Rethinking long-term care

In the context of several proposals for financing long-term care (LTC), this article suggests three areas in which reform of the structure of LTC is needed to create more appropriate incentives for better care. The interfaces between short- and long-term care can be addressed by either a number of specific changes or more global approaches, such as one or another form of capitated care. Using the ratio of achieved/expected outcomes as a prominent part of a regulatory strategy offers a means to increase the flexibility of regulation to encourage innovation while retaining meaningful accountability. New combinations of housing and nursing care offer a way for both a better and more flexible way of living in the context of an approach that guarantees universal coverage of care together with an incentive to save to afford better accommodations.

Impact of geriatric nurse practitioners on nursing-home residents' functional status, satisfaction, and discharge outcomes

This study evaluated the impact of geriatric nurse practitioners (GNP) employed by nursing homes on quality of patient care and residents' outcomes during a 12-month study period. Quality of care was assessed in standardized interviews of 525 residents in five nursing homes with GNPs and 323 residents in five other nursing homes without GNPs. Each resident was interviewed up to four times during the study period (at baseline, and 3, 6, and 12 months later) to determine functional status, satisfaction with care, and physical condition at each of these points. The only significant difference between groups was that fewer newly admitted residents were hospitalized from GNP homes than from those without a GNP. The results of this interview study showed that the GNP as a nursing home employee had little impact on residents' functional status, physical condition, or satisfaction.

Career paths of geriatric nurse practitioners employed in nursing homes

The career paths of geriatric nurse practitioners (GNPs) trained with support from the W. K. Kellogg Foundation through the Mountain States Health Corporation (MSHC) were studied. Under this program, GNPs were recruited from sponsoring nursing homes and returned to GNP positions in the sponsoring facilities following training. Training was carried out under a continuing education model offered through six university-based schools of nursing. Questionnaires were sent to the 111 GNPs trained. Of the 102 respondents, 97 provided complete information about past and present education, work experience, and job functions. The GNPs were women with a median age of 45 years, and they were employed in rural settings in the western United States. More than 45 percent of the nurses had at least a baccalaureate degree at the time of GNP training. The GNPs remained employed in long-term care positions that implemented the practitioner role. The median length of GNP employment in their first jobs after training was more than 4.5 years. The resignation rate from this first position was 1.66 resignations for each 10 years of GNP employment. Job changes were likely to be attributed to organizational changes with subsequent positions shifting toward a diversification of the GNP role. The study demonstrates the success of the MSHC program in introducing and retaining GNPs in nursing homes.

Assessing cost effects of nursing-home-based geriatric nurse practitioners

Employment of geriatric nurse practitioners (GNPs) is one strategy to improve nursing home care. The effects of GNPs on costs and profitability of nursing homes and on costs of patient medical service use outside the nursing home are examined. Employment of GNPs does not adversely affect nursing home costs or significantly affect profits. There is some evidence of cost savings in medical service use for newly admitted patients but no evidence of savings for continuing residents. GNPs reduce the use of hospital services for both groups, and the reduction is statistically significant for newly admitted patients.

Education, survival, and independence in elderly Catholic sisters, 1936-1988

Mortality among 306 Roman Catholic sisters (nuns) from Mankato, Minnesota, was assessed during the period 1936-1988; daily use of nursing services by survivors was determined in 1986; and the ability of survivors to eat, dress, and perform other self-care activities was evaluated in 1987. The median age at death was 89.4 years for sisters with educational attainment of a bachelor's degree or higher, 82.2 years for sisters with some high school or college education, and 82.0 years for sisters with only a grade school education. Odds ratios were calculated for "survival and independence" (i.e., sisters survived to 1986 (ages 75-94 years) and did not use daily nursing services at that time). These odds ratios were 2.67 (95% confidence interval (CI) 1.16-6.16) for sisters with a bachelor's degree or higher, 1.00 for the reference group with some high school or college, and 0.94 (95% CI 0.32-2.73) for sisters with only grade school. Sisters with a bachelor's degree or higher were also more likely than others to survive to old age while maintaining their ability to perform self-care activities. These findings suggest that college graduates lived longer and maintained their ability to care for themselves longer than other persons.

