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Bernal OA, McClintock HF, Kurichi JE, Kwong PL, Xie D, Streim JE, Pezzin LE, Bogner HR. Patient Satisfaction and Perceived Quality of Care Among Younger Medicare Beneficiaries According to Activity Limitation Stages. Arch Phys Med Rehabil 2019; 100:289-299. [PMID: 30316959 DOI: 10.1016/j.apmr.2018.09.114] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/19/2018] [Accepted: 09/02/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To examine the association between activity limitation stages and patient satisfaction and perceived quality of medical care among younger Medicare beneficiaries. DESIGN Cross-sectional study. SETTING Medicare Current Beneficiary Survey (MCBS) for calendar years 2001-2011. PARTICIPANTS A population-based sample (N=9323) of Medicare beneficiaries <65 years of age living in the community. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physician (PCP), interpersonal skills of PCP, and quality of information provided by PCP. Persons were classified into an activity limitation stage (0-IV) which was derived from self-reported difficulty performing activities of daily living (ADL) and instrumental activities of daily living (IADL). RESULTS Compared to beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (95% confidence intervals) for stage I (mild) to stage IV (complete) for satisfaction with access barriers ranged from 0.62 (0.53-0.72) at stage I to a minimum of 0.31 (0.22-0.43) at stage IV. Similarly, compared to beneficiaries at IADL stage 0, satisfaction with access barriers ranged from 0.66 (0.55-0.79) at stage I to a minimum of 0.36 (0.26-0.51) at stage IV. Satisfaction with care coordination and quality and perceived quality of medical care were not associated with activity limitation stages. CONCLUSIONS Younger Medicare beneficiaries with disabilities reported decreased satisfaction with access to medical care, highlighting the need to improve access to health care and human services and to enhance workforce capacity to meet the needs of this patient population.
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Affiliation(s)
- Olivia A Bernal
- Center for Public Health Initiatives, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Heather F McClintock
- Department of Public Health, College of Health Sciences, Arcadia University, Glenside, PA
| | - Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pui L Kwong
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania and VISN 4 Mental Illness Research Education and Clinical Center, Philadelphia VA Medical Center, Philadelphia, PA
| | - Liliana E Pezzin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Hillary R Bogner
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Family Medicine and Community Health, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Na L, Kwong PL, Xie D, Pezzin LE, Kurichi JE, Streim JE. Functional Impairments Associated With Patient Activation Among Community-Dwelling Older Adults. Am J Phys Med Rehabil 2018; 97:839-847. [PMID: 29894313 PMCID: PMC6193847 DOI: 10.1097/phm.0000000000000979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/26/2022]
Abstract
OBJECTIVES Activity of daily living stages and instrumental activity of daily living stages demonstrated ordered associations with mortality, risk of hospitalization, and receipt of recommended care. This article explores the associations of stages with the following three dimensions of patient activation: self-care efficacy, patient-doctor communication, and health-information seeking. We hypothesized that higher activity of daily living and instrumental activity of daily living stages (greater limitation) are associated with a lower level of patient activation. METHODS Patient activation factors were derived from the 2004 and 2009 Medicare Current Beneficiary Survey. In this cross-sectional study (N = 8981), the associations of activity limitation stages with patient activation factors were assessed in latent factor models. RESULTS Greater activity limitation was in general inversely associated with self-efficacy, patient-doctor communication, and health information seeking, even after adjusting for sociodemographic and clinical characteristics. For instance, the mean of self-care efficacy across activity of daily living stages I-IV (mild, moderate, severe, and complete limitation) compared with stage 0 (no limitation) decreased significantly by 0.17, 0.29, 0.34, and 0.60, respectively. Covariates associated with suboptimal patient activation were also identified. DISCUSSION Our study identified multiple opportunities to improve patient activation, including providing support for older adults with physical impairments, at socioeconomic disadvantages, or with psychological or cognitive impairment.
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Affiliation(s)
- Ling Na
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pui L. Kwong
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Liliana E Pezzin
- Medical College of Wisconsin, PCOR and Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel E. Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
The AHRQ's Prevention Quality Indicators assume inpatient hospitalizations for certain conditions, referred as ambulatory-care sensitive (ACS) conditions, are potentially preventable and may indicate reduced access to and a lower quality of ambulatory care. Using a cohort drawn from the Medicare Current Beneficiary Survey (MCBS) linked to Medicare claims, we examined the extent to which barriers to healthcare are associated with ACS hospitalizations and related costs, and whether these associations differ by beneficiaries' disability status. Our results indicate that the regression-adjusted cost of ACS hospitalizations for elderly Medicare beneficiaries with no disabilities was $799. This cost increased six-fold, by $5148, among beneficiaries with mild disability, by $9045 for beneficiaries with moderate disability, by $5513 for those with severe disability, and by $8557 for persons with complete disability (P < 0.001). Persons reporting having foregone or delayed needed medical care because of financial difficulties (+$2082, P = .05), those experiencing low satisfaction with care coordination (+$1714, P = .01), and those reporting low satisfaction with access to care (+$1237, P = .02) also incurred significant excess ACS hospitalization costs relative to persons reporting no such barriers. This pattern held true for those with and without a disability, but were especially marked among persons with no functional limitations. These findings suggest that a better understanding of how public policy might effectively improve care coordination and reduce financial barriers to care is essential to formulating programs that reduce excess hospitalizations among the large and growing number of elderly Medicare beneficiaries.
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Affiliation(s)
- Liliana E. Pezzin
- Department of Medicine and Center for Patient Care and Outcomes Research (PCOR), Medical College of Wisconsin, Milwaukee, WI
| | - Hillary R. Bogner
- Department of Family and Medicine & Community Health, Perelman School of Medicine, University of Pennsylvania, PA
| | - Jibby E. Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine
| | - Pui L. Kwong
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine
| | - Joel E. Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine
| | - Ling Na
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine
- Center for Pharmacoepidemiology Research and Training
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Abstract
OBJECTIVE This study examined whether a telephone-delivered collaborative care intervention (SUpporting Seniors Receiving Treatment And INtervention [SUSTAIN]) improved access to mental health services similarly among older adults in rural areas and those in urban-suburban areas. METHODS This cohort study of 8,621 older adults participating in the SUSTAIN program, a clinical service provided to older adults in Pennsylvania newly prescribed a psychotropic medication by a primary care or non-mental health provider, examined rural versus urban-suburban differences in rates of initial clinical interview completion, patient clinical characteristics, and program penetration. RESULTS Participants in rural counties were more likely than those in urban-suburban counties to complete the initial clinical interview (27.0% versus 24.0%, p=.001). Program penetration was significantly higher in rural than in urban-suburban counties (p=.02). CONCLUSIONS Telephone-based care management programs such as SUSTAIN may be an effective strategy to facilitate access to collaborative mental health care regardless of patients' geographic location.
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Affiliation(s)
- Lauren B Gerlach
- Dr. Gerlach and Dr. Maust are with the Department of Psychiatry, University of Michigan, Ann Arbor. Dr. Maust is also with the Department of Psychiatry, Department of Veterans Affairs (VA) Ann Arbor Healthcare System. Dr. Mavandadi, Dr. Streim, and Dr. Oslin are with the Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center, and the Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Shahrzad Mavandadi
- Dr. Gerlach and Dr. Maust are with the Department of Psychiatry, University of Michigan, Ann Arbor. Dr. Maust is also with the Department of Psychiatry, Department of Veterans Affairs (VA) Ann Arbor Healthcare System. Dr. Mavandadi, Dr. Streim, and Dr. Oslin are with the Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center, and the Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Donovan T Maust
- Dr. Gerlach and Dr. Maust are with the Department of Psychiatry, University of Michigan, Ann Arbor. Dr. Maust is also with the Department of Psychiatry, Department of Veterans Affairs (VA) Ann Arbor Healthcare System. Dr. Mavandadi, Dr. Streim, and Dr. Oslin are with the Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center, and the Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Joel E Streim
- Dr. Gerlach and Dr. Maust are with the Department of Psychiatry, University of Michigan, Ann Arbor. Dr. Maust is also with the Department of Psychiatry, Department of Veterans Affairs (VA) Ann Arbor Healthcare System. Dr. Mavandadi, Dr. Streim, and Dr. Oslin are with the Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center, and the Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - David W Oslin
- Dr. Gerlach and Dr. Maust are with the Department of Psychiatry, University of Michigan, Ann Arbor. Dr. Maust is also with the Department of Psychiatry, Department of Veterans Affairs (VA) Ann Arbor Healthcare System. Dr. Mavandadi, Dr. Streim, and Dr. Oslin are with the Department of Psychiatry, Corporal Michael J. Crescenz VA Medical Center, and the Department of Psychiatry, University of Pennsylvania, Philadelphia
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Kurichi JE, Bogner HR, Streim JE, Xie D, Kwong PL, Saliba D, Hennessy S. Predicting 3-year mortality and admission to acute-care hospitals, skilled nursing facilities, and long-term care facilities in Medicare beneficiaries. Arch Gerontol Geriatr 2017; 73:248-256. [PMID: 28863353 DOI: 10.1016/j.archger.2017.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 06/06/2017] [Revised: 06/30/2017] [Accepted: 08/10/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE The ability to predict mortality and admission to acute care hospitals, skilled nursing facilities (SNFs), and long-term care (LTC) facilities in the elderly and how it varies by activity of daily living (ADL) and instrumental ADL (IADL) status could be useful in measuring the success or failure of economic, social, or health policies aimed at disability prevention and management. We sought to derive and assess the predictive performance of rules to predict 3-year mortality and admission to acute care hospitals, SNFs, and LTC facilities among Medicare beneficiaries with differing ADL and IADL functioning levels. METHODS Prospective cohort using Medicare Current Beneficiary Survey data from the 2001 to 2007 entry panels. In all, 23,407 community-dwelling Medicare beneficiaries were included. Multivariable logistic models created predicted probabilities for all-cause mortality and admission to acute care hospitals, SNFs, and LTC facilities, adjusting for sociodemographics, health conditions, impairments, behavior, and function. RESULTS Sixteen, 22, 14, and 14 predictors remained in the final parsimonious model predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission, respectively. The C-statistic for predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission was 0.779, 0.672, 0.753, and 0.826 in the ADL activity limitation stage development cohorts, respectively, and 0.788, 0.669, 0.748, and 0.799 in the ADL activity limitation stage validation cohorts, respectively. CONCLUSIONS Parsimonious models can identify elderly Medicare beneficiaries at risk of poor outcomes and can aid policymakers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.
