Activity Limitation Stages empirically derived for Activities of Daily Living (ADL) and Instrumental ADL in the U.S. Adult community-dwelling Medicare population

Implications of Rebalancing Home-Based Care for Family Caregivers to Older Adults

Over the last several decades, Medicaid has been "rebalancing" services from institutions to the community, increasing support of home- and community-based services (HCBS). These services could potentially substitute for care typically provided by family members, replacing or reducing care from kin. Leveraging one of the most recent Medicaid rebalancing programs, the Balancing Incentive Program (BIP), and using data from the 2008-2016 Health and Retirement Study on 953 Medicaid beneficiaries ages 65 and over with at least one functional limitation, we examined the relationship between exposure to BIP and family and professional caregiving. BIP exposure was not associated with receipt of care or total hours of care. It was, however, associated with more hours of professional care and fewer hours of family care from non-spouse kin. These findings suggest that recent Medicaid rebalancing programs, while intended to meet the desires of older adults, could have implications for their families.

The Association of Retinal Disease with Vision Impairment and Functional Status in Medicare Patients

Background: The association of neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO) with functional status in the general Medicare population are not well established. Objectives: This study examined patient-reported survey data linked with Medicare claims to describe the burden of these vision-threatening retinal diseases (VTRDs) among Medicare beneficiaries. Methods: Medicare Current Beneficiary Survey data linked with Medicare Fee-for-Service claims data from 2006 to 2018 were used in a nationally representative retrospective pooled cross-sectional population-based comparison study. Outcomes between community-dwelling beneficiaries with nAMD (n = 1228), DME (n = 101), or RVO (n = 251) were compared with community-dwelling beneficiaries without any VTRDs (n = 104 088), controlling for baseline demographic and clinical differences. Beneficiaries with a diagnosis of nAMD, DME, or RVO during the data year were included; those with other VTRDs were excluded. Outcomes included vision function and loss, overall functioning as assessed by difficulties with activities of daily living (ADLs) and instrumental ADLs (iADLs), anxiety/depression, falls, and fractures. Results: In patient cohorts with nAMD, DME, and RVO, approximately one-third (34.2%-38.3%) reported "a little trouble seeing" (vs 28.3% for controls), and 26%, 17%, and 9%, respectively, reported "a lot of trouble seeing/blindness" (vs 5% of controls). Difficulty walking and doing heavy housework were the most reported ADLs and iADLs, respectively. Compared with those without VTRDs, beneficiaries with nAMD had higher odds of diagnosed vision loss (odds ratio [OR], 5.39; 95% confidence interval, 4.06-7.16; P < .001) and difficulties with iADLs (odds ratio, 1.41; 95% confidence interval, 1.11-1.80; P = .005); no differences were observed for DME or RVO vs control. After adjusting for age, sex, race/ethnicity, poverty status, comorbidities, and other relevant covariates, nAMD, DME, and RVO were not significantly associated with anxiety/depression, falls, or fractures. Discussion: Patients with nAMD or DME were more likely to report severe visual impairment than those without VTRDs, although only those with nAMD were more likely to be diagnosed with vision loss. Conclusions: Patients with nAMD continue to experience more vision impairment and worse functional status compared with a similar population of Medicare beneficiaries despite availability of therapies like antivascular endothelial growth factor to treat retinal disease.

Dimensionality and invariance of ADL, IADL, BI-M2/WG-SS, and GALI in large surveys in France (2008-2014) and implications for measuring disability in epidemiology

BACKGROUND

The epidemiological investigation and surveillance of disability requires well-constructed, invariant, and, if possible, exchangeable measures. However, the current or recommended measures have not been thoroughly investigated with respect to these issues. Here we examined the dimensional structure and invariance of four measures across sociodemographic groups: Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Budapest Initiative Mark 2 (BI-M2) and Washington Group on Disability Statistics Short Set (WG-SS), and Global Activity Limitation Indicator (GALI).

METHODS

We used data from three large nationwide representative surveys conducted in France between 2008 and 2014. The surveys included these four measures and classical and modern approaches (correlations, principal component analysis, Rasch modeling) were used to assess their dimensional structure as well as their invariance through differential item functioning (DIF) for sociodemographic characteristics. Polytomous logistic regression models were used to assess gradients in health inequalities associated with these measures.

RESULTS

For many items of ADL, IADL, and BI-M2/WG-SS, we consistently observed disordered response thresholds, rejection of unidimensionality, and DIF evidence for sociodemographic characteristics across the survey samples. Health inequality gradients were erratic. In addition, it was impossible to identify a common continuum for GALI, ADL, IADL, and BI-M2/WG-SS or their constituent items.

CONCLUSION

This study warns against the current practice of investigating disability in epidemiology using measures that are unsuitable for epidemiological use, incommensurable, and inadequate regarding the basic requisites of dimensionality and invariance. Developing invariant measures and equating them along a common continuum to enlarge the common bases of measurement should therefore be a priority.

