dose multidrug regimens over nearly a decade and to explore factors predicting declines in medication self-management. DESIGN Longitudinal cohort study funded by the National Institute on Aging. SETTING One academic internal medicine clinic and six community health centers. PARTICIPANTS Beginning in 2008, 900 English-speaking adults, aged 55 to 74 years, were enrolled in the study, completing a baseline (T1) assessment. To date, 303 participants have completed the same assessment 9 years postbaseline (T4). MEASUREMENTS At T1, subjects were given a standardized, seven-drug regimen and asked to demonstrate how they would take medicine over 24 hours. The number of dosing errors made and times per day that a participant would take medicine were recorded. Health literacy was measured via the Newest Vital Sign, and cognitive decline was measured by the Mini-Mental State Examination. RESULTS Participants on average made 2.9 dosing errors (SD = 2.5 dosing errors; range = 0-21 dosing errors) of 21 potential errors at T1 and 5.0 errors (SD = 2.1 errors; range = 1-18 errors; P < .001) at T4. In a multivariate model, limited literacy (β = .69; 95% confidence interval [CI] = .18-1.20; P = .01), meaningful cognitive decline (β = 1.72; 95% CI = .70-2.74; P = .01), number of chronic conditions (β = .21; 95% CI = .07-.34; P = .01), and number of baseline dosing errors (β = -.76; 95% CI = -.85 to -.67; P < .001) were significant, independent predictors of changes in dosing errors. Most patients overcomplicated their daily medication schedule; no sociodemographic characteristics were predictive of poor regimen organization in multivariate models. In a multivariate model, there were no significant predictors of changes in regimen consolidation over time, except regimen consolidation at T1. CONCLUSIONS Older patients frequently overcomplicated drug regimens and increasingly made more dosing errors over 9 years of follow-up. Patients with limited literacy, cognitive decline, and multimorbidity were at greatest risk for errors. J Am Geriatr Soc 68:569-575, 2020.
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Affiliation(s)
- Stacy Cooper Bailey
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lauren A Opsasnick
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Laura M Curtis
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Julia Y Benavente
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rachel O'Conor
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael S Wolf
- Health Literacy and Learning Program, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Bendayan R, Federman AD, Dobson RJ. COGNITION AND HISTORY OF MULTIPLE HEALTH CONDITIONS OVER 20 YEARS: EVIDENCE FROM THE HEALTH AND RETIREMENT STUDY. Innov Aging 2019. [PMCID: PMC6840578 DOI: 10.1093/geroni/igz038.1159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Research to date on multimorbidity and cognitive impairment is mainly cross-sectional or with limited history information of the health conditions. The present study explores the association between cognitive performance and previous history of health conditions over 24 years in a sample of 4858 respondents of the Health Retirement Study. Data from health conditions between 1998 and 2014 included self-reports for hypertension, diabetes, arthritis, stroke, cancer, lung and heart diseases and psychiatric problems. Duration of the health condition was categorized as more than 10 years, between 4 and 10 years, less than 4 years and no condition. Cognition was assessed using a summary index of cognitive performance including measures of memory, working memory, speed processing, knowledge, and language. ANOVA and post hoc tests were performed to explore the association between cognition and the duration of each health condition independently. Multiple linear regression analyses were performed to explore the association between multiple health conditions and cognitive performance. Results showed significant independent associations between cognitive performance in 2014 and each health condition, except for cancer [F(1,4)=2.60; p =.51]. When all the health conditions were considered in the regression models, we found that cognitive performance is negatively associated with high blood pressure and stroke (independently of the duration of the condition), long-term diabetes and lung diseases (i.e., for more than 10 years) and recent cancer (i.e., in the last 4 years). Our findings highlight that considering duration of co-existent health conditions is key for identifying individuals at greater risk of cognitive impairment.
