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Friedman EM, Edgington S, Escarce JJ, Ghosh-Dastidar B, Shih RA. Implications of Rebalancing Home-Based Care for Family Caregivers to Older Adults. J Appl Gerontol 2024:7334648241270025. [PMID: 39120543 DOI: 10.1177/07334648241270025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
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.
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Affiliation(s)
- Esther M Friedman
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Regina A Shih
- RAND Corporation, Santa Monica, CA, USA
- Emory University, Atlanta, GA, USA
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Bailey MD, Gambert S, Gruber-Baldini A, Guralnik J, Kozar R, Qato DM, Shardell M, Albrecht JS. Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data. J Neurotrauma 2023; 40:86-93. [PMID: 35793112 PMCID: PMC10162579 DOI: 10.1089/neu.2022.0003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.
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Affiliation(s)
- M. Doyinsola Bailey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Steven Gambert
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ann Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jack Guralnik
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rosemary Kozar
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Danya M. Qato
- Department of Pharmaceutical Health Services Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michelle Shardell
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Health Outcomes of Elder Orphans: an Umbrella and Scoping Review of the Literature. JOURNAL OF POPULATION AGEING 2022. [DOI: 10.1007/s12062-022-09387-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Effects of Systemic Rehabilitation Nursing Combined with WeChat Publicity and Education on the Early Cognitive Function and Living Quality of the Patients with Cerebral Arterial Thrombosis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7396950. [PMID: 35251575 PMCID: PMC8894030 DOI: 10.1155/2022/7396950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 12/21/2022]
Abstract
Objective To investigate the effects of systemic rehabilitation nursing combined with WeChat publicity and education on the early cognitive function and living quality of the patients with cerebral arterial thrombosis. Methods Ninety-two patients with cerebral arterial thrombosis treated in our hospital (January 2019–January 2021) were selected as the research objects and equably divided into control group and study group according to their nursing model, with 46 patients in each group. The control group received routine nursing, while the study group received systemic rehabilitation nursing combined with WeChat publicity and education based on the routine nursing. The early cognitive functions, living quality, and other observation indexes of the two groups after nursing were compared, and the intervention effects were evaluated. Results No statistical difference in the general data was observed between the two groups (P > 0.05). The NIHSS (National Institutes of Health Stroke Scale) scores, Fugl-Meyer scores, and MoCA (Montreal Cognitive Assessment) scores of the two groups after nursing were all better than those before nursing, and the NIHSS score, Fugl-Meyer score, and MoCA score of the study group after nursing were better than those of the control group (P < 0.05). Compared with the control group, the study group had a remarkably higher excellent and good rate of daily living ability after nursing (P < 0.05) and prominently higher SIS (Sensory Index Score) after nursing (P < 0.05). The SIS included the scores of emotion, strength, ADL (activities of daily living), memory and thinking, hand function, communication and participation as well as the total score. Conclusion The systemic rehabilitation nursing combined with WeChat publicity and education can effectively reduce the degree of neurological deficit of the patients with cerebral arterial thrombosis, improve their early cognitive function and motor function, and increase their daily living ability and prognostic living quality.
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Crescioli G, Boscia E, Bettiol A, Pagani S, Spada G, Vighi GV, Bonaiuti R, Venegoni M, Vighi GD, Vannacci A, Lombardi N. Risk of Hospitalization for Adverse Drug Events in Women and Men: A Post Hoc Analysis of an Active Pharmacovigilance Study in Italian Emergency Departments. Pharmaceuticals (Basel) 2021; 14:ph14070678. [PMID: 34358104 PMCID: PMC8308702 DOI: 10.3390/ph14070678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/30/2022] Open
Abstract
This post hoc analysis of an Italian active pharmacovigilance study describes pharmacological differences of ADEs leading to emergency department (ED) visits and hospitalization in women and men. During the study period (January 2007-December 2018), 61,855 reports of ADEs leading to ED visits were collected. Overall, 30.6% of ADEs resulted in hospitalization (30% in women and 31% in men). Multivariate logistic regression showed that, among women, drug classes significantly associated with an increased risk of hospitalization were heparins (ROR 1.41, CI 1.13-176), antidepressants (ROR 1.12, CI 1.03-1.23) and antidiabetics (ROR 1.13, CI 1.02-1.24). Among men, only vitamin K antagonists (ROR 1.28, CI 1.09-1.50), opioids (ROR 1.30, CI 1.06-1.60) and digitalis glycosides (ROR 1.32, CI 1.09-1.59) were associated with a higher risk of hospitalization. Overall, older age, multiple suspected drugs and the presence of comorbidities were significantly associated with a higher risk of hospitalization. A significantly reduced risk of hospitalization was observed in both women and men experiencing an adverse event following immunization (ROR 0.36, CI 0.27-0.48 and 0.83, 0.42-0.74, respectively) compared to drugs. Results obtained from this real-world analysis highlight important aspects of drug safety between sexes.