Accuracy of Self-Reported Physical Capacities as a Clinical Screening Test for Older Adults With Mobility Disability

Background: Screening for poor physical performance has the potential to identify older adults at risk for loss of future independence, yet clinically feasible measures have yet to be identified. Methods: Using data from the National Health and Aging Trends Study, we evaluated the diagnostic utility of self-reported physical capacities of older adults (walking three blocks or six blocks, climbing 10 stairs or 20 stairs) compared to the objectively measured Short Physical Performance Battery (SPPB). Sensitivity, specificity, and likelihood ratio (LR) were calculated across three SPPB cut-points (≤8, ≤9, ≤10). Results: Sensitivity of single item-measures for detecting a low SBBP averaged 0.39 (range: 0.26-0.52), specific averaged 0.97 (range: 0.94-0.99) and likelihood ratio averaged 20.0 (range: 9.0-35.5). Among age and gender subgroups, all measures maintained clinically applicable LRs (minimum = 4.59). Conclusion: Single-item self-reported physical capacities are accurate for screening older adults with physical limitations, making them potentially useful in healthcare settings.

Association between self-reported body mass index and active life expectancy in a large community-dwelling sample of older U.S. adults

Background

Obesity may have a protective effect (greater survival) in older adults, a finding known as the “obesity paradox.” This study examined the association between self-reported body mass index (BMI) and active life expectancy (ALE) among older U.S. adults.

Methods

Using the Medicare Health Outcomes Survey Cohort 15 (2012 baseline, 2014 follow-up), we estimated life expectancy and ALE by participants’ baseline BMI and age using multi-state models. A participant was classified as in an active state if this person reported having no difficulty for any of these six activities of daily living (ADLs).

Results

Small differences in life expectancy were noted among persons in normal weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25–29.9 kg/m²), and obesity ranges (BMI 30 kg/m² and higher). However, persons with obesity had a significantly lower ALE. ALE at age 65 was 11.1 (11.0–11.2) years for persons with obesity, 1.2 (1.1–1.3) years less than that for the normal weight and overweight persons (12.3 years for both, 12.2–12.4). Persons with class III obesity had a significantly lower life expectancy and ALE than normal weight persons. Although persons with class I or II obesity had a similar life expectancy as normal weight persons, they have a shorter ALE.

Conclusions

Although older adults with obesity have a similar life expectancy as normal weight persons, they have a significantly shorter ALE. Given the complex relationship of BMI and ALE, a “one size fits all” approach to weight management is not advisable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03021-7.

Misuse of Prescription Medications among Individuals with Mobility Disability

BACKGROUND

The ability of walking a quarter mile is predictive of subsequent disability, mortality, and health care costs. Individuals with mobility disability are at increased risk of chronic conditions and unmet care needs. Thus they may misuse prescription medications to self-medicate.

OBJECTIVES

We aimed to explore the difference of misuse of four types of prescription medications (sedatives, tranquilizers, painkillers, depression medications) and overall misuse by mobility status and identify the correlates of overall misuse.

METHODS

A national probability sample from the survey Midlife in the United States (MIDUS) was used to assess the difference in misuse by mobility status during 2011-2014. To assess the correlates of misuse, mobility status, usual source of care, unmet care needs, insurance coverage, sociodemographic variables, and clinical conditions were added to a survey weighted logistic regression model with backward selection.

RESULTS

Compared to those without mobility disability, individuals with mobility disability had higher risk of misuse in most types of medications and in overall misuse. Mobility disability, lower education, unmarried status, the emergency room or public health clinic as the most often used care, pain, and depressed affect were identified as correlates of overall misuse of studied medications.

CONCLUSIONS

Individuals with mobility disability are a vulnerable group susceptible to medication misuse, which warrants the urgent need for interventions to ameliorate misuse and reduce risks in this population.

Self-Care Capacity and Its Relationship to Age, Disability, and Perceived Well-Being in Medicare Beneficiaries

BACKGROUND

Self-care is a multicomponent set of capacities that influence beliefs about health and well-being.

OBJECTIVES

We examined the relationship between self-care capacity, age, and disability status with two perceptions of well-being in a cohort of Medicare beneficiaries.

METHODS

The current study is part of a multisite research project to determine factors associated with cross-sectional and longitudinal morbidity and mortality trajectories observed in Medicare beneficiaries. Variable selection was informed by the health disparities and outcomes model. Using data from the 2013 Medicare Current Beneficiary Survey and logistic regression models, we determined associations between self-care capacity, including indicators of self-care ability and self-care agency and two perceptions of well-being. Participants were divided into four groups based on how they qualified for Medicare: (a) over 65 years of age, and below 65 years of age and disabled because of (b) physical or (c) mental disorder, or (d) disabled and could not be classified as physically or mentally disabled as the primary cause of eligibility.