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Affiliation(s)
- Jibby E Kurichi
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Hillary R Bogner
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA.
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; VISN 4 Mental Illness Research Education and Clinical Center (MIRECC), Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Pui L Kwong
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Debra Saliba
- Department of Geriatrics and Gerontology at UCLA, Los Angeles, California, VA Greater Los Angeles Healthcare System (GLAHS) Geriatric Research, Education and Clinical Center (GRECC), Los Angeles, CA, USA; RAND Health, Santa Monica, CA, USA.
| | - Sean Hennessy
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Pharmacoepidemiology Research and Training, University of Pennsylvania, Philadelphia, PA, USA.
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McClintock HF, Kurichi JE, Kwong PL, Xie D, Streim JE, Pezzin LE, Hennessy S, Na L, Bogner HR. Disability Stages and Trouble Getting Needed Health Care Among Medicare Beneficiaries. Am J Phys Med Rehabil 2017; 96:408-416. [PMID: 27754997 PMCID: PMC5391295 DOI: 10.1097/phm.0000000000000638] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine whether activity limitation stages were associated with patient-reported trouble getting needed health care among Medicare beneficiaries. DESIGN This was a population-based study (n = 35,912) of Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey for years 2001-2010. Beneficiaries were classified into an activity limitation stage from 0 (no limitation) to IV (complete) derived from self-reported or proxy-reported difficulty performing activities of daily living and instrumental activities of daily living. Beneficiaries reported whether they had trouble getting health care in the subsequent year. A multivariable logistic regression model examined the association between activity limitation stages and trouble getting needed care. RESULTS Compared with beneficiaries with no limitations (activities of daily living stage 0), the adjusted odds ratios (ORs) (95% confidence intervals [CIs]) for stage I (mild) to stage IV (complete) for trouble getting needed health care ranged from OR = 1.53 (95% CI, 1.32-1.76) to OR = 2.86 (95% CI, 1.97-4.14). High costs (31.7%), not having enough money (31.2%), and supplies/services not covered (24.2%) were the most common reasons for reporting trouble getting needed health care. CONCLUSION Medicare beneficiaries at higher stages of activity limitations reported trouble getting needed health care, which was commonly attributed to financial barriers.
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Affiliation(s)
- Heather F. McClintock
- Department of Community and Global Health, College of Health Sciences, Arcadia University, Glenside, Pennsylvania
| | - Jibby E. Kurichi
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pui L. Kwong
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel E. Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania and VISN 4 Mental Illness Research Education and Clinical Center (MIRECC), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Liliana E. Pezzin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ling Na
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hillary R. Bogner
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Na L, Streim JE, Pezzin LE, Kurichi JE, Xie D, Bogner HR, Kwong PL, Asch SM, Hennessy S. Disparities in receipt of recommended care among younger versus older medicare beneficiaries: a cohort study. BMC Health Serv Res 2017; 17:241. [PMID: 28356149 PMCID: PMC5371256 DOI: 10.1186/s12913-017-2168-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 08/17/2016] [Accepted: 03/16/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although health disparities have been documented between Medicare beneficiaries based on age (<65 years vs. older age groups), underuse of recommended medical care in younger beneficiaries has not been thoroughly investigated. In this study, we aim to identify and characterize vulnerabilities of the younger Medicare age group (aged <65 years) in relation to older age groups (aged 65-74 years and ≥75 years) and to explore age group as a determinant of use of recommended care among Medicare beneficiaries. METHODS We conducted a cohort study of community-dwelling Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey between 2001 and 2008 (N = 30,117). Age group characteristics were compared using cross-sectional data at baseline. During follow-up, we assessed the association between age and receipt of recommended care on 38 recommended care indicators, adjusting for sociodemographic and clinical characteristics. Follow-up periods differed by component indicator. RESULTS At baseline, a higher proportion of younger beneficiaries experienced social disadvantage, disability and certain morbidities than older age groups. During follow-up, younger beneficiaries were significantly less likely to receive overall recommended care compared to those 65-74 years of age (adjusted odds ratio and 95% confidence interval: 0.75, 0.70-0.80). In addition, male gender, non-Hispanic black race, less than high school education, living alone, with children or with others, psychiatric disorders and higher activity limitation stages were all associated with underuse of recommended care. CONCLUSIONS Younger Medicare beneficiary status appears to be an independent risk factor for underuse of appropriate care. Support to ameliorate disparities in different social and health aspects may be warranted.
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Affiliation(s)
- Ling Na
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Liliana E Pezzin
- Center for Patient Care and Outcomes Research (PCOR), Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hillary R Bogner
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pui L Kwong
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven M Asch
- Division of General Medical Disciplines, Stanford University School of Medicine, Menlo Park, CA, USA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Center for Pharmacoepidemiology Research and Training, University of Pennsylvania, Philadelphia, PA, USA.
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Bal S, Kurichi JE, Kwong PL, Xie D, Hennessy S, Na L, Pezzin LE, Streim JE, Bogner HR. Presence of Vision Impairment and Risk of Hospitalization among Elderly Medicare Beneficiaries. Ophthalmic Epidemiol 2017; 24:364-370. [PMID: 28346032 DOI: 10.1080/09286586.2017.1296961] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 10/19/2022]
Abstract
PURPOSE To examine the association between vision impairment and all-cause hospitalization among elderly Medicare beneficiaries. METHODS A population-based study (N = 22,681) of community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Current Beneficiary Survey for the years 2001-2007. Beneficiaries were classified into self-reported presence of vision impairment versus no vision impairment. Inpatient hospitalizations were identified using Medicare claims data. A multivariable Cox proportional hazard model examined the association between presence of vision impairment and time to first hospitalization within 3 years of survey entry after adjusting for sociodemographics, comorbidities, hearing impairment, and activity limitation stages derived from difficulty performing the activities of daily living. RESULTS Medicare beneficiaries who self-reported the presence of vision impairment were significantly more likely to be hospitalized over 3 years compared to beneficiaries without vision impairment even after adjustment for potentially influential covariates (hazard ratio = 1.14 and 95% confidence interval: 1.05-1.23). CONCLUSIONS Medicare beneficiaries with self-reported vision impairment were at higher risk of hospitalization during a 3-year period. Further research may identify reasons that are amenable to policy interventions.
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Affiliation(s)
- Sila Bal
- a Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA
| | - Jibby E Kurichi
- a Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA
| | - Pui L Kwong
- a Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA
| | - Dawei Xie
- a Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA
| | - Sean Hennessy
- a Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA.,b Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA
| | - Ling Na
- a Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA
| | - Liliana E Pezzin
- c Department of Medicine , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Joel E Streim
- d Geriatric Psychiatry Section of the Department of Psychiatry , Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, and VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), Corporal Michael J. Crescenz VA Medical Center , Philadelphia , PA , USA
| | - Hillary R Bogner
- a Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania , Philadelphia , PA , USA.,e Department of Family Medicine and Community Health, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
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Na L, Streim JE. Psychosocial Well-Being Associated With Activity of Daily Living Stages Among Community-Dwelling Older Adults. Gerontol Geriatr Med 2017; 3:2333721417700011. [PMID: 28540343 PMCID: PMC5433668 DOI: 10.1177/2333721417700011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 11/03/2016] [Revised: 01/02/2017] [Accepted: 02/14/2017] [Indexed: 11/28/2022] Open
Abstract
Objectives: Activity of daily living (ADL) stages demonstrated ordered associations with risk of chronic conditions, hospitalization, nursing home use, and mortality among community-living elderly. This article explores the association of stages with psychosocial well-being. We hypothesized that higher ADL stages (greater ADL limitation) are associated with more restricted social networks, less perceived social support, greater social isolation, and poorer mental health. Methods: Cross-sectional data from the National Social Life, Health, and Aging Project (N = 3,002) were analyzed in regression models and latent factor models. Results: Although ADL stages had a nearly monotonic relationship with most mental health measures (e.g., Center for Epidemiologic Studies Depression Scale [CES-D]), only the complete limitation stage (Stage IV) showed significant disadvantage in the majority of social network measures. Discussion: The study may aid clinicians and policy makers to better understand the social and mental health needs of older adults at different ADL stages and provide well-planned social and mental health care.