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Affiliation(s)
- Rebecca Bendayan
- Dept. Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, London, United Kingdom, United Kingdom
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Richard J Dobson
- Dept. Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, London, United Kingdom
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Bendayan R, Carr E, Federman AD, Dobson RJ. A MULTIDIMENSIONAL MODEL FOR POLYPHARMACY MEASUREMENT IN OLDER ADULTS: EVIDENCE FROM THE HEALTH RETIREMENT STUDY. Innov Aging 2019. [PMCID: PMC6846857 DOI: 10.1093/geroni/igz038.2599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Polypharmacy is associated with increased health care costs and adverse health outcomes. Traditional research on polypharmacy uses dichotomous measures which overlook its multidimensional nature. We propose a new approach to grouping older adults based on the number and type of medications taken as well as other indicators of polypharmacy. Data was extracted from 1328 respondents of the 2007 Prescription Drug Survey (a sub-study of the Health Retirement Study) who were between 50 and 70 years old and taking ≥1 medication each month. Latent class analysis was carried out with the optimal number of classes assessed based on relative model fit (AIC, adjusted BIC) and interpretability. Latent classes were formed based on the number of medications, drug types, duration of medication intake, side effects, and presence of chronic health conditions. A four-class model was selected based on model fit and interpretability of the solutions. Although there was some overlap when we compared our model with standard cut-offs for polypharmacy (i.e., ‘high polypharmacy’ classes were more likely to take 5+ and 9+ medications), chi-square tests showed significant differences between our latent classes and cut-offs based on 5+ [X2 = 894; p<0.001] and 9+ medications [X2 = 398; p<0.001]. Among individuals taking <5 medications, our model differentiated two distinct types of ‘low polypharmacy’ based on the types of drugs reported. Our proposal to incorporate a multidimensional assessment of polypharmacy considers the wider context of medication use and chronic health in older age, moving beyond crude medication counts.
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Affiliation(s)
- Rebecca Bendayan
- Dept. Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, London, United Kingdom, United Kingdom
| | - Ewan Carr
- Dept. Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, London, United Kingdom, United Kingdom
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Richard J Dobson
- Dept. Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King’s College London, London, United Kingdom, United Kingdom
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O'Conor R, Benavente JY, Kwasny MJ, Eldeirawi K, Hasnain-Wynia R, Federman AD, Hebert-Beirne J, Wolf MS. Daily Routine: Associations With Health Status and Urgent Health Care Utilization Among Older Adults. Gerontologist 2019; 59:947-955. [PMID: 30247549 DOI: 10.1093/geront/gny117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Chronically ill older adults must integrate self-care behaviors into their daily routine to promote health and reduce urgent health care utilization. Individuals of lower socioeconomic position (SEP) experience a disproportionate burden of stressors that challenge the formation of regular routines. We examined associations between the presence of a daily routine and older adults' health status and urgent health care utilization, to determine whether higher levels of daily routine mediates associations between SEP and health outcomes. RESEARCH DESIGN AND METHODS We used data from a cohort of older adult primary care patients in Chicago. Daily routine was measured using a brief, validated scale. A single factor score of SEP was created with measures of education, income, homeownership, and insurance status. Health status was assessed by Patient Reported Outcomes Measurement Information Service physical function, depression, and anxiety. Urgent health care utilization was patient reported. Multivariable models were used to assess the effect of routine and SEP on health status and urgent health care utilization. RESULTS Individuals reporting low levels of daily routine reported worse physical function (β = -2.34; 95% CI -4.18, -0.50), more anxiety (β = 2.73; 95% CI 0.68, 4.78) and depressive symptoms (β = 2.83; 95% CI 0.94, 4.74) than those with greater daily routine. No differences in urgent health care utilization were observed by daily routine. Daily routine varied by SEP (p < .001); routine partially mediated the relationship between SEP and physical function and anxiety symptoms (ps < .05). DISCUSSION AND IMPLICATIONS A daily routine may be an under recognized modifiable factor that could promote health outcomes among older adults.
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Affiliation(s)
- Rachel O'Conor
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL
| | | | - Mary J Kwasny
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Kamal Eldeirawi
- College of Nursing, University of Illinois at Chicago, Chicago, IL
| | | | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York
| | - Jennifer Hebert-Beirne
- Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL
| | - Michael S Wolf
- Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL
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O'Conor R, Arvanitis M, Wismer G, Opsasnick L, Sanchez Muñoz A, Kannry J, Lin JJ, Kaiser D, Kwasny MJ, Persell SD, Parker R, Wood AJJ, Federman AD, Wolf MS. Rationale and design of the regimen education and messaging in diabetes (REMinD) trial. Contemp Clin Trials 2019; 83:46-52. [PMID: 31260791 PMCID: PMC6642855 DOI: 10.1016/j.cct.2019.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/13/2019] [Accepted: 06/27/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Individuals with type 2 diabetes manage complex multi-drug regimens, but nearly half of all patients do not consistently take the dose prescribed for them, and therefore may not receive the full potential therapeutic benefit. Both patient and health system factors contribute to achieving and maintaining medication adherence. To determine if patients with type 2 diabetes who are concurrently managing other chronic conditions could improve their adherence, we devised and are testing a multifaceted, primary care-based strategy to provide health literacy-appropriate and language concordant regimen information, guidance and reminders. OBJECTIVE We are testing the effectiveness of an electronic health record (EHR) based strategy and short message service (SMS) text reminders to help patients with type 2 diabetes adhere to their medications. METHODS We are conducting a 3-arm, multi-site trial to test and compare the effectiveness of the EHR, and EHR + SMS text reminder strategies compared to usual care on medication adherence. Our goal is to enroll a total of 900 English or Spanish-speaking patients with type 2 diabetes and hemoglobin A1C value ≥7.5%. Enrolled participants will complete interviews at baseline and 3 and 6 months following their baseline interview. CONCLUSIONS Our trial is evaluating practical, clinic-based, scalable, evidence-based solutions for patients with type 2 diabetes managing complex medication regimens. Our findings will evaluate strategies that can be implemented broadly in primary care practices, and programmed as defaults within EHRs to support appropriate medication adherence to allow the widespread implementation of those strategies.