RESULTS

Self-care ability limitations in activities of daily living (ADL), instrumental activities of living (IADL), and social activity participation were associated with both health perceptions. Those with physical disabilities reported more ADL and IADL limitations when compared with the other eligibility groups and were significantly more likely to have negative health perceptions. Those with serious mental illness were most likely to report the most severe IADL limitations. The over 65 years of age group reported less self-care incapacity than the other three eligibility types. Other components of self-care, including health literacy, agency, and health behaviors, significantly influenced perceptions of health. Women and people identifying as non-Whites were more likely to have negative health perceptions.

DISCUSSION

Self-care capacity is a complex construct, and its varied elements have differential relationships with perceptions of well-being. Those with physical disabilities reported more self-care limitations, poorer perceived health, and more health worries than the other groups. Still, there were different patterns of self-care capacities in the serious mental illness type-especially in IADL limitations. The study adds empirical evidence to previous research documenting inequities in health outcomes for women and non-Whites. Findings provide empirical support for the health disparities and outcomes model.

Psychological and behavioral responses during the COVID-19 pandemic among individuals with mobility and/or self-care disabilities

Background

The lockdowns during the COVID-19 pandemic created major obstacles for individuals with disabilities to obtain support in their daily living.

Objectives

This study was to examine the psychological and behavioral responses of US individuals with mobility and/or self-care disabilities during the pandemic.

Methods

From a nationally representative longitudinal survey (n = 6403) administered during the pandemic, individuals were classified at baseline as having no mobility/self-care disability (ADL = 0, n = 4975), mobility or self-care disability (ADL = 1, n = 1061), and both mobility and self-care disabilities (ADL = 2, n = 367). Weighted mean of baseline mental distress scores (PHQ4), psychological risk factors (loneliness, stress, perceived COVID risk), resilience, and coping were compared among these groups. Random effects models were employed to assess the effects of disability and disability-moderated effects of risk factors on mental distress.

Results

At baseline, mental distress increased with greater ADL disabilities (Mean[95%CI] = 1.88[1.77, 1.98], 2.54[2.29, 2.79], and 3.55[3.01, 4.08] for ADL = 0, 1, and 2, respectively, p < .0001). Loneliness, stress, and perceived risk increased with ADL disabilities, but resilience and social coping decreased with it (p's < 0.0001). In the random-effects models, greater ADL disabilities, higher psychological risks, and use of cannabis and other recreational drugs were associated with greater mental distress. Greater ADL disabilities augmented the detrimental effects of risk factors on mental health, but resilience protected mental health both independently and through a buffering effect on its risk factors across all groups.

Conclusion

Individuals with mobility and/or self-care disability tend to have poorer mental health and are differentially more affected by its risk factors. Mental health professionals should address these modifiable factors in interventions.

Impact of self-assessed health status and physical and functional limitations on healthcare utilization and mortality among older cancer survivors in US

PURPOSE

The purpose of this study was to examine the impact of physical limitations, functional limitations and self-assessed health status on mortality and healthcare utilization among older cancer survivors.

METHODS

National Medicare Current Beneficiary Survey (MCBS) cost and use data from 2008 to 2013 were used for analysis. Physical limitations, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL) were assessed on multiple questions, and self-assessed health was measured on a five-point scale (1-5: Excellent-Poor). Multivariable logistic regression and Poisson regression models were used for hospitalization, re-hospitalization and mortality rates based on three follow up years.

RESULTS

This study included 17,715 cancer patients with a mean age of 75 years and 57% females. Cancer survivors with poor self-assessed health had a higher rate of hospitalizations (adjusted Odds Ratio: aOR: 1.60, 95% Confidence Interval: CI: 1.47-1.72, p < 0.001) relative to non-cancer participants. Compared to participants with no history of cancer, cancer survivors with IADL (aOR: 1.41, 95% CI: 1.25-1.58, p < 0.001) or with poor self-assessed health (aOR: 1.39, 95% CI: 1.21-1.60, p < 0.001) were more likely to have a higher number of hospital readmissions within 30 days of a prior hospitalization. Three-year mortality rate was significantly higher among cancer survivors with poor self-assessed health (Hazard Ratio: 2.81, 95% CI: 2.81-2.82, p < 0.001).

CONCLUSION

Self-assessed health and physical and functional limitations significantly and independently impact healthcare utilization and mortality among older cancer survivors. Healthcare providers should incorporate formal assessments of both self-assessed health and functional status among older cancer survivors in their clinical practice.

IMPLICATION FOR CANCER SURVIVORS

Self-reported health status is a valuable and independent predictor of healthcare utilization and mortality among cancer survivors.

Association of AM-PAC "6-Clicks" Basic Mobility and Daily Activity Scores With Discharge Destination

OBJECTIVE

The objective was to use the Activity Measure for Post-Acute Care "6-Clicks" scores at initial physical therapist and/or occupational therapist evaluation to assess (1) predictive ability for community versus institutional discharge, and (2) association with discharge destination (home/self-care [HOME], home health [HHA], skilled nursing facility [SNF], and inpatient rehabilitation facility [IRF]).