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Affiliation(s)
- Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, 50139 Florence, Italy; (G.C.); (E.B.); (R.B.); (A.V.)
- Tuscan Regional Center of Pharmacovigilance, 50122 Florence, Italy
| | - Ennio Boscia
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, 50139 Florence, Italy; (G.C.); (E.B.); (R.B.); (A.V.)
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Silvia Pagani
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, 20871 Vimercate, Italy; (S.P.); (G.S.); (G.V.V.); (G.D.V.)
| | - Giulia Spada
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, 20871 Vimercate, Italy; (S.P.); (G.S.); (G.V.V.); (G.D.V.)
| | - Giuditta Violetta Vighi
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, 20871 Vimercate, Italy; (S.P.); (G.S.); (G.V.V.); (G.D.V.)
| | - Roberto Bonaiuti
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, 50139 Florence, Italy; (G.C.); (E.B.); (R.B.); (A.V.)
- Joint Laboratory of Technological Solutions for Clinical Pharmacology, Pharmacovigilance and Bioinformatics, University of Florence, 50139 Florence, Italy
| | - Mauro Venegoni
- Pharmacology Unit, Department of Diagnostics and Public Health, University of Verona, 37100 Verona, Italy;
| | - Giuseppe Danilo Vighi
- Internal Medicine, Medical Department, Vimercate Hospital, ASST di Vimercate, 20871 Vimercate, Italy; (S.P.); (G.S.); (G.V.V.); (G.D.V.)
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, 50139 Florence, Italy; (G.C.); (E.B.); (R.B.); (A.V.)
- Tuscan Regional Center of Pharmacovigilance, 50122 Florence, Italy
- Joint Laboratory of Technological Solutions for Clinical Pharmacology, Pharmacovigilance and Bioinformatics, University of Florence, 50139 Florence, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, 50139 Florence, Italy; (G.C.); (E.B.); (R.B.); (A.V.)
- Tuscan Regional Center of Pharmacovigilance, 50122 Florence, Italy
- Correspondence: ; Tel.: +39-055-27-58-206
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Wang J, Ying M, Temkin-Greener H, Caprio TV, Yu F, Simning A, Conwell Y, Li Y. Care-Partner Support and Hospitalization in Assisted Living During Transitional Home Health Care. J Am Geriatr Soc 2021; 69:1231-1239. [PMID: 33394506 PMCID: PMC8127345 DOI: 10.1111/jgs.17005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/03/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Care-partner support affects outcomes among assisted living (AL) residents. Yet, little is known about care-partner support and its effects on hospitalization during post-acute care transitions. This study examined the variation in care-partner support and its impact on hospitalizations among AL residents receiving Medicare home health (HH) services. DESIGN Analysis of national data from the Outcome and Assessment Information Set, Medicare claims, Area Health Resources File, and the Social Deprivation Index File. SETTING AL facilities and Medicare HH agencies in the United States. PARTICIPANTS 741,926 Medicare HH admissions of AL residents in 2017. MEASUREMENTS Care-partner support during the HH admission was measured based on the type and frequency of assistance from AL staff in seven domains (i.e., activities of daily living (ADL), instrumental ADLs, medication administration, treatment, medical equipment, home safety, and transportation). Care-partner support in each domain was measured as "assistance not needed" (reference group), "Care-partner currently provides assistance," "care-partner need additional training/support to provide assistance" (i.e., inadequate care-partner support), and "care-partner unavailable/unlikely to provide assistance" (i.e., unavailable care-partner support). Outcome was time-to-hospitalization during the HH admission. RESULTS Among the 741,926 Medicare HH admissions of AL residents, inadequate care-partner support was identified for all seven domains that ranged from 13.1% (for transportation) to 49.8% (for treatment), and care-partner support was unavailable from 0.9% (for transportation) to 11.0% (for treatment). In Cox proportional hazard models adjusted for patient covariates and geography, compared with "assistance not needed", having inadequate and unavailable care-partner support was related to increased risk of hospitalization by 8.9% (treatment (hazard ratio (HR) =1.089, P < .001)) to 41.3% (medication administration (HR =1.413, P < .001)). CONCLUSION For AL residents receiving HH services, having less care-partner support was related to increased risk of hospitalization, particularly regarding medication administration, medical equipment, and transportation/advocacy.