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Affiliation(s)
- Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America.
| | - Marina Arvanitis
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Guisselle Wismer
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Lauren Opsasnick
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Angela Sanchez Muñoz
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Joseph Kannry
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Jenny J Lin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Darren Kaiser
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Mary J Kwasny
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Stephen D Persell
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Ruth Parker
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Alastair J J Wood
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, United States of America
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
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Federman AD, O'Conor R, Mindlis I, Hoy-Rosas J, Hauser D, Lurio J, Shroff N, Lopez R, Erblich J, Wolf MS, Wisnivesky JP. Effect of a Self-management Support Intervention on Asthma Outcomes in Older Adults: The SAMBA Study Randomized Clinical Trial. JAMA Intern Med 2019; 179:1113-1121. [PMID: 31180474 PMCID: PMC6563560 DOI: 10.1001/jamainternmed.2019.1201] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
IMPORTANCE Older adults with asthma have worse control and outcomes than younger adults. Interventions to address suboptimal self-management among older adults with asthma are typically not tailored to the specific needs of the patient. OBJECTIVE To test the effect of a comprehensive, patient-tailored asthma self-management support intervention for older adults on clinical and self-management outcomes. DESIGN, SETTING, AND PARTICIPANTS Three-arm randomized clinical trial conducted between February 2014 and December 2017 at primary care practices and personal residences in New York City. Adults 60 years and older with persistent, uncontrolled asthma were identified from electronic medical records at an academic medical center and a federally qualified health center. Of 1349 patients assessed for eligibility, 406 met eligibility criteria, consented to participate, and were randomized to 1 of 3 groups: home-based intervention, clinic-based intervention, or control (usual care). A total of 391 patients received the allocated treatment. INTERVENTIONS Screening for psychosocial, physical, cognitive, and environmental barriers to asthma control and self-management with actions to address identified barriers. The intervention was delivered in the home or primary care practices by asthma care coaches. MAIN OUTCOMES AND MEASURES Primary outcomes were the Asthma Control Test, Mini Asthma Quality of Life Questionnaire, Medication Adherence Rating Scale, metered dose inhaler technique, and emergency department visits for asthma care. Primary analyses compared intervention (home or clinic based) with usual care. RESULTS Of the 391 patients who received treatment, 58 (15.1%) were men, and the mean (SD) age was 67.8 (7.4) years. After accounting for baseline scores, scores on the asthma control test were better in the intervention groups vs the control group (difference-in-differences at 3 months, 1.2; 95% CI, 0.2-2.2; P = .02; 6 months, 1.0; 95% CI, 0.0-2.1; P = .049; 12 months, 0.6; 95% CI, -0.5 to 1.8; P = .28; and overall, χ2 = 13.4, with 4 degrees of freedom; P = .01). Emergency department visits were lower at 12 months for the intervention groups vs the control group (16 [6.2%] vs 17 [12.7%]; P = .03; adjusted odds ratio, 0.8; 95% CI, 0.6-0.99; P = .03). Statistically significant improvements were observed for the intervention vs control patients in quality of life (overall effect: χ2 = 10.5, with 4 degrees of freedom; P = .01), medication adherence (overall effect: χ2 = 9.5, with 4 degrees of freedom; P = .049), and inhaler technique (metered-dose inhaler technique, correctly completed steps at 12 months, median [range]: 75% [0%-100%] vs 58% [0%-100%]). No significant differences in outcomes were observed between patients receiving the intervention in home vs practice settings. CONCLUSIONS AND RELEVANCE An intervention directed by patients' needs and barriers improved asthma outcomes and self-management behaviors among older adults. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02316223.