METHODS

In this retrospective cohort study, initial "6-Clicks" Basic Mobility and/or Daily Activity t scores and discharge destination were obtained from electronic health records of 17,546 inpatient admissions receiving physical therapy/occupational therapy at an academic hospital between October 1, 2015 and August 31, 2018. For objective (1), postacute discharge destination was dichotomized to community (HOME and HHA) and institution (SNF and IRF). Receiver operator characteristic curves determined the most predictive Basic Mobility and Daily Activity scores for discharge destination. For objective (2), adjusted odds ratios (OR) from multinomial logistic regression assessed association between discharge destination (HOME, HHA, SNF, IRF) and cut-point scores for Basic Mobility (≤40.78 vs >40.78) and Daily Activity (≤40.22 vs >40.22), accounting for patient and clinical characteristics.

RESULTS

Area under the curve for Basic Mobility was 0.80 (95% CI = 0.80-0.81) and Daily Activity was 0.81 (95% CI = 0.80-0.82). The best cut-point for Basic Mobility was 40.78 (raw score = 16; sensitivity = 0.71 and specificity = 0.74) and for Daily Activity was 40.22 (raw score = 19; sensitivity = 0.68 and specificity = 0.79). Basic Mobility and Daily Activity were significantly associated with discharge destination, with those above the cut-point resulting in increased odds of discharge HOME. The Basic Mobility scores ≤40.78 had higher odds of discharge to HHA (OR = 1.7 [95% CI = 1.5-1.9]), SNF (OR = 7.8 [95% CI = 6.8-8.9]), and IRF (OR = 7.5 [95% CI = 6.3-9.1]), and the Daily Activity scores ≤40.22 had higher odds of discharge to HHA (OR = 1.8 [95% CI = 1.7-2.0]), SNF (OR = 8.9 [95% CI = 7.9-10.0]), and IRF (OR = 11.4 [95% CI = 9.7-13.5]).

CONCLUSION

6-Clicks at physical therapist/occupational therapist initial evaluation demonstrated good prediction for discharge decisions. Higher scores were associated with discharge to HOME; lower scores reflected discharge to settings with increased support levels.

IMPACT

Initial Basic Mobility and Daily Activity scores are valuable clinical tools in the determination of discharge destination.

Incident Instrumental Activities of Daily Living Difficulty in Older Adults: Which Comes First? Findings From the Advanced Cognitive Training for Independent and Vital Elderly Study

Introduction: Instrumental activities of daily living (IADLs) are complex daily tasks important for independent living. Many older adults experience difficulty with IADLs as their physical and/or cognitive function begins to decline. However, it is unknown in what order IADLs become difficult. Methods: Participants from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study who were free of IADL difficulty at baseline (N = 1,277) were followed up to 10 years until first reported IADL difficulty. A total of 19 IADL tasks were grouped into seven task categories. A discrete-time multiple-event process survival mixture model (MEPSUM) was used to generate hazard estimates of incident IADL difficulty in seven groups from ages 65 to 80. Hazard estimates were compared in the three intervention groups (memory, inductive reasoning, and speed of information processing) vs. the no-contact control group. Results: A total of 887 (69.5%) participants reported incident difficulty in at least one IADL task category. Compared to individuals who remained free of IADL difficulty, those who reported incident difficulty were more likely to be older, female, and have lower Short Form 36 general health scores. The IADL task categories to first become difficult were housework, managing health care, and phone use. There were no differences by intervention group in the hazard estimates of incident IADL difficulty. Conclusion: Managing health care and phone use are more cognitively demanding IADLs, and individuals who experience difficulty in these tasks first may be more likely to experience cognitive decline. Recognizing early difficulty in managing health care may allow for implementation of compensation strategies to minimize unintentional medication misuse, increased adverse medical events, and unnecessary hospitalization. Training of a specific cognitive domain may not influence ordering of IADL difficulty because IADL tasks require proficiency in, and integration of, multiple cognitive domains.

Life expectancy and active life expectancy by disability status in older U.S. adults

Objectives

The Medicare Health Outcome Survey (HOS) is the largest longitudinal survey of the U.S. community-dwelling elderly population. This study estimated total life expectancy, active life expectancy (ALE), and disability-free life expectancy (DFLE) by disability status among HOS participants.

Methods

Data were from the Medicare HOS Cohort 15 (baseline 2012, follow-up 2014). We included respondents aged ≥ 65 years (n = 164,597). Participants’ disability status was assessed based on the following six activities of daily living (ADL): bathing, dressing, eating, getting in or out of chairs, walking, and using the toilet. The multi-state models were used to estimate life expectancy, ALE, and DFLE by participants’ baseline disability status and age.