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Affiliation(s)
| | - Meiling Ying
- University of Rochester, Department of Public Health Sciences, NY
| | | | - Thomas V. Caprio
- University of Rochester Medical Center, Department of Medicine, NY
- University of Rochester Medical Home Care, NY
- Finger Lakes Geriatric Education Center, NY
| | - Fang Yu
- Arizona State University, College of Nursing and Health Innovation, AZ
| | - Adam Simning
- University of Rochester, Department of Public Health Sciences, NY
- University of Rochester Medical Center, Department of Psychiatry, NY
| | - Yeates Conwell
- University of Rochester Medical Center, Department of Psychiatry, NY
| | - Yue Li
- University of Rochester, Department of Public Health Sciences, NY
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Asaithambi G, Tong X, Lakshminarayan K, Coleman King SM, George MG. Effect of Insurance Status on Outcomes of Acute Ischemic Stroke Patients Receiving Intra-Arterial Treatment: Results from the Paul Coverdell National Acute Stroke Program. J Stroke Cerebrovasc Dis 2021; 30:105692. [PMID: 33676326 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Stroke continues to be a leading cause of death and disability in the United States. Rates of intra-arterial reperfusion treatments (IAT) for acute ischemic stroke (AIS) are increasing, and these treatments are associated with more favorable outcomes. We sought to examine the effect of insurance status on outcomes for AIS patients receiving IAT within a multistate stroke registry. METHODS We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) from 2014 to 2019 to quantify rates of IAT (with or without intravenous thrombolysis) after AIS. We modeled outcomes based on insurance status: private, Medicare, Medicaid, or no insurance. Outcomes were defined as rates of discharge to home, in-hospital death, symptomatic intracranial hemorrhage (sICH), or life-threatening hemorrhage during hospitalization. RESULTS During the study period, there were 486,180 patients with a clinical diagnosis of AIS (mean age 70.6 years, 50.3% male) from 674 participating hospitals in PCNASP. Only 4.3% of patients received any IAT. As compared to private insurance, uninsured patients receiving any IAT were more likely to experience in-hospital death (AOR 1.36 [95% CI 1.07-1.73]). Medicare (AOR 0.78 [95% CI 0.71-0.85]) and Medicaid (AOR 0.85 [95% CI 0.75-0.96]) beneficiaries were less likely but uninsured patients were more likely (AOR 1.90 [95% CI 1.61-2.24]) to be discharged home. Insurance status was not found to be independently associated with rates of sICH. CONCLUSIONS Insurance status was independently associated with in-hospital death and discharge to home among AIS patients undergoing IAT.
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Affiliation(s)
- Ganesh Asaithambi
- United Hospital Comprehensive Stroke Center, Allina Health, 310 North Smith Avenue, Suite 440, St. Paul, MN, United States.
| | - Xin Tong
- Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, United States; Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Sallyann M Coleman King
- Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Mary G George
- Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States
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Weaver RH, Roberto KA, Brossoie N. A Scoping Review: Characteristics and Outcomes of Residents Who Experience Involuntary Relocation. THE GERONTOLOGIST 2020; 60:e20-e37. [PMID: 31112600 DOI: 10.1093/geront/gnz035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Relocation to a residential care facility has been described as the most significant relocation affecting older adults, yet subsequent relocations, like in the case of a facility closure, have received minimal attention in the scholarly research literature. This paper reviews the published literature on involuntary relocation, focusing on the experiences of residents, families, and staff and the effects of involuntary relocation on nursing home residents' health. RESEARCH DESIGN AND METHODS We conducted a scoping review to identify peer-reviewed studies reporting on involuntary relocation of nursing home residents. A total of 28 quantitative, qualitative, and mixed-method articles met inclusion criteria. RESULTS Researchers mostly relied on longitudinal designs and quantitative indicators of functional health, cognitive status, psychological and emotional well-being, environment, and relocation context to examine residents' mortality risk and health outcomes associated with involuntary relocation. Inclusion of qualitative and mixed-method approaches was infrequent, as were indicators of social engagement and perceptions of relocation. Residents' awareness of and preparation for involuntary relocation positively influenced their health and well-being. Family involvement was frequently hindered by communication challenges with facilities. Staff expressed concern about residents, experienced increased workload demands, and acknowledged challenges with planning and communication. DISCUSSION AND IMPLICATIONS Based on the collective findings, we propose a conceptual model of critical factors at play during relocation for consideration for guiding future research and developing provisions to current policies guiding relocation processes. Facilities and policymakers need to consider procedures that enhance planning efforts and decision-making among this vulnerable population and their families.