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Affiliation(s)
- Ling Na
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Joel E Streim
- Geriatric Psychiatry Section, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Na L, Hennessy S, Bogner HR, Kurichi JE, Stineman M, Streim JE, Kwong PL, Xie D, Pezzin LE. Disability stage and receipt of recommended care among elderly medicare beneficiaries. Disabil Health J 2016; 10:48-57. [PMID: 27765676 DOI: 10.1016/j.dhjo.2016.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 04/15/2016] [Revised: 07/25/2016] [Accepted: 09/28/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Receipt of recommended care among older adults is generally low. Findings regarding service use among persons with disabilities supports the notion of disparities but provides inconsistent evidence of underuse of recommended care. OBJECTIVE To examine the extent to which receipt of recommended care among older Medicare beneficiaries varies by disability status, using a newly developed staging method to classify individuals according to disability. METHODS In a cohort study, we included community-dwelling Medicare beneficiaries aged 65 and older who participated in the Medicare Current Beneficiary Survey between 2001 and 2008. Logistic regression modeling assessed the association of receiving recommended care on 38 indicators across different activity limitation stages. RESULTS Nearly one out of every three elderly Medicare beneficiaries did not receive overall recommended care. Adjusted odds ratios (ORs) revealed a decrease in use of recommended care with increasing activity limitation stage. For instance, ORs (95% CIs) across mild, moderate, severe and complete limitation stages (stages I-IV) compared to no limitation (stage 0) in ADLs were 0.99 (0.94-1.05), 0.89 (0.83-0.95), 0.81 (0.75-0.89) and 0.56 (0.46-0.68). Disparities in receipt of recommended care by disability stage were most marked for care related to post-hospitalization follow-up and, to a lesser degree, care of chronic conditions and preventive care. CONCLUSIONS Elderly beneficiaries at higher activity limitation stages experienced substantial disparities in receipt of recommended care. Tailored interventions may be needed to reduce disparities in receipt of recommended medical care in this population.
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Affiliation(s)
- Ling Na
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Pharmacoepidemiology Research and Training, University of Pennsylvania, Philadelphia, PA, USA
| | - Hillary R Bogner
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Margaret Stineman
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pui L Kwong
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Liliana E Pezzin
- Center for Patient Care and Outcomes Research (PCOR), Medical College of Wisconsin, Milwaukee, WI, USA; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
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Schüssler-Fiorenza Rose SM, Xie D, Streim JE, Pan Q, Kwong PL, Stineman MG. Identifying neuropsychiatric disorders in the Medicare Current Beneficiary Survey: the benefits of combining health survey and claims data. BMC Health Serv Res 2016; 16:537. [PMID: 27716198 PMCID: PMC5045603 DOI: 10.1186/s12913-016-1774-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 03/01/2016] [Accepted: 09/20/2016] [Indexed: 12/02/2022] Open
Abstract
Background To address the impact of using multiple sources of data in the United States Medicare Current Beneficiary Survey (MCBS) compared to using only one source of data to identify those with neuropsychiatric diagnoses. Methods Our data source was the 2010 MCBS with associated Medicare claims files (N = 14, 672 beneficiaries). The MCBS uses a stratified multistage probability sample design to select a nationally representative sample of Medicare beneficiaries. We excluded those participants in Medicare Health Maintenance Organizations (n = 3894) and performed a cross-sectional analysis. We classified neuropsychiatric conditions according to four broad categories: intellectual/developmental disorders, neurological conditions affecting the central nervous system (Neuro-CNS), dementia, and psychiatric conditions. To account for different baseline prevalence differences of the categories we calculated the relative increase in prevalence that occurred from adding information from claims in addition to the absolute increase to allow comparison among categories. Results The estimated proportion of the sample with neuropsychiatric disorders increased to 50.0 (both sources) compared to 38.9 (health survey only) and 33.2 (claims only) with an overlap between sources of only 44.1 %. Augmenting health survey data with claims led to an increase in estimated percentage of intellectual/developmental disorders, psychiatric disorders, Neuro-CNS disorders and dementia of 1.3, 5.9, 11.5 and 3.8 respectively. In the community sample, the largest relative increases were seen for dementia (147.6 %) and Neuro-CNS disorders (87.4 %). With the exception of dementia, larger relative increases were seen in the facility sample with the greatest being for intellectual/developmental disorders (121.5 %) and Neuro-CNS disorders (93.8 %). Conclusions The magnitude of potentially underestimated sample proportions using health survey only data varied strikingly according to the category of diagnosis and setting. Augmentation of survey data with claims appears essential particularly when attempting to estimate proportion of the sample affected by conditions that cause cognitive impairment which may affect ability to self-report. Augmenting proxy survey data with claims data also appears to be essential when ascertaining proportion of the facility-dwelling sample affected by neuropsychiatric disorders.
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Affiliation(s)
- Sophia Miryam Schüssler-Fiorenza Rose
- Spinal Cord Injury Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave (MC 140), Palo Alto, CA, 94304, USA. .,Department of Neurosurgery, Stanford University, Stanford, California, USA.
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Blockley Hall, Philadelphia, PA, 19104-6021, USA
| | - Joel E Streim
- Geriatric Psychiatry Section, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA.,VISN 4 Mental Illness Research Education and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
| | - Qiang Pan
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Blockley Hall, Philadelphia, PA, 19104-6021, USA
| | - Pui L Kwong
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Blockley Hall, Philadelphia, PA, 19104-6021, USA
| | - Margaret G Stineman
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 19104, USA
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Na L, Pan Q, Xie D, Kurichi JE, Streim JE, Bogner HR, Saliba D, Hennessy S. Activity Limitation Stages Are Associated With Risk of Hospitalization Among Medicare Beneficiaries. PM R 2016; 9:433-443. [PMID: 27664405 DOI: 10.1016/j.pmrj.2016.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/21/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Activity limitation stages based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are associated with 3-year mortality in elderly Medicare beneficiaries, yet their associations with hospitalization risk in this population have not been studied. OBJECTIVE To examine the independent association of activity limitation stages with risk of hospitalization within a year among Medicare beneficiaries aged 65 years and older. DESIGN Cohort study. SETTING Community. PARTICIPANTS A total of 9447 community-dwelling elderly Medicare beneficiaries from the Medicare Current Beneficiary Survey for years 2005-2009. METHODS Stages were derived for ADLs and IADLs separately. Associations of stages with time to first hospitalization and time to recurrent hospitalizations within a year were assessed with Cox proportional hazards models, with which we accounted for baseline sociodemographics, smoking status, comorbidities, and the year of survey entry. MAIN OUTCOMES Time to first hospitalization and time to recurrent hospitalizations within 1 year. PRINCIPLE FINDINGS The adjusted risk of first hospitalization increased with greater activity limitation stages (except stage III). The hazard ratios (95% confidence intervals) for ADL stages I-IV compared with stage 0 (no limitations) were 1.49 (1.36-1.63), 1.61 (1.44-1.80), 1.54 (1.35-1.76), and 2.06 (1.61-2.63), respectively. The pattern for IADL stages was similar. For recurrent hospitalizations, activity limitation stages were associated with the risk of the first hospitalization but not with subsequent hospitalizations. CONCLUSION Activity limitation stages are associated with the risk of first hospitalization in the subsequent year among elderly Medicare beneficiaries. Stages capture clinically interpretable profiles of ADL and IADL functionality and describe preserved functions and activity limitation in an aggregated measure. Stage can inform interventions to ameliorate disability and thus reduce the risk of a subsequent hospitalization in this population. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Ling Na
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA(∗)
| | - Qiang Pan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA(†)
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA(‡)
| | - Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA(§)
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA(¶)
| | - Hillary R Bogner
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA(‖)
| | - Debra Saliba
- U.S. Department of Veterans Affairs, Geriatrics Research Education and Clinical Center, Los Angeles, CA; Borun Center, UCLA Department of Medicine, University of California, Los Angeles, CA; RAND, Santa Monica, CA(#)
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Pharmacoepidemiology Research and Training, University of Pennsylvania, 803 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021(∗∗).
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13
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Bogner HR, de Vries McClintock HF, Kurichi JE, Kwong PL, Xie D, Hennessy S, Streim JE, Stineman MG. Patient Satisfaction and Prognosis for Functional Improvement and Deterioration, Institutionalization, and Death Among Medicare Beneficiaries Over 2 Years. Arch Phys Med Rehabil 2016; 98:1-10. [PMID: 27590442 DOI: 10.1016/j.apmr.2016.07.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 06/03/2016] [Accepted: 07/19/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine how patient satisfaction with care coordination and quality and access to medical care influence functional improvement or deterioration (activity limitation stage transitions), institutionalization, or death among older adults. DESIGN National representative sample with 2-year follow-up. SETTING Medicare Current Beneficiary Survey from calendar years 2001 to 2008. PARTICIPANTS Community-dwelling adults (N=23,470) aged ≥65 years followed for 2 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A multinomial logistic regression model taking into account the complex survey design was used to examine the association between patient satisfaction with care coordination and quality and patient satisfaction with access to medical care and activities of daily living (ADL) stage transitions, institutionalization, or death after 2 years, adjusting for baseline socioeconomics and health-related characteristics. RESULTS Out of 23,470 Medicare beneficiaries, 14,979 (63.8% weighted) remained stable in ADL stage, 2508 (10.7% weighted) improved, 3210 (13.3% weighted) deteriorated, 582 (2.5% weighted) were institutionalized, and 2281 (9.7% weighted) died. Beneficiaries who were in the top quartile of satisfaction with care coordination and quality were less likely to be institutionalized (adjusted relative risk ratio [RRR], .68; 95% confidence interval [CI], .54-.86). Beneficiaries who were in the top quartile of satisfaction with access to medical care were less likely to functionally deteriorate (adjusted RRR, .87; 95% CI, .79-.97), be institutionalized (adjusted RRR, .72; 95% CI, .56-.92), or die (adjusted RRR, .86; 95% CI, .75-.98). CONCLUSIONS Knowledge of patient satisfaction with medical care and risk of functional deterioration may be helpful for monitoring and addressing disability-related health care disparities and the effect of ongoing policy changes among Medicare beneficiaries.