Results

Persons who had higher-level ADL limitations had a shorter life expectancy, ALE, and DFLE. Also persons with disability had greater expected life years with disability than those with no limitations and those with mild limitations. For example, among 65-year old respondents with no limitations, mild limitations, and disability, life expectancy was 19.9, 18.6, and 17.1 years, respectively; ALE was 14.0, 9.5, and 7.2 years, respectively; DFLE was 17.3, 15.2, and 11.4 years, respectively; and expected years with disability was 2.6, 3.4, and 5.7 years, respectively.

Conclusions

This study demonstrated that greater levels of disability adversely impact life expectancy, ALE, DFLE, and expected number of years with a disability among U.S. older adults. Understanding levels of disability, and how these may change over time, would enhance health care quality and planning services related to home care and housing in this community-dwelling population.

Psychophysical Health Factors and Its Correlations in Elderly Wheelchair Users Who Live in Nursing Homes

Background: The aging is a multi-faceted process comprising both-the physical and mental alterations. Thus, the aim of the study was to evaluate the variables affecting the psychophysical state of the elderly people using wheelchairs and living in nursing homes (NH). Methods: 165 older wheelchair users were included in the study after meeting the inclusion criteria and expressing written consent. The assessment involved cognitive functioning, depression, body balance and flexibility, lung capacity and upper limbs dexterity, strenght and endurance. The results showed negative correlation between depression and balance, upper limb dexterity and endurance and shoulder flexion. A positive correlation between cognitive functioning and balance, upper limb dexterity, strenght and endurance, lung capacity and joint mobility was determined. Also, the study proved positive correlation between daily functioning and functional fitness, muscle strength and endurance, body flexibility, joint mobility. The regression analysis showed that better scores in balance test and joint mobility implied with higher scores in cognitive functioning. The most important determinants of functional fitness were balance, hand grip strenght and joint mobility. Conclusion: The future study should be focused on developing interventions aimed at senior wheelchair users living in NHs to prevent the deterioration of their mental and physical fitness.

Relationship between instrumental activities of daily living performance and incidence of mild cognitive impairment among older adults: A 48-month follow-up study

Early prevention of mild cognitive impairment MCI is crucial because individuals with MCI are at high risk for progression to dementia. The purpose of the present study was to examine the relationship between the performance of instrumental activities of daily living IADL and future incidence of MCI among community-dwelling older adults in Japan. A total of 1595 individuals without cognitive impairment at baseline participated in this prospective cohort study with a 48-month follow-up period. Performance on the following IADL was assessed at baseline: handling cash and banking, shopping for necessities, going out using buses/trains, using maps to travel to unfamiliar places, and operating video/DVD players. Objective cognitive screening using the National Center for Geriatrics and Gerontology-Functional Assessment Tool and Mini-Mental State Examination was conducted at baseline and follow-up; new MCI incidence over the 48 months was determined. Of all participants, 922 (57.8 %) had a limitation in at least one IADL at baseline. During the follow-up period, 179 (11.2 %) participants experienced a transition from normal cognition to MCI. Participants who had not engaged in "going out using buses/trains" or "using maps to travel to unfamiliar places" at baseline showed a significantly higher risk of MCI incidence than those who had engaged in such activities. Limitations in outdoor IADL were associated with MCI onset. Individuals with such limitations need to be monitored, as these limitations are strong indicators of cognitive decline and MCI.

New Composite Measure for ADL Limitations: Application to Predicting Nursing Home Placement for Michigan MI Choice Clients

Functional status measured by activities of daily living (ADL) may be used to predict nursing home placement. Scoring of ADL measures is summarized for convenience, yet this is accompanied by losing detail regarding deficits. We sought to determine whether a revised composite measure tailored to Michigan Medicaid beneficiaries would better identify those at risk for nursing home admission. We compared composite ADL measures created by exploratory factor analysis and additive modeling to Medicaid Enrollment, MI Choice Waiver program, and Nursing Facility claims data from 2013 to 2017. There were moderate to high levels of correlation between ADLs (.4-.82). Exploratory factor analysis extracted two factors, corresponding to domains of mobility or self-care tasks. Application of the self-care-based ADL limitations composite measure provided prediction power equivalent to an additive measure incorporating all ADL limitations for nursing home admission. This approach demonstrated improved interpretability with the need for just five measures.

State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment

OBJECTIVE

To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment.

DATA SOURCE

2010-2013 Medicare Current Beneficiary Survey.

STUDY DESIGN

Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies.

PRINCIPAL FINDINGS

Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs.