Manual dexterity as a correlate of dependency in the elderly

Physical and mental correlates of dependent living were determined in 128 Catholic sisters (nuns), aged 75 to 94 years, who had similar social support systems and lifestyles. The primary a priori hypothesis was that poor manual dexterity would correlate strongly with living in the nursing home. Stepwise discriminant analysis indicated that manual dexterity explained 51% of the variance in the sisters' residential living site (ie, nursing home, retirement home, or living in community). The discriminant analysis equation using manual dexterity predicted living site correctly for 63% of the sisters in the nursing home with a specificity of 99%, a positive predictive value of 96% and negative predictive value of 84%. The addition of age and mental status to the equation improved the prediction only slightly.

Effects of a geriatric nurse practitioner on process and outcome of nursing home care

We compared measures of quality of care and health services utilization in 30 nursing homes employing geriatric nurse practitioners with those in 30 matched control homes. Information for this analysis came from reviews of samples of patient records drawn at comparable periods before and after the geriatric NPs were employed. The measures of geriatric nurse practitioner impact were based on comparisons of changes from pre-NP to post-NP periods. Separate analyses were done for newly admitted and long-stay residents; a subgroup of homes judged to be best case examples was analyzed separately as well as the whole sample. Favorable changes were seen in two out of eight activity of daily living (ADL) measures: five of 18 nursing therapies; two of six drug therapies; six of eight tracers. There was some reduction in hospital admissions and total days in geriatric NP homes. Overall measures of medical attention showed a mixed pattern with some evidence of geriatric NP care substituted for physician care. These findings suggest that the geriatric NP has a useful role in nursing home care.

A response to Mapou

Mapou (1988) has suggested that detection of brain damage has become an irrelevant task for neuropsychology, and that neuropsychological assessment should be used to generate profiles of cognitive function useful for sophisticated diagnosis and rehabilitation. While agreeing the latter considerations are important and germane, we affirm that the detection of brain damage remains an important task for neuropsychology. This affirmation is based on considerations of the nature of brain damage, the development and validation of neuropsychological tests, the utilization of neuropsychological assessment in current practice and the appropriate professional practice of clinical neuropsychology.

Is early natural menopause a biologic marker of health and aging?

The relation between age at natural menopause and all-cause mortality was investigated in a sample of 5,287 White women, ages 55 to 100 years, naturally-postmenopausal, Seventh-day Adventists who had completed mailed questionnaires in 1976. The age-adjusted odds ratio of death during 1976-82 in women with natural menopause before age 40 was 1.95 (95% confidence interval = 1.24, 3.07), compared to the reference group of women reporting natural menopause at ages 50 to 54. Corresponding odds ratios of death were 1.39 (95% CI = 1.06, 1.81) for natural menopause at ages 40 to 44, and 1.03 (95% CI = 0.84, 1.25) for natural menopause at ages 45 to 49. Among 3,166 White, 55- to 100-year-old, surgically-postmenopausal, Adventist women, there was no relation between age at surgical menopause and mortality. Logistic regression analyses indicated that findings from this study were apparently not due to confounding by smoking, over- or underweight, reproductive history, or replacement estrogen use.

Methodology for measuring health-state preferences--I: Measurement strategies

Values play a critical part in decision making at both the individual and policy levels. Numerous methodologies for determining the preferences of individuals and groups have been proposed, but agreement has not been reached regarding their scientific adequacy and feasibility. This is the first of a four-part series of papers that analyzes and critiques the state-of-the-art in measuring preferences, particularly the measurement of health-state preferences. In this first paper we discuss the selection of relevant attributes to comprise the health-state descriptions, and the relative merits of three measurement strategies: holistic, explicitly decomposed, and statistically inferred decomposed. The functional measurement approach, a statistically inferred decomposed strategy, is recommended because it simultaneously validates the process by which judges combine attributes, the scale values they assign to health states, and the interval property of the scale.