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Affiliation(s)
- Hillary R Bogner
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Heather F de Vries McClintock
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jibby E Kurichi
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pui L Kwong
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | - Margaret G Stineman
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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14
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Schüssler-Fiorenza Rose SM, Stineman MG, Pan Q, Bogner H, Kurichi JE, Streim JE, Xie D. Potentially Avoidable Hospitalizations among People at Different Activity of Daily Living Limitation Stages. Health Serv Res 2016; 52:132-155. [PMID: 26990312 DOI: 10.1111/1475-6773.12484] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 11/27/2022] Open
Abstract
OBJECTIVE To determine whether higher activity of daily living (ADL) limitation stages are associated with increased risk of hospitalization, particularly for ambulatory care sensitive (ACS) conditions. DATA SOURCE Secondary data analysis, including 8,815 beneficiaries from 2005 to 2006 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN ADL limitation stages (0-IV) were determined at the end of 2005. Hospitalization rates were calculated for 2006 and age adjusted using direct standardization. Multivariate negative binomial regression, adjusting for baseline demographic and health characteristics, with the outcome hospitalization count was performed to estimate the adjusted rate ratio of ACS and non-ACS hospitalizations for beneficiaries with ADL stages > 0 compared to beneficiaries without limitations. DATA COLLECTION Baseline ADL stage and health conditions were assessed using 2005 MCBS data and count of hospitalization determined using 2006 MCBS data. PRINCIPAL FINDINGS Referenced to stage 0, the adjusted rate ratios (95 percent confidence interval) for stage I to stage IV ranged from 1.9 (1.4-2.5) to 4.1 (2.2-7.8) for ACS hospitalizations compared with from 1.6 (1.3-1.9) to 1.8 (1.4-2.5) for non-ACS hospitalizations. CONCLUSIONS Hospitalization rates for ACS conditions increased more dramatically with ADL limitation stage than did rates for non-ACS conditions. Adults with ADL limitations appear particularly vulnerable to potentially preventable hospitalizations for conditions typically manageable in ambulatory settings.
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Affiliation(s)
- Sophia Miryam Schüssler-Fiorenza Rose
- Department of Veterans Affairs Palo Alto Health Care System, Spinal Cord Injury and Disorders Center, Palo Alto, CA.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Margaret G Stineman
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA.,Perelman School of Medicine University of Pennsylvania, Philadelphia, PA
| | - Qiang Pan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Hillary Bogner
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Joel E Streim
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.,Mental Illness Research Education and Clinical Center Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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15
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Stineman MG, Xie D, Pan Q, Kurichi JE, Saliba D, Rose SMSF, Streim JE. Understanding non-performance reports for instrumental activity of daily living items in population analyses: a cross sectional study. BMC Geriatr 2016; 16:64. [PMID: 26956616 PMCID: PMC4784362 DOI: 10.1186/s12877-016-0235-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 02/26/2016] [Indexed: 11/10/2022] Open
Abstract
Background Concerns about using Instrumental Activities of Daily Living (IADLs) in national surveys come up frequently in geriatric and rehabilitation medicine due to high rates of non-performance for reasons other than health. We aim to evaluate the effect of different strategies of classifying “does not do” responses to IADL questions when estimating prevalence of IADL limitations in a national survey. Methods Cross-sectional analysis of a nationally representative sample of 13,879 non-institutionalized adult Medicare beneficiaries included in the 2010 Medicare Current Beneficiary Survey (MCBS). Sample persons or proxies were asked about difficulties performing six IADLs. Tested strategies to classify non-performance of IADL(s) for reasons other than health were to 1) derive through multiple imputation, 2) exclude (for incomplete data), 3) classify as “no difficulty,” or 4) classify as “difficulty.” IADL stage prevalence estimates were compared across these four strategies. Results In the sample, 1853 sample persons (12.4 % weighted) did not do one or more IADLs for reasons other than physical problems or health. Yet, IADL stage prevalence estimates differed little across the four alternative strategies. Classification as “no difficulty” led to slightly lower, while classification as “difficulty” raised the estimated population prevalence of disability. Conclusions These analyses encourage clinicians, researchers, and policy end-users of IADL survey data to be cognizant of possible small differences that can result from alternative ways of handling unrated IADL information. At the population-level, the resulting differences appear trivial when applying MCBS data, providing reassurance that IADL items can be used to estimate the prevalence of activity limitation despite high rates of non-performance.
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Affiliation(s)
- Margaret G Stineman
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvani, 423 Guardian Drive, 617 Blockley Hall, Philadelphia, PA, 19104, USA.
| | - Qiang Pan
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvani, 423 Guardian Drive, 617 Blockley Hall, Philadelphia, PA, 19104, USA.
| | - Jibby E Kurichi
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvani, 423 Guardian Drive, 617 Blockley Hall, Philadelphia, PA, 19104, USA.
| | - Debra Saliba
- Anna and Harry Borun Chair in Geriatrics and Gerontology at UCLA, RAND, Santa Monica, CA, USA. .,Research Physician, VA GLAHS GRECC, RAND, Santa Monica, CA, USA. .,UCLA/JH Borun Center for Gerontological Research, RAND, Santa Monica, CA, USA. .,RAND Health, RAND, Santa Monica, CA, USA.
| | - Sophia Miryam Schüssler-Fiorenza Rose
- Spinal Cord Injury Service, Veterans Affairs Palo Health Care System, 3801 Miranda Ave, Palo Alto, CA, 94304, USA. .,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,VISN 4 Mental Illness Research Education & Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
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Abstract
More than five million Americans suffer from Alzheimer's disease (AD), and this number is expected to triple by 2050. While impairments in cognition, particularly memory, are typically the defining features of the clinical syndrome, behavioral symptoms are extremely common, affecting up to 90% of patients. Behavioral symptoms in AD can be difficult to manage and may require a combination of non-pharmacological and pharmacological approaches. The latter is complicated by FDA "black-box warnings" for the medication classes most often used to target these symptoms, and currently there are initiatives in place to limit their use. In this review, we describe common behavioral symptoms of AD-with a particular focus on the challenging symptoms of "agitation" and "irritability"-and discuss evidence-based approaches to their management. Ultimately, multidimensional approaches must be tailored to the patient and their environment, though evidence-based practices should define the treatment of agitation and irritability in AD.
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Affiliation(s)
- Aaron M Koenig
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Steven E Arnold
- MassGeneral Institute for Neurodegenerative Disease, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Joel E Streim
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
- Behavioral Health Service, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
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17
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Mavandadi S, Benson A, DiFilippo S, Streim JE, Oslin D. A Telephone-Based Program to Provide Symptom Monitoring Alone vs Symptom Monitoring Plus Care Management for Late-Life Depression and Anxiety: A Randomized Clinical Trial. JAMA Psychiatry 2015; 72:1211-8. [PMID: 26558530 DOI: 10.1001/jamapsychiatry.2015.2157] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [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: 11/14/2022]
Abstract
IMPORTANCE Mental health (MH) conditions are undertreated in late life. It is important to identify treatment strategies that address variability in treatment content and delivery and take individual-specific symptoms into account, particularly among low-income, community-dwelling older adults. OBJECTIVE To evaluate program feasibility and MH outcomes among community-dwelling older adults randomized to 1 of 2 treatment arms of varying intensity of evidence-based, collaborative MH care management services (ie, the Supporting Seniors Receiving Treatment and Intervention [SUSTAIN] program) that provide standardized, measurement-based, software-aided MH assessment and symptom monitoring and connection to community resources via telephone. DESIGN, SETTING, AND PARTICIPANTS Trial participants were 1018 older, community-dwelling, low-income adults prescribed an antidepressant or anxiolytic by a primary care or non-MH professional and experiencing clinically significant MH symptoms at intake. The participant subsample was drawn from a larger parent sample of older adults enrolled in the SUSTAIN program. Individuals were randomized to receive MH symptom monitoring alone (hereafter monitoring alone) or MH symptom monitoring plus care management (hereafter care management) provided by an MH professional. Baseline characteristics were examined, and changes in clinical MH outcomes were evaluated at 3-month and 6-month follow-up. The study dates were August 5, 2010, to May 5, 2014. INTERVENTIONS Monitoring alone or care management delivered by an MH professional. MAIN OUTCOMES AND MEASURES Overall MH functioning (primary) and depressive and anxiety symptoms. RESULTS A total of 509 participants were randomized to the monitoring alone group and 509 to the care management group; 377 and 401 completed ≥2 research assessments in the monitoring alone and case management groups, respectively. Compared with those randomized to monitoring alone, individuals randomized to care management showed greater improvements in the 3 domains of MH functioning (β [SE], 0.36 [0.12]; 95% CI, 0.12 to 0.60; P = .004), depressive symptoms (β [SE], -0.20 [0.06]; 95% CI, -0.32 to -0.09; P < .001), and anxiety symptoms (β [SE], -0.23 [0.05]; 95% CI, -0.33 to -0.14; P < .001) over time. CONCLUSIONS AND RELEVANCE The SUSTAIN program, which provides assessment, monitoring, care management, and brief therapies for MH symptoms and needs in primary care settings, is feasible and scalable. A more intense level of care (ie, symptom monitoring plus care management) is associated with more favorable individual outcomes for low-income, community-dwelling older adults experiencing clinically significant MH symptoms. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02440594.