CONCLUSIONS

Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

Impact of Physical and Functional Limitations on Health Care Utilization in Older Cancer Survivors: A Medicare Current Beneficiary Survey

Objective: This study examines effects of physical and functional limitations on health care utilization among older cancer survivors, compared with those without cancer and without physical and functional limitations. Method: Medicare Current Beneficiary Survey data from 2008 to 2011 were used. Physical limitations (PL), activities of daily living (ADL), and instrumental activities of daily living (IADL) were measured on a 5-point scale. Propensity score weighting was developed using logistic regressions. Results: Older cancer survivors with physical and functional limitations had higher rate of emergency department visits than those without limitations (PL: 21.8% vs.17%, adjusted odds ratio [aOR]:1.72, 95% confidence interval [CI]: [1.26, 2.35], p < .05; ADL: 25.8% vs.17.4%, aOR: 2.68, 95% CI: [1.86, 3.86], p < .001), and higher cost of hospitalization (IADL: M = US$24,916, SD: 3,877.1). Conclusion: Older cancer survivors with physical and functional limitations had higher health care utilization compared with those without cancer. Addressing complex and unique health care needs in this population will help reduce excess burden on the health care system.

Premorbid Activity Limitation Stages Are Associated With Posthospitalization Discharge Disposition

OBJECTIVE

Activity of daily living stages and instrumental activity of daily living stage have demonstrated associations with mortality and health service use among older adults. This cohort study aims to assess the associations of premorbid activity limitation stages with acute hospital discharge disposition among community-dwelling older adults.

DESIGN

Study participants were Medicare beneficiaries aged 65 yrs or older who enrolled in the Medicare Current Beneficiary Survey between 2001 and 2009. Associations of premorbid stages with discharge dispositions were estimated with multinomial logistic regression models adjusted for covariates.

RESULTS

The proportions of elderly Medicare patients discharged to home with self-care, home with services, postacute care facilities, and other dispositions were 59%, 15%, 19%, and 7%, respectively. The following adjusted relative risk ratios and 95% confidence intervals of postacute care facilities versus home with self-care discharge increased with higher premorbid activity limitation stages (except nonfitting stage III): 1.7 (1.5-2.0), 2.4 (2.0-2.9), 2.4 (1.9-3.0), and 2.5 (1.6-4.1) for activity of daily living stages I-IV; a similar pattern was found for instrumental activity of daily living stages. The adjusted relative risk ratios of discharge to home with services also increased with higher premorbid activity limitation stages compared with no limitation.

CONCLUSIONS

Routinely assessed activity limitation stages predict posthospitalization discharge disposition among older adults and may be used to anticipate postacute care and services use by elderly Medicare beneficiaries.

The importance of pathophysiology to the understanding of functional limitations in the bioarchaeology of care approach

This article presents a partial bioarchaeology of care case study of a mummified adult female with chronic obstructive pulmonary disease (COPD) from late historic period United States. It examines likely clinical and functional impacts of disease and corresponding need for provision of care, stopping short of Stage 4 Interpretation/analysis. The case study illustrates and argues for the importance of an interdisciplinary research team for achieving a comprehensive understanding of disability and care. The article highlights the necessity of knowledge of pathophysiology for identifying the potential interventions (supports) dictated by the associated functional limitations. inter alia, this case is a powerful illustration of the way analysis of preserved soft tissue can provide insights into disease and likely care that are inaccessible using skeletal analysis alone. The article represents an interesting contribution to the theory and methodology of both the bioarchaeology of care approach and mummy studies.

Patient Satisfaction and Perceived Quality of Care Among Younger Medicare Beneficiaries According to Activity Limitation Stages

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.

Long-Term Services and Supports Use Among Older Medicare Beneficiaries in Rural and Urban Areas

State and federal policies have shifted long-term services and support (LTSS) priorities from nursing home care to home and community-based services (HCBS). It is not clear whether the rural LTSS system reflects this system transformation. Using the Medicare Current Beneficiary Survey, we examined nursing home use among rural and urban Medicare beneficiaries aged 65 and older. Study findings indicate that even after controlling for known predictors of nursing home use, rural Medicare beneficiaries exhibited greater odds of nursing home residence and that the higher odds of rural nursing home residence are, in part, associated with higher rural nursing home bed supplies. A complex interplay of policy, LTSS infrastructure, and social, cultural, and other factors may be influencing the observed differences. Federal and state efforts to build rural HCBS capacity may be necessary to mitigate stubbornly persistent rural-urban differences in the patterns of institutional and community-based LTSS use.

Functional Impairments Associated With Patient Activation Among Community-Dwelling Older Adults

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.

A Risk Scoring System for the Prediction of Functional Deterioration, Institutionalization, and Mortality Among Medicare Beneficiaries

OBJECTIVE

We sought to develop a risk scoring system for predicting functional deterioration, institutionalization, and mortality. Identifying predictors of poor health outcomes informs clinical decision-making, service provision, and policy development to address the needs of persons at greatest risk for poor health outcomes.

DESIGN

This is a cohort study with 21,257 community-dwelling Medicare beneficiaries 65 yrs and older who participated in the 2001-2008 Medicare Current Beneficiary Survey. Derivation of the model was conducted in 60% of the sample and validated in the remaining 40%. Multinomial logistic regression model generated β coefficients, which were used to create a risk scoring system. Our outcome was instrumental activity of daily living stage transitions (stable/improved function and functional deterioration), institutionalization, or mortality for 2 yrs of follow-up.