Methodology for measuring health-state preferences--II: Scaling methods

This paper begins with a discussion of measurement principles relevant to determining health-state preferences. Six scaling methods are described and evaluated on the basis of their reliability, validity, and feasibility. They are the standard gamble, time trade-off, rating scale, magnitude estimation, equivalence, and willingness-to-pay methods. Reliability coefficients for most methods are acceptable although the low coefficients for measurements taken a year apart suggest that preferences change over time. Convergent validity among methods has been supported in some but not all studies, and there are limited data supporting hypothetical relationships between preferences and other variables. The category ratings method is easiest to administer and appears to yield valid scale values; thus, it is recommended for large-sample studies. However, decision-oriented methods, particularly the time trade-off and standard gamble, may be more effective in small-scale investigations and individual decision making.

Years of life with good and poor mental and physical function in the elderly

A population of Roman Catholic sisters (nuns) were divided into a high education group (i.e. at least a Bachelor's degree) and a low education group (i.e. less than a Bachelor's degree). Prevalence data on 132, 75-94 year old, sisters indicated that the high-educated had better mobility and hand coordination, stronger handgrip, better distant and near visual acuity, and fewer mental impairments than the low-educated group. Life table analyses on 154 sisters indicated that the high-educated lived an average of 3.28 years longer after age 75 than the low-educated. Years of life with relatively good and poor mental and physical function after age 75 were estimated by a mathematical model that used mortality and prevalence data. According to the model, high-educated sisters lived an average of 3.57 years longer with good function and 0.29 of a year less with poor function than low-educated sisters.

Methodology for measuring health-state preferences--III: Population and context effects

In addition to the scaling method, there are many other aspects of the measurement process that may affect rater judgments of the relative desirability of health states. Although we find little compelling evidence of population differences in preferences due to demographic characteristics, there is some evidence suggesting that medical knowledge and/or experience with illness may influence raters' valuations of health states. Other aspects of the rating process that affect rater judgments can be classified as one of two types: inconsistencies due to limitations in human judgment, and inconsistencies due to situation-specific variables. When inconsistencies are due to limitations in human judgment, such as framing effects, a reasonable solution is to help the rater to see and correct the inconsistency. When inconsistencies are due to situation-specific variables, such as the way the health state is defined and presented, investigators should attempt to standardize conditions across studies.

Methodology for measuring health-state preferences--IV: Progress and a research agenda

Remaining questions relative to the measurement of health-state preferences are outlined and applications discussed. We recommend more widespread use of functional measurement to better understand preference structures. Further research should be conducted on the reliability and validity of preference values produced by different scaling methods, including careful examination of the content validity of health-state descriptions. Construct validation studies using the multitrait-multimethod matrix would be useful as well as comparisons of stated preferences with revealed preferences. Despite the many unanswered measurement questions, preference values are currently being used in decision making at both the individual and societal levels. Several global health status measures incorporate preference values, and preferences are increasingly being used in cost-effectiveness studies. If preferences are to be used effectively, research on their measurement must accelerate to keep pace with the urgency for application.

Do physicians spend less time with older patients?