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Affiliation(s)
- Shahrzad Mavandadi
- Veterans Integrated Services Network 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania2Department of Psychiatry, Perelman School of Medicine, University of P
| | - Amy Benson
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Suzanne DiFilippo
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joel E Streim
- Veterans Integrated Services Network 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania2Department of Psychiatry, Perelman School of Medicine, University of P
| | - David Oslin
- Veterans Integrated Services Network 4 Mental Illness Research, Education, and Clinical Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania2Department of Psychiatry, Perelman School of Medicine, University of P
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18
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Streim JE, Oslin DW. Bronze Award: A Private-Public Partnership to Deliver Population-Level Integrated Care to Low-Income Seniors in Pennsylvania. SUSTAIN (SUpporting Seniors receiving Treatment And INtervention), Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and the Department of Aging, Commonwealth of Pennsylvania, Harrisburg. Psychiatr Serv 2015; 66:e12-4. [PMID: 26423172 DOI: 10.1176/appi.ps.661009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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19
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Kurichi JE, Streim JE, Bogner HR, Xie D, Kwong PL, Hennessy S. Comparison of predictive value of activity limitation staging systems based on dichotomous versus trichotomous responses in the Medicare Current Beneficiary Survey. Disabil Health J 2015; 9:64-73. [PMID: 26590119 DOI: 10.1016/j.dhjo.2015.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 06/19/2015] [Revised: 07/30/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Traditional ways of measuring disability include summary indices, binary expressions, or counts of limitations. However, counts of activity of daily living (ADL) or instrumental activity of daily living (IADL) limitations do not specify which activities are limited. Activity limitation staging systems within the ADL and IADL domains depict both the severity and types of limitations experienced and specify clinically meaningful patterns of increasing difficulty with self-care. OBJECTIVE To compare the predictive value and utility of ADL and IADL stages based on dichotomous versus trichotomous responses to ADL and IADL questions based on "difficulty" and "receive help" responses. METHODS Data were analyzed from the 2005, 2006, and 2007 Medicare Current Beneficiary Survey (MCBS) entry panels on 11,706 beneficiaries. This was a prospective cohort study that examined time to inpatient admission, all-cause mortality, skilled nursing facility (SNF) admission, and long-term care (LTC) facility admission based on dichotomous versus trichotomous stages. RESULTS For both ADLs and IADLs, Akaike information criteria for most outcomes were lower (indicating better-performing models) for the trichotomous staging systems than the dichotomous staging systems. The hazard ratios (HRs) and 95% confidence intervals (CIs) of the dichotomous ADL staging system increased as disability increased, whereas the HRs of the other staging systems fluctuated. CONCLUSIONS Both staging systems have strong associations with each outcome. The dichotomous staging system is more clinically relevant while the trichotomous staging system may provide utility for clinicians, health care organizations, and policy makers seeking to predict death or admission to a hospital, SNF, or LTC facility.
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Affiliation(s)
- Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Joel E Streim
- Geriatric Psychiatry Section, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; VISN 4 Mental Illness Research Education and Clinical Center (MIRECC), Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Hillary R Bogner
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pui L Kwong
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Pharmacoepidemiology Research and Training, University of Pennsylvania, Philadelphia, PA, USA
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Meeks S, Van Haitsma K, Mast BT, Arnold S, Streim JE, Sephton S, Smith PJ, Kleban M, Rovine M. Psychological and social resources relate to biomarkers of allostasis in newly admitted nursing home residents. Aging Ment Health 2015; 20:88-99. [PMID: 26237175 PMCID: PMC4628586 DOI: 10.1080/13607863.2015.1072796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This paper presents preliminary baseline data from a prospective study of nursing home adaptation that attempts to capture the complexity of residents' adaptive resources by examining psychological, social, and biological variables from a longitudinal conceptual framework. Our emphasis was on validating an index of allostasis. METHOD In a sample of 26 long-term care patients, we measured 6 hormone and protein biomarkers to capture the concept of allostasis as an index of physiological resilience, related to other baseline resources, including frailty, hope and optimism, social support, and mental health history, collected via interview with the resident and collaterals. We also examined the performance of self-report measures reflecting psychosocial and well-being constructs, given the prevalence of cognitive impairment in nursing homes. RESULTS Our results supported both the psychometric stability of our self-report measures, and the preliminary validity of our index of allostasis. Each biomarker was associated with at least one other resilience resource, suggesting that our choice of biomarkers was appropriate. As a group, the biomarkers showed good correspondence with the majority of other resource variables, and our standardized summation score was also associated with physical, social, and psychological resilience resources, including those reflecting physical and mental health vulnerability as well as positive resources of social support, optimism, and hope. CONCLUSION Although these results are based on a small sample, the effect sizes were large enough to confer some confidence in the value of pursuing further research relating biomarkers of allostasis to psychological and physical resources and well-being.
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Affiliation(s)
- Suzanne Meeks
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY, USA
| | - Kimberly Van Haitsma
- College of Nursing, Pennsylvania State University, 201 Health and Human Development East, University Park, PA, USA
| | - Benjamin T. Mast
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY, USA
| | - Steven Arnold
- Geriatric Psychiatry Section, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Joel E. Streim
- Geriatric Psychiatry Section, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Sandra Sephton
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY, USA
| | - Patrick J. Smith
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, KY, USA
| | - Morton Kleban
- Polisher Research Institute, Abramson Center for Jewish Life, North Wales, PA, USA
| | - Michael Rovine
- Department of Human Development and Family Studies, College of Health and Human Development, Pennsylvania State University, University Park, PA, USA
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Bogner HR, de Vries McClintock HF, Hennessy S, Kurichi JE, Streim JE, Xie D, Pezzin LE, Kwong PL, Stineman MG. Patient Satisfaction and Perceived Quality of Care Among Older Adults According to Activity Limitation Stages. Arch Phys Med Rehabil 2015; 96:1810-9. [PMID: 26119464 DOI: 10.1016/j.apmr.2015.06.005] [Citation(s) in RCA: 18] [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] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/14/2015] [Accepted: 06/02/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine whether patient satisfaction and perceived quality of medical care are related to stages of activity limitations among older adults. DESIGN Cross-sectional study. SETTING Medicare Current Beneficiary Survey (MCBS) for calendar years 2001 to 2011. PARTICIPANTS A population-based sample (N=42,584) of persons aged ≥65 years living in the community. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physicians, interpersonal skills of primary care physicians, and quality of information provided by primary care physicians. Persons were classified into a stage of activity limitation (0-IV) derived from self-reported difficulty levels performing activities of daily living (ADL) and instrumental ADL. RESULTS Compared with older beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (ORs) for stage I (mild) to stage III (severe) for satisfaction with care coordination and quality ranged from .85 (95% confidence interval [CI], .80-.92) to .79 (95% CI, .70-.89). Compared with ADL stage 0, satisfaction with access barriers ranged from OR=.81 (95% CI, .76-.87) at stage I to a minimum of OR=.67 (95% CI, .59-.76) at stage III. Similarly, compared with older beneficiaries at ADL stage 0, perceived quality of the technical skills of their primary care physician ranged from OR=.87 (95% CI, .82-.94) at stage I to a minimum of OR=.81 (95% CI, .72-.91) at stage III. CONCLUSIONS Medicare beneficiaries at higher stages of activity limitation, although not necessarily the highest stage of activity limitation, reported less satisfaction with medical care.
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Affiliation(s)
- Hillary R Bogner
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Heather F de Vries McClintock
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pharmacoepidemiology Research and Training, University of Pennsylvania, Philadelphia, PA
| | - Jibby E Kurichi
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; VISN 4 Mental Illness Research Education and Clinical Center, Philadelphia VA Medical Center, Philadelphia, PA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Liliana E Pezzin
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Pui L Kwong
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Margaret G Stineman
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Maust DT, Chen SH, Benson A, Mavandadi S, Streim JE, DiFilippo S, Snedden TM, Oslin DW. Older adults recently started on psychotropic medication: where are the symptoms? Int J Geriatr Psychiatry 2015; 30:580-6. [PMID: 25116369 DOI: 10.1002/gps.4187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 01/23/2014] [Accepted: 07/18/2014] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective of this study is to understand the characteristics of older adults on newly prescribed psychotropic medication with minimal psychiatric symptoms. METHODS Naturalistic cohort study of non-institutionalized older adults in Pennsylvania participating in the Pharmaceutical Assistance Contract for the Elderly. Persons newly prescribed antidepressant or anxiolytic monotherapy or combination therapy were contacted for clinical assessment by a telephone-based behavioral health service. The initial assessment included standardized mental health screening instruments and scales including the Blessed Orientation-Memory-Concentration test, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Medical Outcomes Survey (SF-12). In addition, patients were asked for their understanding of the prescription indication. RESULTS Of the 254 participants who met minimal symptom criteria (Patient Health Questionnaire-9 < 5 and Generalized Anxiety Disorder-7 < 5), women comprised slightly more of the anxiolytic compared with antidepressant monotherapy group (88.9% vs. 76.7%, p = 0.04). The most common self-reported reason for prescription of an antidepressant or anxiolytic was depression or anxiety, respectively, despite near-absence of these symptoms on clinical assessment. Comparing monotherapy to combination therapy groups, those with combination therapy were more likely to report a history of depression (12.6% vs. 1.8%, p < 0.001) and also report depression as the reason for the prescription (40.2% vs. 21.0%, p < 0.01). CONCLUSIONS In this sample of older adults on new psychotropic medication with minimal psychiatric symptoms, there are few patient characteristics that distinguish those on antidepressant versus anxiolytic monotherapy or those on monotherapy versus combination therapy. While quality of care in late-life mental health has focused on improving detection and treatment, there should be further attention to low-symptom patients potentially receiving inappropriate pharmacotherapy.