RESULTS

A total of 18 factors were identified for functional deterioration (P < 0.05). In the derivation cohort, the likelihood of functional deterioration ranged from 6.27% to 33.51%, risk of institutionalization from 0.07% to 12.13%, and risk of mortality from 2.13% to 31.83%, in comparison with stable/improved function.

CONCLUSIONS

A risk scoring system predicting Medicare beneficiaries' risk of functional deterioration, institutionalization, and mortality based on demographic and clinical indicators may feasibly be developed with implications for healthcare delivery.

Preventable hospitalizations, barriers to care, and disability

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.

Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS)

BACKGROUND

Little is known about how the proportions of dependency states have changed between generational cohorts of older people. We aimed to estimate years lived in different dependency states at age 65 years in 1991 and 2011, and new projections of future demand for care.

METHODS

In this population-based study, we compared two Cognitive Function and Ageing Studies (CFAS I and CFAS II) of older people (aged ≥65 years) who were permanently registered with a general practice in three defined geographical areas (Cambridgeshire, Newcastle, and Nottingham; UK). These studies were done two decades apart (1991 and 2011). General practices provided lists of individuals to be contacted and were asked to exclude those who had died or might die over the next month. Baseline interviews were done in the community and care homes. Participants were stratified by age, and interviews occurred only after written informed consent was obtained. Information collected included basic sociodemographics, cognitive status, urinary incontinence, and self-reported ability to do activities of daily living. CFAS I was assigned as the 1991 cohort and CFAS II as the 2011 cohort, and both studies provided prevalence estimates of dependency in four states: high dependency (24-h care), medium dependency (daily care), low dependency (less than daily), and independent. Years in each dependency state were calculated by Sullivan's method. To project future demands for social care, the proportions in each dependency state (by age group and sex) were applied to the 2014 UK [corrected] population projections.

FINDINGS

Between 1991 and 2011, there were significant increases in years lived from age 65 years with low dependency (1·7 years [95% CI 1·0-2·4] for men and 2·4 years [1·8-3·1] for women) and increases with high dependency (0·9 years [0·2-1·7] for men and 1·3 years [0·5-2·1] for women). The majority of men's extra years of life were spent independent (36·3%) or with low dependency (36·3%) whereas for women the majority were spent with low dependency (58·0%), and only 4·8% were independent. There were substantial reductions in the proportions with medium and high dependency who lived in care homes, although, if these dependency and care home proportions remain constant in the future, further population ageing will require an extra 71 215 care home places by 2025.

INTERPRETATION

On average older men now spend 2·4 years and women 3·0 years with substantial care needs, and most will live in the community. These findings have considerable implications for families of older people who provide the majority of unpaid care, but the findings also provide valuable new information for governments and care providers planning the resources and funding required for the care of their future ageing populations.

FUNDING

Medical Research Council (G9901400) and (G06010220), with support from the National Institute for Health Research Comprehensive Local research networks in West Anglia and Trent, UK, and Neurodegenerative Disease Research Network in Newcastle, UK.

Predicting 3-year mortality and admission to acute-care hospitals, skilled nursing facilities, and long-term care facilities in Medicare beneficiaries

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.

The Association Between Activity Limitation Stages and Admission to Facilities Providing Long-term Care Among Older Medicare Beneficiaries

OBJECTIVE

This study aimed to examine whether activity limitation stages are associated with admission to facilities providing long-term care (LTC).

DESIGN

Cohort study using Medicare Current Beneficiary Survey data from the 2005-2009 entry panels. A total of 14,580 community-dwelling Medicare beneficiaries 65 years or older were included. Proportional subhazard models examined associations between activity limitation stages and time to first LTC admission, adjusting for baseline sociodemographics and health conditions.

RESULTS

The weighted annual rate of LTC admission was 1.1%. In the adjusted model, compared to activity of daily living (ADL) stage 0, the hazard ratios (95% confidence intervals [CIs]) were 2.0 (1.5-2.7), 3.9 (2.9-5.4), 3.6 (2.5-5.3), and 4.7 (2.5-9.0) for ADL stage I (mild limitation), ADL stage II (moderate limitation), ADL stage III (severe limitation), and ADL stage IV (complete limitation), respectively. Compared to instrumental ADL (IADL) stage 0, the hazard ratios, and 95% CIs for IADL stages I to IV were 2.0 (1.4-2.7), 3.7 (2.6-5.4), 4.6 (3.3-6.5), and 7.6 (4.6-12.3), respectively.

CONCLUSIONS

Activity limitation stages are strongly associated with future admission to LTC and may therefore be useful in identifying specific supportive care needs among vulnerable older community-dwelling adults, which may reduce or the delay need for admission to LTC.

Disability Stages and Trouble Getting Needed Health Care Among Medicare Beneficiaries

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.