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Affiliation(s)
- Raven H Weaver
- Department of Human Development, Washington State University, Pullman
| | - Karen A Roberto
- Institute for Society, Culture and Environment.,Center for Gerontology, Virginia Tech, Blacksburg
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Haley WE, Roth DL, Sheehan OC, Rhodes JD, Huang J, Blinka MD, Howard VJ. Effects of Transitions to Family Caregiving on Well-Being: A Longitudinal Population-Based Study. J Am Geriatr Soc 2020; 68:2839-2846. [PMID: 32835436 DOI: 10.1111/jgs.16778] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Few studies have rigorously examined the magnitude of changes in well-being after a transition into sustained and substantial caregiving, especially in population-based studies, compared with matched noncaregiving controls. DESIGN We identified individuals from a national epidemiological investigation who transitioned into caregiving over a 10- to 13-year follow-up and provided continuous in-home care for at least 18 months and at least 5 hours per week. Individuals who did not become caregivers were individually matched with caregivers on age, sex, race, education, marital status, self-rated health, and history of cardiovascular disease at baseline. Both groups were assessed at baseline and follow-up. SETTING REasons for Geographic And Racial Differences in Stroke study. PARTICIPANTS A total of 251 incident caregivers and 251 matched controls. MEASUREMENTS Perceived Stress Scale (PSS), 10-Item Center for Epidemiological Studies-Depression (CES-D), and 12-item Short-Form Health Survey quality-of-life mental (MCS) and physical (PCS) component scores. RESULTS Caregivers showed significantly greater worsening in PSS, CES-D, and MCS, with standardized effect sizes ranging from 0.676 to 0.796 compared with changes in noncaregivers. A significant but smaller effect size was found for worsening PCS in caregivers (0.242). Taking on sustained caregiving was associated with almost a tripling of increased risk of transitioning to clinically significant depressive symptoms at follow-up. Effects were not moderated by race, sex, or relationship to care recipient, but younger caregivers showed greater increases in CES-D than older caregivers. CONCLUSION Persons who began substantial, sustained family caregiving had marked worsening of psychological well-being, and relatively smaller worsening of self-reported physical health, compared with carefully matched noncaregivers. Previous estimates of effect sizes on caregiver well-being have had serious limitations due to use of convenience sampling and cross-sectional comparisons. Researchers, public policy makers, and clinicians should note these strong effects, and caregiver assessment and service provision for psychological well-being deserve increased priority.
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Affiliation(s)
- William E Haley
- School of Aging Studies, University of South Florida, Tampa, Florida, USA
| | - David L Roth
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Orla C Sheehan
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - J David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jin Huang
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcela D Blinka
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Ornstein KA, Roth DL, Huang J, Levitan EB, Rhodes JD, Fabius CD, Safford MM, Sheehan OC. Evaluation of Racial Disparities in Hospice Use and End-of-Life Treatment Intensity in the REGARDS Cohort. JAMA Netw Open 2020; 3:e2014639. [PMID: 32833020 PMCID: PMC7445597 DOI: 10.1001/jamanetworkopen.2020.14639] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Although hospice use is increasing and patients in the US are increasingly dying at home, racial disparities in treatment intensity at the end of life, including hospice use, remain. Objective To examine differences between Black and White patients in end-of-life care in a population sample with well-characterized causes of death. Design, Setting, and Participants This study used data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, an ongoing population-based cohort study with enrollment between January 25, 2003, and October 3, 2007, with linkage to Medicare claims data. Multivariable logistic regression models were used to examine racial and regional differences in end-of-life outcomes and in stroke mortality among 1212 participants with fee-for-service Medicare who died between January 1, 2013, and December 31, 2015, owing to natural causes and excluding sudden death, with oversampling of Black individuals and residents of Southeastern states in the United States. Initial analyses were conducted in March 2019, and final primary analyses were conducted in February 2020. Main Outcomes and Measures The primary outcomes of interest were hospice use of 3 or more days in the last 6 months of life derived from Medicare claims files. Other outcomes included multiple hospitalizations, emergency department visits, and use of intensive procedures in the last 6 months of life. Cause of death was adjudicated by an expert panel of clinicians using death certificates, proxy interviews, autopsy reports, and medical records. Results The sample consisted of 1212 participants (630 men [52.0%]; 378 Black individuals [31.2%]; mean [SD] age at death, 81.0 [8.6] years) of 2542 total deaths. Black decedents were less likely than White decedents to use hospice for 3 or more days (132 of 378 [34.9%] vs 385 of 834 [46.2%]; P < .001). After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among persons who died of cardiovascular disease but not among patients who died of cancer. In analyses adjusted for cause of death (dementia, cancer, cardiovascular disease, and other) and clinical and demographic variables, Black decedents were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% CI, 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with White decedents. Conclusions and Relevance Despite the increase in the use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. More research is required to better understand racial disparities in access to and quality of end-of-life care.