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Affiliation(s)
- Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Hennessy S, Kurichi JE, Pan Q, Streim JE, Bogner HR, Xie D, Stineman MG. Disability Stage is an Independent Risk Factor for Mortality in Medicare Beneficiaries Aged 65 Years and Older. PM R 2015; 7:1215-1225. [PMID: 26003869 DOI: 10.1016/j.pmrj.2015.05.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/11/2015] [Accepted: 05/14/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Stages of activity limitation based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) have been found to predict mortality in persons aged 70 years and older but have not been examined in Medicare beneficiaries aged 65 years and older using data that are routinely collected. OBJECTIVE To examine the association between functional stages based on items of ADLs and IADLs with 3-year mortality in Medicare beneficiaries aged 65 years and older, accounting for baseline sociodemographics, health status, smoking, subjective health, and psychological well-being. DESIGN A cohort study using the Medicare Current Beneficiary Survey (MCBS) and associated health care utilization data. SETTING Community administered survey. PARTICIPANTS The study included 9698 Medicare beneficiaries aged 65 years and older who participated in the MCBS in 2005-2007. MAIN OUTCOME MEASURES Death within 3 years of cohort entry. RESULTS The overall mortality rate was 3.6 per 100 person years, and 3-year cumulative mortality was 10.3%. Unadjusted 3-year mortality was monotonically associated with both ADL stage and IADL stage. Adjusted 3-year mortality was associated with ADL and IADL stages, except that in some models the hazard ratio for stage III (which includes persons with atypical activity limitation patterns) was numerically lower than that for stage II. CONCLUSION We found nearly monotonic relationships between ADL and IADL stage and adjusted 3-year mortality. These findings could aid in the development of population health approaches and metrics for evaluating the success of alternative economic, social, or health policies on the longevity of older adults with activity limitations.
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Affiliation(s)
- Sean Hennessy
- Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 803 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104-6021.,Center for Pharmacoepidemiology Research and Training, University of Pennsylvania, Philadelphia, PA
| | - Jibby E Kurichi
- Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Qiang Pan
- Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,VISN 4 Mental Illness Research Education and Clinical Center, Philadelphia VA Medical Center, Philadelphia, PA
| | - Hillary R Bogner
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA
| | - Dawei Xie
- Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Margaret G Stineman
- Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Stineman MG, Streim JE, Pan Q, Kurichi JE, Schüssler-Fiorenza Rose SM, Xie D. Activity Limitation Stages empirically derived for Activities of Daily Living (ADL) and Instrumental ADL in the U.S. Adult community-dwelling Medicare population. PM R 2014; 6:976-87; quiz 987. [PMID: 24798263 DOI: 10.1016/j.pmrj.2014.05.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 04/23/2014] [Accepted: 05/01/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stages quantify severity like conventional measures but further specify the activities that people are still able to perform without difficulty. OBJECTIVE To develop Activity Limitation Stages for defining and monitoring groups of adult community-dwelling Medicare beneficiaries. DESIGN Cross-sectional. SETTING Community. PARTICIPANTS There were 14,670 respondents to the 2006 Medicare Current Beneficiary Survey. METHODS Stages were empirically derived for the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs) by profiling the distribution of performance difficulties as reported by beneficiaries or their proxies. Stage prevalence estimates were determined, and associations with demographic and health variables were examined for all community-dwelling Medicare beneficiaries. MAIN OUTCOME MEASUREMENTS ADL and IADL stage prevalence. RESULTS Stages (0-IV) define 5 groups across the separate ADL and IADL domains according to hierarchically organized profiles of retained abilities and difficulties. For example, at ADL-I, people are guaranteed to be able to eat, toilet, dress, and bathe/shower without difficulty, whereas they experience limitations getting in and out of bed or chairs and/or difficulties walking. In 2006, an estimated 6.0, 2.9, 2.2, and 0.5 million beneficiaries had mild (ADL-I), moderate (ADL-II), severe (ADL-III), and complete (ADL-IV) difficulties, respectively, with estimates for IADL stages even higher. ADL and IADL stages showed expected associations with age and health-related concepts, supporting construct validity. Stages showed the strongest associations with conditions that impair cognition. CONCLUSIONS Stages as aggregate measures reveal the ADLs and IADLs that people are still able to do without difficulty, along with those activities in which they report having difficulty, consequently emphasizing how groups of people with difficulties can still participate in their own lives. Over the coming decades, stages applied to populations served by vertically integrated clinical practices could facilitate large-scale planning, with the goal of maximizing personal autonomy among groups of community-dwelling people with disabilities.
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Affiliation(s)
- Margaret G Stineman
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA∗
| | - Joel E Streim
- Geriatric Psychiatry Section of the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; and VISN 4 Mental Illness Research Education & Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA†
| | - Qiang Pan
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA‡
| | - Jibby E Kurichi
- Department of Biostatistics and Epidemiology, The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; 423 Guardian Drive, 907 Blockley Hall, Philadelphia, PA 19104-6021§.
| | - Sophia Miryam Schüssler-Fiorenza Rose
- Mental Illness Research Education & Clinical Center, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA; and VA Healthcare System Palo Alto, Spinal Cord Injury Service‖
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA¶
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Stineman MG, Schussler-Fiorenza CM, Pan Q, Streim JE, Kurichi J, Xie D. Understanding the Severity and Types of Activity Limitation in Large Populations Through Disability Staging. PM R 2013. [DOI: 10.1016/j.pmrj.2013.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Maust DT, Mavandadi S, Benson A, Streim JE, DiFilippo S, Snedden T, Weber AL, Oslin DW. Telephone-based care management for older adults initiated on psychotropic medication. Int J Geriatr Psychiatry 2013; 28:410-6. [PMID: 22678956 PMCID: PMC3514587 DOI: 10.1002/gps.3839] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [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: 02/18/2012] [Accepted: 05/04/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to explore the longitudinal, 6-month symptom course of older adults newly started on an antidepressant or anxiolytic by non-psychiatrist physicians and enrolled in a care management program. METHOD This is a naturalistic cohort study of older adults (age ≥65 years) receiving pharmacotherapy and telephone-based care management. Participants are non-institutionalized adults participating in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly who completed telephone-based clinical assessments including demographic data, self-report on history of psychiatric treatment and adherence, and standardized symptom scales. RESULTS A total of 162 participants with an average age of 77.2 years (SD 6.8) were followed and, for analysis, split into two groups by PHQ-9 score: 75 (46.3%) scoring 0-4 (minimally symptomatic group, MSG) and 87 (53.7%) scoring ≥5 (symptomatic group, SG). Over 6 months, the SG improved with PHQ-9 scores beginning on average at 10.0 (SD 4.6) and falling to 5.4 (SD 4.2) (F(1, 86) = 29.53, p < 0.0001). The MSG had no significant change in depressive symptoms. Emotional health as measured by SF-12 Mental Composite Score mirrored the PHQ-9 change and lack thereof in the SG and MSG, respectively. No clinical or demographic features were associated with symptom improvement in the SG although they were more likely to report medication adherence (66.7% vs. 44.0%, χ(2) (1) = 8.4, p = 0.0037) compared with the MSG. CONCLUSIONS Participation of symptomatic older adults initiated on psychotropic medication in a telephone-based care management program was associated with improvement in depressive symptoms and overall emotional well-being, notable findings given participants' advanced age, state-wide distribution, and history of limited utilization of mental health care.
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Affiliation(s)
- Donovan T Maust
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Shahrzad Mavandadi
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Philadelphia Veterans Affairs Medical Center and the VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), Philadelphia, PA
| | - Amy Benson
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joel E. Streim
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Philadelphia Veterans Affairs Medical Center and the VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), Philadelphia, PA
| | - Suzanne DiFilippo
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Philadelphia Veterans Affairs Medical Center and the VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), Philadelphia, PA
| | - Thomas Snedden
- PACE Program, Pennsylvania Department of Aging, Harrisburg, PA
| | - Anita L. Weber
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David W. Oslin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Philadelphia Veterans Affairs Medical Center and the VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), Philadelphia, PA
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Stineman MG, Zhang G, Kurichi JE, Zhang Z, Streim JE, Pan Q, Xie D. Prognosis for functional deterioration and functional improvement in late life among community-dwelling persons. PM R 2013; 5:360-71. [PMID: 23454447 DOI: 10.1016/j.pmrj.2013.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 01/30/2013] [Accepted: 02/21/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine how health-related, socioeconomic, and environmental factors combine to influence the onset of activity of daily living (ADL) limitations or prognosis for death or further functional deterioration or improvement among elderly people. DESIGN A national representative sample with 2-year follow-up. SETTING Community-dwelling people. PARTICIPANTS Included were 9447 persons (≥70 years of age) in the United States from the Second Longitudinal Study of Aging who were interviewed in 1994, 1995, or 1996. METHODS Self- or proxy-reported health conditions, ADLs expressed as 5 stages describing severity and pattern of limitations, and other baseline characteristics were obtained. A multinomial logistic regression model was used to predict stage transitions. Because of incomplete follow-up (17.7% of baseline sample), primary analyses were determined by multiple imputation to address potential bias associated with loss to follow-up. MAIN OUTCOME MEASUREMENT ADL stage transitions in 2 years (death, deteriorated, stable, and improved ADL function). RESULTS In the imputed-case analysis, the percentages for those who died, deteriorated, were stable, and improved were 12.6%, 32.7%, 48.4%, and 6.2%, respectively. Persons at a mild stage of ADL limitation were most likely to deteriorate further. Persons at advanced stages were most likely to die. Married people and high school graduates had a lower likelihood of deterioration. The risk of mortality and functional deterioration increased with age. Certain conditions, such as diabetes, were associated both with mortality and functional deterioration; other conditions, such as cancer, were associated with mortality only, and arthritis was associated only with functional deterioration. CONCLUSIONS Although overlap occurs, different clinical traits are associated with mortality, functional deterioration, and functional improvement. ADL stages might aid physical medicine and rehabilitation clinicians and researchers in developing and monitoring disability management strategies targeted to maintaining and enhancing self-care among community-dwelling older people.