Perceived barriers to healthcare and receipt of recommended medical care among elderly Medicare beneficiaries

PURPOSE

Many Medicare beneficiaries perceive barriers to receiving healthcare, although the consequences are unknown. Facilitators can aid in the receipt of healthcare services. The objective was to assess the relationship between perceived facilitators and barriers to healthcare and actual receipt of recommended medical care among elderly beneficiaries.

METHODS

A cohort study using data from the 2001-2008 entry panels of the Medicare Current Beneficiary Survey that included 24,607 community-dwelling beneficiaries 65 years of age and older. Surveys elicited perceptions of healthcare with respect to: care coordination and quality; access to medical care; getting or delaying healthcare because of financial reasons; transportation; and usual source of care. The outcome was receipt of recommended medical care, expressed as an aggregate of 38 indicators covering initial evaluation, diagnostic tests, therapeutic interventions, hospitalization follow-up, and routine preventive care. Multivariable survey logistic regression produced odds ratios (ORs) and 95% confidence intervals (CIs) for receipt of recommended medical care, adjusted for sociodemographics, insurance, comorbidities, and disability.

RESULTS

Beneficiaries who reported having trouble getting or reported delaying healthcare because of financial reasons (barrier) (adjusted OR=0.79, 95% CI: 0.73-0.86) and those who reported having no usual source of care (facilitator) (adjusted OR=0.55, 95% CI: 0.48-0.63) were less likely to receive recommended medical care.

CONCLUSIONS

Survey data that capture patient perceptions of facilitators and barriers to healthcare may be useful for identifying system factors that affect timely receipt of recommended medical care. This information can inform the design of policies and programs to improve the healthcare of older adults.

Predictive Indices for Functional Improvement and Deterioration, Institutionalization, and Death Among Elderly Medicare Beneficiaries

BACKGROUND

Prediction models can help clinicians provide the best and most appropriate care to their patients and can help policy makers design services for groups at highest risk for poor outcomes.

OBJECTIVE

To develop prediction models identifying both risk factors and protective factors for functional deterioration, institutionalization, and death.

DESIGN

Cohort study using data from the Medicare Current Beneficiary Survey (MCBS).

SETTING

Community survey.

PARTICIPANTS

This study included 21,264 Medicare beneficiaries 65 years of age and older who participated in the MCBS from the 2001-2008 entry panels and were followed up for 2 years.

METHODS

The index was derived in 60% and validated in the remaining 40%. β Coefficients from a multinomial logistic regression model were used to derive points, which were added together to create scores associated with the outcome.

MAIN OUTCOME MEASURE

The outcome was activity of daily living (ADL) stage transitions over 2 years following entry into the MCBS. Beneficiaries were categorized into 1 of 4 outcome categories: stable or improved function, functional deterioration, institutionalization, or death.

RESULTS

Our model identified 16 factors for functional deterioration (age, gender, education, living arrangement, dual eligibility, proxy use, Alzheimer disease/dementia, angina pectoris/coronary heart disease, diabetes, emphysema/asthma/chronic obstructive pulmonary disease, mental/psychiatric disorder, Parkinson disease, stroke/brain hemorrhage, hearing impairment, vision impairment, and baseline ADL stage) after backward selection (P < .05). Compared to stable or improved function, the risk of functional deterioration ranged from ≤1 to ≥6, ≤4 to ≥22 for the risk of institutionalization, and ≤3 to ≥16 for the risk of death.

CONCLUSION

Predictive indices, or point and scoring systems used to predict outcomes, can identify elderly Medicare beneficiaries at risk for functional deterioration, institutionalization, and death and can aid policy makers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.

LEVEL OF EVIDENCE

III.

Disparities in receipt of recommended care among younger versus older medicare beneficiaries: a cohort study

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.

Presence of Vision Impairment and Risk of Hospitalization among Elderly Medicare Beneficiaries

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.

Psychosocial Well-Being Associated With Activity of Daily Living Stages Among Community-Dwelling Older Adults

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.

Disability stage and receipt of recommended care among elderly medicare beneficiaries

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.

Identifying neuropsychiatric disorders in the Medicare Current Beneficiary Survey: the benefits of combining health survey and claims data

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.

Activity Limitation Stages Are Associated With Risk of Hospitalization Among Medicare Beneficiaries

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.

Patient Satisfaction and Prognosis for Functional Improvement and Deterioration, Institutionalization, and Death Among Medicare Beneficiaries Over 2 Years

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.

Potentially Avoidable Hospitalizations among People at Different Activity of Daily Living Limitation Stages

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.

Understanding non-performance reports for instrumental activity of daily living items in population analyses: a cross sectional study

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.

Comparison of predictive value of activity limitation staging systems based on dichotomous versus trichotomous responses in the Medicare Current Beneficiary Survey

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.

Patient Satisfaction and Perceived Quality of Care Among Older Adults According to Activity Limitation Stages

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.

Disability Stage is an Independent Risk Factor for Mortality in Medicare Beneficiaries Aged 65 Years and Older

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.