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Affiliation(s)
- Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David L. Roth
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jin Huang
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - J. David Rhodes
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - Chanee D. Fabius
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Monika M. Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Orla C. Sheehan
- Center on Aging and Health, Johns Hopkins School of Medicine, Baltimore, Maryland
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Stamm BJ, Burke JF, Lin CC, Price RJ, Skolarus LE. Disability in Community-Dwelling Older Adults: Exploring the Role of Stroke and Dementia. J Prim Care Community Health 2020; 10:2150132719852507. [PMID: 31185786 PMCID: PMC6563403 DOI: 10.1177/2150132719852507] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: We sought to determine the relative contributions of stroke, dementia, and their combination to disability and racial differences in disability among community-dwelling older adults. Methods: We performed a cross-sectional study of 6848 community-dwelling older adults. We evaluated the associations of stroke, dementia, and their combination with activities of daily living (ADL) limitations (range 0-7). We then explored the impact of stroke and dementia on race differences in ADL limitations using Poisson regression after accounting for sociodemographics and comorbidities. Results: After full adjustment, ADL limitations differed among older adults with stroke and dementia. Older adults without stroke or dementia had 0.32 (95% CI 0.29-0.35) ADL limitations compared to 0.64 (95% CI 0.54-0.73) with stroke, 1.36 (95% CI 1.20-1.53) with dementia and 1.84 (95% CI 1.54-2.15) with stroke and dementia. Overall, blacks had 0.27 (95%CI 0.19-0.36) more ADL limitations than whites. Models accounting for stroke led to a 3.7% (95%CI 2.98%-4.43%) reduction in race differences, while those for dementia led to a 29.26% (95%CI 28.53%-29.99%) reduction and the stroke-dementia combination -1.48% (95%CI -2.21% to -0.76) had little impact. Discussion: Older adults with stroke and dementia have greater disability than older adults with either of these conditions alone. However, the amount of disability experienced by older adults with stroke and dementia is less than the sum of the contributions from stroke and dementia. Dementia is likely a key contributor to race differences in disability.
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Affiliation(s)
| | - James F Burke
- 2 University of Michigan, Ann Arbor, MI, USA.,3 Ann Arbor VA, Ann Arbor, MI, USA
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12
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Roofeh R, Smith DM, Clouston SAP. Estimated Prevalence of Elder Orphans Using National Health and Aging Trends Study. J Aging Health 2020; 32:1443-1449. [PMID: 32559117 DOI: 10.1177/0898264320932382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: By 2050, individuals aged 65 years and older will comprise over 20% of the American population. A portion is at risk for becoming elder orphans: older adults living in the community who lack caregivers or surrogates. Methods: Using the first wave of the National Health and Aging Trends Survey, we estimated the prevalence of older adults who reside in the community, who are socially or physically isolated, and who lack caregivers. Individuals who are "at risk" meet all of these criteria, with the exception that they live with and receive caregiving from their spouse. Results: We estimated the elder orphan prevalence for this population to be 2.62% (2.24-3.00), with an additional 21.29% determined to be at risk. Discussion: As the population of the United States ages, an understanding of the prevalence and demographics of elder orphans will be useful to guide policies and services to assist this population.