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Affiliation(s)
- Margaret G Stineman
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Ishii S, Streim JE, Saliba D. A Conceptual Framework for Rejection of Care Behaviors: Review of Literature and Analysis of Role of Dementia Severity. J Am Med Dir Assoc 2012; 13:11-23.e1-2. [DOI: 10.1016/j.jamda.2010.11.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Revised: 10/31/2010] [Accepted: 11/05/2010] [Indexed: 10/18/2022]
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Stineman MG, Streim JE. The biopsycho-ecological paradigm: a foundational theory for medicine. PM R 2011; 2:1035-45. [PMID: 21093839 DOI: 10.1016/j.pmrj.2010.06.013] [Citation(s) in RCA: 33] [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: 02/03/2010] [Revised: 06/16/2010] [Accepted: 06/17/2010] [Indexed: 01/01/2023]
Abstract
The current biomedical and psychosocial frameworks that form the conceptual basis of medicine today are insufficient to address the needs of the medically complex and environmentally challenged populations of patients often cared for by physical medicine and rehabilitation specialists. The expanded biopsycho-ecological model of health, illness, injury, and disability operating through mechanisms of Health Environmental Integration (HEI) encourages a more complete understanding of illness, injury, activity limitation, and participation restriction as arising at the interface between the person and the environment. HEI recognizes complex interacting multilevel functional hierarchies beginning at the cellular level and ending at the individual's experience of the environment. Although the foci of illness and injury are within the body and mind, the physical and social environments contain elements that can cause or exacerbate disease and barriers that interact in ways that lead to injuries and disabilities. Furthermore, these environments hold the elements from which treating agents, facilitators, and social supports must be fashioned. The highly integrative biopsycho-ecological framework provides an expanded basis for understanding the objective causes and subjective meanings of disabilities. Disabilities are reduced through HEI by seeking to maximally integrate the body and mind (the self) with both the surrounding physical environment and other people in society. HEI offers mechanisms for interdisciplinary research, an expanded framework for education and empowerment, and a blueprint for optimizing day-to-day clinical care at both the individual patient and treatment population levels in the ever-changing scientific, political, and policy environments.
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Affiliation(s)
- Margaret Grace Stineman
- Department of Physical Medicine and Rehabilitation, Center for Clinical Epidemiology and Biostatistics, 904 Blockley Hall, 423 Guardian Dr, Philadelphia, PA 19104-6021, USA.
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Chodosh J, Edelen MO, Buchanan JL, Yosef JA, Ouslander JG, Berlowitz DR, Streim JE, Saliba D. Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief Instrument of Mental Status. J Am Geriatr Soc 2008; 56:2069-75. [DOI: 10.1111/j.1532-5415.2008.01944.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ruckdeschel K, Thompson R, Datto CJ, Streim JE, Katz IR. Using the minimum data set 2.0 mood disturbance items as a self-report screening instrument for depression in nursing home residents. Am J Geriatr Psychiatry 2004; 12:43-9. [PMID: 14729558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE Seeking to enhance nursing home residents' involvement in their care, the authors examined whether the Minimum Data Set, Version 2.0 (MDS) Mood Disturbance items could be administered by self-report. They compared the MDS to the Geriatric Depression Scale (GDS) in terms of its association with depression diagnosis. METHODS Subjects (N=204) were nursing home residents who were interviewed with a psychiatric diagnostic instrument, the GDS, and a self-report version of the MDS mood disturbance items. RESULTS Analyses of variance and receiver operating characteristics analyses demonstrated that MDS items distinguished subjects with any versus no depression about as well as did the GDS. This pattern held within cognitive, gender, and ethnicity subgroups. CONCLUSION The MDS Mood Disturbance items can be reliably and validly administered via self-report to persons scoring at least 12 on the Mini-Mental State Exam.
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Affiliation(s)
- Katy Ruckdeschel
- University of Pennsylvania, Department of Psychiatry and Philadelphia VA Medical Center, Philadelphia, PA, USA
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Oslin DW, Ten Have TR, Streim JE, Datto CJ, Weintraub D, DiFilippo S, Katz IR. Probing the safety of medications in the frail elderly: evidence from a randomized clinical trial of sertraline and venlafaxine in depressed nursing home residents. J Clin Psychiatry 2003; 64:875-82. [PMID: 12927001 DOI: 10.4088/jcp.v64n0804] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND In nursing home residents and other frail elderly patients, old age and potential drug-drug and drug-disease interactions may affect the relative safety and efficacy of medications. The purpose of this study was to examine the efficacy and tolerability of venlafaxine and sertraline for the treatment of depression among nursing home residents. METHOD The study was a 10-week randomized, double-blind, controlled trial of venlafaxine (doses up to 150 mg/day) versus sertraline (doses up to 100 mg/day) among 52 elderly nursing home residents with a DSM-IV depressive disorder and, at most, moderate dementia. The primary measure of outcome was the Hamilton Rating Scale for Depression (HAM-D). Adverse events were monitored and recorded systematically during the trial. RESULTS Twelve subjects were discontinued due to serious adverse events (SAE), 5 were discontinued due to other significant side effects, and 2 withdrew consent. Tolerability estimated by the time to termination was lower for venlafaxine than sertraline for serious adverse events (log rank statistic = 5.28, p =.022), for serious adverse events or side effects (log rank statistic = 8.08, p =.005), or for serious adverse events, side effects, or withdrawal of consent (log rank statistic = 10.04, p =.002). Mean (SD) HAM-D scores at baseline were 20.2 (3.4) for sertraline and 20.3 (3.7) for venlafaxine; intent-to-treat endpoint HAM-D scores were 12.2 (5.1) and 15.7 (6.2) (F = 3.45; p =.069). There were no differences in categorical responses for the intent-to-treat sample or completers. CONCLUSION In this frail elderly population, venlafaxine was less well tolerated and, possibly, less safe than sertraline without evidence for an increase in efficacy. This unexpected finding demonstrates the need for systematic research on the safety of drugs in the frail elderly.
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Affiliation(s)
- David W Oslin
- Section of Geriatric Psychiatry, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pa., USA
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Weintraub D, Streim JE, Datto CJ, Katz IR, DiFilippo SD, Oslin DW. Effect of increasing the dose and duration of sertraline trial in the treatment of depressed nursing home residents. J Geriatr Psychiatry Neurol 2003; 16:109-11. [PMID: 12801161 DOI: 10.1177/0891988703016002008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There has been limited research into defining what constitutes an adequate first-line antidepressant trial in elderly patients. The authors report the outcome of extended, high-dosage sertraline treatment in a sample of nursing home residents experiencing residual significant depressive symptoms after 10 weeks of treatment with sertraline at a final dosage of 100 mg/day. Subjects who had a Hamilton Depression Rating Scale score > or = 12 after 10 weeks of treatment with sertraline were eligible for the 8-week open-label extension phase, which involved titrating the sertraline dosage to 200 mg/day. The cumulative response rate was 52% for the extension phase, compared with 37% for the acute phase. Examining acute phase nonresponders, 39% responded during the extension phase. Rates of discontinuation due to adverse events were comparable in the 2 phases. Our findings suggest that an extended trial or high dosages of sertraline may benefit some depressed elderly patients with persistent depression after acute treatment.
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Affiliation(s)
- Daniel Weintraub
- Section of Geriatric Psychiatry, University of Pennsylvania, and Philadelphia VA Medical Center, USA.
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Datto CJ, Oslin DW, Streim JE, Scheinthal SM, DiFilippo S, Katz IR. Pharmacologic treatment of depression in nursing home residents: a mental health services perspective. J Geriatr Psychiatry Neurol 2003; 15:141-6. [PMID: 12230084 DOI: 10.1177/089198870201500305] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Over the past 10 to 15 years, there has been marked progress in clinical research on depression in nursing home residents. There have also been significant changes in federal regulations designed to improve the quality of care. In 1987, only 10% of nursing home residents diagnosed with depression were receiving treatment, but by 1999,25% of all residents were receiving antidepressants. We report on two studies: one demonstrating that treatment for depression has a substantial, ecologically relevant impact in the nursing home and another demonstrating that profound changes have occurred in the clinical epidemiology of depression and its treatment in the nursing home. Although the numbers of nursing home residents receiving antidepressants have increased dramatically, there are now second-generation problems that must be addressed to ensure the delivery of effective treatment. Developing models to ensure quality of care will require focused mental health services research.
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Affiliation(s)
- Catherine J Datto
- Department of Psychiatry, University of Pennsylvania, and the Philadelphia VA Medical Center, 19104, USA
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Weintraub D, Datto CJ, Streim JE, Katz IR. Second-generation issues in the management of depression in nursing homes. J Am Geriatr Soc 2002; 50:2100-1; author reply 2101. [PMID: 12473032 DOI: 10.1046/j.1532-5415.2002.50632.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
During the past 15 years, federal regulations, survey and inspection programs, and payment policies have presented conflicting incentives and disincentives for the provision of mental health services in nursing homes in the United States. Policies and regulatory measures have reflected the concern that many patients in nursing homes are not receiving the mental health care they need, and, more prominently, the concern that some of the services that are provided seem to be inappropriate or medically unnecessary. Despite evidence that payment policy and regulatory oversight can be used effectively to promote quality improvement, the need for improved access and quality of mental health services in long-term care remains substantial. Recent reports issued by the Surgeon General and by the Institute of Medicine identify a need for refinements in the assessment process, the use of outcomes-based quality measures, and payment policies designed to improve access and quality. These elements must be coordinated to promote humane treatment in nursing homes, including access to medically necessary psychiatric care.