In view of the additional time that older persons require for giving and receiving information, as well as for the examination process, it is important for manpower and reimbursement planning to better understand the nature of the physician-patient encounter with the elderly. We examined a series of national surveys of physicians' professional activities and found that physicians tend to spend less time with their older patients and also that encounter time by physicians in different specialties varies widely. Internists and cardiologists spend substantially more time with patients compared with general and family practitioners. For 65-74-year-old ambulatory patients, the average visit lengths are 18.3 minutes for internists, 18.0 for cardiologists, 11.2 for general practitioners, and 12.1 for family practitioners. Compared with ambulatory visit lengths for patients aged 45 to 64 years, average encounter times for 75-year-olds with family physicians were 0.8 minutes shorter, with general practitioners 1.2 minutes shorter, with internists 2.3 minutes shorter, and with cardiologists 3.0 minutes shorter. However, when all characteristics of the visit were considered, the effect of patient age remained significant only for general practitioners. A multivariate analysis of factors related to physician time for ambulatory care showed that more time is associated with multiple problems, problem severity, and the use of diagnostic testing. For general and family practice, the greater the number of previous visits for a problem, the shorter the encounter time is. Additional characteristics associated with shorter physician-patient encounter times include the volume of patients per week and the use of physician assistants within the practice. These findings have implications for medical education and manpower projections.

Are physicians sensitive to the special problems of older patients?

The sensitivity of primary care physicians to the health care needs of older patients was explored by means of an analysis of the use of diagnostic tests and therapeutic procedures during ambulatory visits. Survey data on a total of 28,265 visits to internists, family and general practitioners were examined to determine possible age-related differences in care. The study found that diagnostic testing falls off significantly for patients 75 years of age or older and that internists use substantially more tests for each age group than do family and general practitioners. The pattern of use of diagnostic tests in this secondary analysis does not address the issue of "appropriateness" but does suggest a pattern that makes little sense based on the known distribution of disease and functional disability in aging populations.

What are we measuring? An examination of self-reported functional status measures

Functional status questionnaires are being used in various types of studies. To determine factors related to self-reported functional ability for rheumatoid arthritis patients, we examined the relationship between a functional and mental health questionnaire and objective disease-specific measures. Using 3-5 predictor variables, we explained 43-57% of the variance in patients' self-reported functioning. Mental and physical health perceptions were significant predictors for each self-reported functional measure. The relationships among mental health and self-reported functioning should be considered when interpreting studies that use functional status questionnaires.

Beyond caring: the challenge to geriatrics

Geriatrics has established itself in the past decade as a recognized part of health care, but several issues remain unsolved about its place in the system. It has been addressed as both an approach to primary care of the elderly and a specialty in its own right. It relies excessively on the technology of assessment. Although geriatrics responds to a pervasive need for coordinating clinical and social care for a subset of the elderly, its potential contributions to this challenge have not yet been well modeled. As it comes of age, there is a need for greater conceptual clarity and a series of demonstrations that its abilities fit the needs identified.

Improved survival for frail elderly inpatients on a geriatric evaluation unit (GEU): who benefits?

Previously reported data from a randomized controlled trial showed that admission to the geriatric evaluation unit (GEU) and follow-up clinic at the Sepulveda VA Medical Center leads to significantly improved outcomes for frail elderly hospital patients--including a 50% reduction of one-year mortality (p less than 0.005). In the present paper, two-year survival curves for GEU and control groups are reported. In addition, we subdivided the population by potential baseline risk factors (both patient- and treatment-related) and examined one-year survival using 12-month survival curves and odds ratios. There is evidence for GEU-related survival effects in specific subgroups of patients (e.g. patients with heart and pulmonary disease, patients with low baseline scores in functional status and mental status, and patients with high baseline morale scores). Finally, employing stepwise logistic regression, we determined the predictors of one-year survival in the pooled study population. These factors were: assignment to the GEU (adjusted odds ratio = 2.45; p less than 0.001); not having a heart diagnosis (2.24; p less than 0.001); and having primarily "geriatric/rehabilitation" problems (1.95; p less than 0.005). A predictive model derived from the regression defines patient subgroups likely to survive only when assigned to the GEU: cardiac patients with primarily "geriatric" or "rehabilitation" problems, and non-cardiac patients whose problems are primarily "medical". The dramatic effect of the GEU on survival appears to be concentrated on certain identifiable subgroups of patients who might be targeted to maximize program cost-effectiveness.