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Affiliation(s)
- Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Irina Mindlis
- Department of Psychology, The Graduate Center, City University of New York, New York, New York
| | | | | | | | | | - Ray Lopez
- Little Sisters of the Assumption Family Health Service, New York, New York
| | - Joel Erblich
- Department of Psychology, Hunter College, City University of New York, New York, New York
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Abstract
The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being "exclusively homebound" (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.
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Affiliation(s)
- Jennifer M Reckrey
- Associate Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA.,Associate Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Alex D Federman
- Professor, Department of Medicine Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Evan Bollens-Lund
- Data Analytics Manager, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - R Sean Morrison
- Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
| | - Katherine A Ornstein
- Associate Professor, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai , New York, NY, USA
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Weerahandi H, Wisnivesky JP, O'Conor R, Wolf MS, Federman AD. The Relationship of Illness Beliefs with Hospital and Emergency Department Utilization in Chronic Obstructive Pulmonary Disease. J Gen Intern Med 2019; 34:923-928. [PMID: 30847827 PMCID: PMC6544700 DOI: 10.1007/s11606-019-04833-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 11/17/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Himali Weerahandi
- Division of General Internal Medicine and Clinical Innovation, Department of Medicine, NYU School of Medicine, Brooklyn, NY, USA.
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel O'Conor
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael S Wolf
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Alex D Federman
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Siu AL, Zimbroff RM, Federman AD, DeCherrie LV, Garrido M, Morano B, Lubetsky S, Catalan E, Leff B. The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop. BMC Health Serv Res 2019; 19:264. [PMID: 31035973 PMCID: PMC6489357 DOI: 10.1186/s12913-019-4063-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 04/05/2019] [Indexed: 02/03/2024] Open
Abstract
Background Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from “voltage drop” (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or “program drift.” (decreased benefit arising from deviations from study protocols). Methods Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics. Results Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11–44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (− 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66). Conclusions We made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential ‘program drift’ or ‘voltage drop.’ Trial registration Not applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study “in which the assignment of the medical intervention is not at the discretion of the investigator.” Electronic supplementary material The online version of this article (10.1186/s12913-019-4063-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Albert L Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA. .,James J. Peters VA Medical Center, New York, NY, USA.
| | | | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Linda V DeCherrie
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Melissa Garrido
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Barbara Morano
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Sara Lubetsky
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Elisse Catalan
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Bruce Leff
- Division of Geriatrics, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Rojano B, West E, Ferdermann E, Markowitz S, Harrison D, Crowley L, Busse P, Federman AD, Wisnivesky JP. Allergen Sensitization and Asthma Outcomes among World Trade Center Rescue and Recovery Workers. Int J Environ Res Public Health 2019; 16:ijerph16050737. [PMID: 30823641 PMCID: PMC6427816 DOI: 10.3390/ijerph16050737] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/15/2019] [Accepted: 02/22/2019] [Indexed: 01/01/2023]
Abstract
A large number of World Trade Center (WTC) rescue and recovery workers are affected by asthma. While physical and mental health comorbidities have been associated with poor asthma control in this population, the potential role of allergen sensitization is unknown. This study examined the association of indoor sensitization and exposure as a risk factor for increased asthma morbidity in WTC workers. We used data from a prospective cohort of 331 WTC workers with asthma. Sensitization to indoor allergens was assessed by measurement of antigen-specific serum immunoglobulin E (IgE) levels. We used validated tools to evaluate the exposure to indoor allergens. Asthma morbidity outcomes included level of control (Asthma Control Questionnaire, ACQ), quality of life (Asthma Quality of Life Questionnaire, AQLQ) and acute resource utilization. The prevalence of sensitization to cat, dog, mouse, dust mite, cockroach, and mold allergens were 33%, 21%, 17%, 40%, 17%, and 17%, respectively. Unadjusted and regression analyses showed no significant relationship between sensitization and increased asthma morbidity (p > 0.05 for all comparisons), except for sensitization to Aspergillus Fumigatus, cat and mouse epithelium, which were associated with decreased morbidity.
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Affiliation(s)
- Belen Rojano
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Erin West
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Emily Ferdermann
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Steven Markowitz
- Barry Commoner Center for Health and the Environment, Queens College, City University of New York, Queens, New York, NY 11367, USA.
| | - Denise Harrison
- Department of Medicine, New York University School of Medicine, Bellevue Hospital Center, New York, NY 10016, USA.
| | - Laura Crowley
- Division of Occupational and Environmental Medicine, Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Paula Busse
- Division of Allergy and Immunology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Alex D Federman
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
| | - Juan P Wisnivesky
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
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