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Affiliation(s)
- Joel E Streim
- Section on Geriatric Psychiatry, University of Pennsylvania, Philadelphia 19104, USA.
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Zapolsky S, Ginsburg P, Streim JE. 1Q[3a]. When will hospitals feel the baby boomer effects? Hosp Health Netw 2002; 76:30. [PMID: 12416459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
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Oslin DW, Streim JE, Katz IR, Smith BD, DiFilippo SD, Ten Have TR, Cooper T. Heuristic comparison of sertraline with nortriptyline for the treatment of depression in frail elderly patients. Am J Geriatr Psychiatry 2000; 8:141-9. [PMID: 10804075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Studies have demonstrated that the selective serotonin reuptake inhibitor antidepressants have similar efficacy to other agents, such as tricyclic antidepressants. However, data are limited for direct comparisons with other antidepressants. The authors conducted a contemporaneous comparison of nursing home residents treated with open-label sertraline in doses up to 100 mg/day with nursing home residents treated in a double-blind randomized study of low vs. regular doses of nortriptyline. There were 97 patients enrolled in the study (28 treated with sertraline), with an average treatment duration of 55 days. There were no differences in the tolerability of sertraline vs. nortriptyline. However, in this group of frail older adults, sertraline was not as effective as nortriptyline for the treatment of depression.
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Affiliation(s)
- D W Oslin
- Section of Geriatric Psychiatry, University of Pennsylvania, Philadelphia 19104, USA.
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Streim JE, Oslin DW, Katz IR, Smith BD, DiFilippo S, Cooper TB, Ten Have T. Drug treatment of depression in frail elderly nursing home residents. Am J Geriatr Psychiatry 2000; 8:150-9. [PMID: 10804076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The authors conducted a randomized, double-blind, 10-week clinical trial of two doses of nortriptyline in eight nursing homes. Sixty-nine patients, average age 79.5 years, were randomized to receive regular doses (60 mg-80 mg/day) vs. low doses (10 mg-13 mg/day) of nortriptyline. Among the more cognitively intact patients, there was a significant quadratic relationship defining a "therapeutic window" for nortriptyline plasma levels and clinical improvement. There were also significant differences in plasma level-response relationships between depressed patients who were cognitively impaired and those who were more cognitively intact. Depression remains a syndrome that responds to specific treatment, even in frail nursing home patients, and those depressions that occur in patients with significant dementia may represent a treatment-relevant condition with a different plasma level-response relationship than in depression alone.
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Affiliation(s)
- J E Streim
- Department of Psychiatry, University of Pennsylvania, Philadelphia, USA.
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Abstract
Studies have consistently shown high prevalence rates of depression associated with negative medical, functional, and psychosocial outcomes in hospitalized, medically ill, older adults. Several issues pose challenges to measurement of depression in this population. In particular, symptoms simultaneously attributable to both medical illness and psychiatric problems may confound measurement of depression, and there is no distinct boundary between normal and abnormal symptoms. This article critiques prevalence research methods used to measure depression in hospitalized, medically ill, older adults and makes recommendations regarding future measurement approaches in both research and clinical practice. Through the identification of appropriate methods for measurement of depression in this population, psychiatric nurses can make a valuable contribution in this area of research as well as enhance effective case-finding and evaluation of depression in older, hospitalized, medically ill patients in the clinical setting.
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Affiliation(s)
- L H Kurlowicz
- School of Nursing, University of Pennsylvania, Philadelphia 19104-6096, USA
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Small GW, Rabins PV, Barry PP, Buckholtz NS, DeKosky ST, Ferris SH, Finkel SI, Gwyther LP, Khachaturian ZS, Lebowitz BD, McRae TD, Morris JC, Oakley F, Schneider LS, Streim JE, Sunderland T, Teri LA, Tune LE. Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society. JAMA 1997; 278:1363-71. [PMID: 9343469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A consensus conference on the diagnosis and treatment of Alzheimer disease (AD) and related disorders was organized by the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society on January 4 and 5, 1997. The target audience was primary care physicians, and the following questions were addressed: (1) How prevalent is AD and what are its risk factors? What is its impact on society? (2) What are the different forms of dementia and how can they be recognized? (3) What constitutes safe and effective treatment for AD? What are the indications and contraindications for specific treatments? (4) What management strategies are available to the primary care practitioner? (5) What are the available medical specialty and community resources? (6) What are the important policy issues and how can policymakers improve access to care for dementia patients? (7) What are the most promising questions for future research? PARTICIPANTS Consensus panel members and expert presenters were drawn from psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health and policy. EVIDENCE The expert presenters summarized data from the world scientific literature on the questions posed to the panel. CONSENSUS PROCESS The panelists listened to the experts' presentations, reviewed their background papers, and then provided responses to the questions based on these materials. The panel chairs prepared the initial drafts of the consensus statement, and these drafts were read by all panelists and edited until consensus was reached. CONCLUSIONS Alzheimer disease is the most common disorder causing cognitive decline in old age and exacts a substantial cost on society. Although the diagnosis of AD is often missed or delayed, it is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Most cases can be diagnosed and managed in primary care settings, yet some patients with atypical presentations, severe impairment, or complex comorbidity benefit from specialist referral. Alzheimer disease is progressive and irreversible, but pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for the behavioral problems associated with dementia can enhance quality of life. Psychotherapeutic intervention with family members is often indicated, as nearly half of all caregivers become depressed. Health care delivery to these patients is fragmented and inadequate, and changes in disease management models are adding stresses to the system. New approaches are needed to ensure patients' access to essential resources, and future research should aim to improve diagnostic and therapeutic effectiveness.
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Abstract
The prevalence of psychiatric disorders was determined in a sample of 196 VA nursing home residents who were interviewed using the modified Schedule for Affective Disorders and Schizophrenia (mSADS). Of the 160 subjects for whom data were available, 86% had a diagnosis of at least one psychiatric disorder. The prevalence of clinically significant cognitive impairment was 60.6% and of major depression 13.8%. Of 110 residents for whom alcohol histories were obtained, 32 (29%) had a lifetime diagnosis of alcohol abuse. The degree of impairment in activities of daily living improved significantly from the time of admission to the time of the evaluation (average 1.4 years) among those who were recently abusing alcohol compared to those who formerly abused alcohol and those who never abused alcohol. The effect is clinically as well as statistically significant and has the potential benefit of reducing caregiver burden and health care costs for the elderly.
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Affiliation(s)
- D W Oslin
- University of Pennsylvania, Philadelphia, USA
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Abstract
Of all long-term care settings, the nursing home has served as the most productive laboratory for the study of the mental health problems of late life. Lessons from geriatric psychiatry research and practice in the nursing home have relevance to general psychiatry and to other health care settings, informing us about (a) psychiatric disorders in medically ill and disabled populations; (b) subsyndromes and subtypes of depression; (c) behavioral disturbances in patients with brain injury; (d) the effects of government regulation and education on mental health care; and (e) essential roles for psychiatrists in changing health care systems. Selected areas of knowledge based on geriatric psychiatry research and experience in long term care are reviewed in this paper, and their applications for the field of psychiatry in general are explored.
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Affiliation(s)
- J E Streim
- Hospital of the University of Pennsylvania, USA
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45
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46
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Affiliation(s)
- J E Streim
- Department of psychiatry, University of Pennsylvania, Philadelphia, USA
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Katz IR, Streim JE. America's other drug problem. Provider 1994; 20:70, 73. [PMID: 10172163] [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] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- I R Katz
- University of Pennsylvania, Philadelphia
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Abstract
The practice of geriatrics frequently involves the services of an interdisciplinary team. Behavior of team members exists on a functional continuum, from adaptive to maladaptive. Health professionals readily identify maladaptive behaviors in patients, but may ignore or avoid such behavior in colleagues. Ignoring these behaviors precludes influencing the affected team member to seek help, and can cause members to leave the team. Team members with maladaptive behavior, and persons colluding with this behavior, can negatively influence care. Using case vignettes, this article categorizes common maladaptive behavior patterns within teams and suggests intervention strategies from an individual, team, and organizational perspective.
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Affiliation(s)
- T J Drinka
- Geriatric Research, Education and Clinical Center, VA Medical Center, Madison, WI 53705
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Abstract
More than half of the people residing in nursing homes in the United States have dementia. A long history of basic contradictions in the conceptualization of nursing home care in the United States has resulted in a serious mismatch between the needs of residents with dementia and the resources of nursing homes to care for these residents. Concern for this discrepancy, and the resultant inadequate and inappropriate care, provided a major impetus for nursing home reform. OBRA 87 was a broad public policy initiative intended to improve the quality of life of nursing home residents. The spirit of the legislation is embodied in federal regulations that explicitly recognize the importance of psychological and social domains of the lives of nursing home residents; restrict the use of psychotropic drugs and physical restraints; and advocate for activities and services to attain or maintain patients' highest practicable physical, mental, and psychosocial well-being. Although the impact of OBRA 87 on the quality of life of residents with dementia is unknown, the federal regulations constitute a major step in the movement for nursing home reform and toward improved quality of care.
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Affiliation(s)
- J E Streim
- Department of Psychiatry, University of Pennsylvania, Philadelphia
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Streim JE, Katz IR. Treating depression. Provider 1994; 20:60, 63. [PMID: 10133547] [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] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Affiliation(s)
- J E Streim
- University of Pennsylvania, Philadelphia
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