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Affiliation(s)
- Regina Roofeh
- Stony Brook University Health Sciences Center, NY, USA.,5799Northwell Health, NY, USA
| | - Dylan M Smith
- Stony Brook University Health Sciences Center, NY, USA
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13
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Sutton KM, Hunter EG, Logsdon B, Santella B, Kitzman PH. The Role of Physical Therapy in Multiple Risk Factor Management Poststroke: A Scoping Review. J Geriatr Phys Ther 2020; 44:165-174. [PMID: 32511115 DOI: 10.1519/jpt.0000000000000248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Individuals after stroke often have multiple chronic conditions, such as hypertension, diabetes, dyslipidemia, obesity, and tobacco use. These comorbidities not only are commonly found in individuals with stroke, but also negatively affect functional outcomes and increase risk for hospital readmission and overall mortality. It is important for physical therapists to address the whole person during treatment after stroke, including comorbidities, not just the problems resulting from the stroke itself. However, it is unclear how common it is for physical therapists to address multiple diagnoses at once using a wellness model. Therefore, the purpose of this scoping review was to examine current evidence regarding the role of physical therapy in addressing modifiable risk factors for individuals after stroke, to identify gaps in research associated with physical therapy management of related comorbid diagnoses during treatment for stroke. METHODS A scoping review methodology was utilized searching PubMed and CINAHL databases to identify interventional research studies specifically addressing multiple modifiable risk factors utilizing physical therapy for individuals after stroke. RESULTS The initial search yielded 5358 articles and 12 articles met full inclusion criteria. Only 2 studies included participants with significant mobility impairments, and none included individuals with communication impairments. Only 4 of the 12 studies provided education in their design. Eight studies did not include any patient-reported outcome measures. Only 3 studies included long-term follow-up assessments. DISCUSSION Secondary stroke risk factors can be positively addressed using physical therapy interventions; however, more research is needed regarding individuals with moderate to severe mobility or communication deficits. Opportunities for physical therapy research to address stroke risk factors in this complex population include expanding follow-up periods, improving educational interventions, and including caregivers in study design. CONCLUSIONS This review highlights the need for better integration of clinical considerations into stroke rehabilitation research as a whole, along with the need for additional research regarding the role physical therapy can play in addressing multimorbidity in individuals with stroke.
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Affiliation(s)
| | | | - Brooke Logsdon
- Department of Physical Therapy, University of Kentucky, Lexington
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14
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Vadas D, Kalichman L. The impact of availability and identity of the caregiver on the post-stroke patient. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2020. [DOI: 10.12968/ijtr.2019.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background After having a stroke, most patients are helped by a caregiver with activities that they cannot perform by themselves. The caregiver presence and actions are an important variable that may affect rehabilitation in many ways. The aim of this review study was to evaluate the impact of caregiver presence (or absence) and identity (spouse, family, or foreign domestic worker) on therapeutic exercise performance, depression symptoms, patient–spouse relations and total functional outcomes of stroke patients. Assessing these effects may help health care professionals and families to prioritise/choose the caregiver for their patient/family member. Methods A narrative literature review was conducted, focusing on one-direction effects (caregiver on patient effects) on the topics of interest mentioned, in a post-stroke population. PubMed, CINAHL, PEDro, Trip database, and Google Scholar were searched, and included studies of most designs and research qualities. The search strategy had not been specified before commencing the review. Each study was analysed individually with the purpose of synthesising the available evidence to achieve a greater understanding of this topic. Results A total of 17 relevant papers were included: six randomised controlled trials, six observational studies, two systematic reviews, two survey-based studies, and one case series. Trials were consistent with the positive effect that caregivers have on therapeutic exercise performance. Studies have shown a positive effect of caregivers on the patient's depressive symptoms, but only at the chronic phase after stroke. A spouse caregiver seems to more positively affect the patient–spouse relations in the acute phase of rehabilitation, while foreign domestic workers can improve these relations at more chronic phases. The presence of a caregiver is shown to decrease functional outcomes within institutionalised rehabilitation centres, while it is necessary and positively affects functionality at more chronic phases within community settings. Conclusions The advantages and disadvantages of employing a caregiver depend in many cases on the rehabilitation phase. The caregiver might be beneficial or harmful to the patient's functional progress, depressive symptoms and marital relationship depending on the rehabilitation phase. More studies are needed to assess the caregiver effects on post-stroke patients' rehabilitation and quality of life.
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Affiliation(s)
- Dor Vadas
- The Israel Rehabilitation Center for Stroke and Brain Injury, Rehovot, Israel; Oxford University, Oxford, UK
| | - Leonid Kalichman
- Department of Physical Therapy, Recanati School for Community Health Professions, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Skolarus LE, Feng C, Burke JF. Exploring Factors Contributing to Race Differences in Poststroke Disability. Stroke 2020; 51:1813-1819. [PMID: 32404036 DOI: 10.1161/strokeaha.119.027700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Cross sectional analyses have found large race differences in poststroke disability, yet these analyses do not account for prestroke disability, hospitalization factors, postacute care, transitions, or mortality. In this context, we explore mortality, nursing home placement, and disability in a longitudinal analysis of older stroke survivors who survived at least 90 days poststroke. Methods- A prospective cohort of black or white stroke survivors from the National Health and Aging Trends Study (2009-2016) linked to Medicare were used. Disability was assessed during in-person interviews with validated scales (0-7). We used cox proportional hazards models to separately assess mortality and nursing home admission adjusting for age, sex, sociodemographics (marital status, education, income, insurance status, social network size), comorbidities, hospitalization factors, postacute care, and 90-day readmissions. To estimate racial differences in disability, we used a multilevel linear regression model initially adjusting for age and sex and then compared with a model adjusted for sociodemographics, comorbidities, hospitalization factors, postacute care, and 90-day readmissions. Results- There were 282 stroke survivors, of which 76 (12.6%) were black. There were no race differences in long-term mortality (hazard ratio for black, 1.2 [95% CI, 0.7-2.2]; P=0.5) or nursing home placement (hazard ratio for black, 0.7 [95% CI, 0.2-2.4]; P=0.5). The largest race differences in disability were observed immediately prestroke, estimated age- and sex-adjusted activity limitations were (2.6 [2.0-3.2] in blacks versus 1.4 [1.0-1.8] in whites, mean difference, 1.2 [0.5-1.9], P<0.001) and immediately poststroke (2.6 [2.0-3.3] in blacks versus 1.7 [1.2-2.1] in whites, mean difference, 1.0 [0.2-1.7], P<0.01). Full adjustment did not substantially change the associations between race and disability. Conclusions- Race differences in nursing home placement, long-term mortality, sociodemographics, comorbidities, hospitalization factors, postacute care, and readmissions are unlikely to be large contributors to race differences in poststroke disability. Further research is needed to understand the drivers of race differences in poststroke disability.
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Affiliation(s)
- Lesli E Skolarus
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.)
| | - Chunyang Feng
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.)
| | - James F Burke
- From the Department of Neurology, University of Michigan, Ann Arbor (L.E.S., C.F., J.F.B.).,Department of Neurology, Ann Arbor VA, MI (J.F.B.)
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16
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Sex Differences in Care Need and Survival in Patients Admitted to Nursing Home Poststroke. Can J Neurol Sci 2020; 47:153-159. [PMID: 31987059 DOI: 10.1017/cjn.2019.335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Women are more likely to be admitted to nursing home after stroke than men. Differences in patient characteristics and outcomes by sex after institutionalization are less understood. We examined sex differences in the characteristics and care needs of patients admitted to nursing home following stroke and their subsequent survival. METHODS We identified patients with stroke newly admitted to nursing home between April 2011 and March 2016 in Ontario, Canada, with follow-up until March 2018 using linked administrative data. We calculated prevalence ratios and 95% confidence intervals (CIs) for the primary outcomes of dependence for activities of daily living, cognitive impairment, frailty, health instability, and symptoms of depression or pain, comparing women to men. The secondary outcome was all-cause mortality. RESULTS Among 4831 patients, 60.9% were women. Compared to men, women were older (median age [interquartile range, IQR]: 84 [78, 89] vs. 80 [71, 86]), more likely to be frail (prevalence ratio 1.14, 95% CI [1.08, 1.19]), have unstable health (1.45 [1.28, 1.66]), and experience symptoms of depression (1.25 [1.11, 1.40]) or pain (1.21 [1.13, 1.30]), and less likely to have aggressive behaviors (0.87 [0.80, 0.94]). Overall median survival was 2.9 years. In a propensity-score-matched cohort, women had lower mortality than men (hazard ratio 0.85, 95% CI [0.77, 0.94]), but in the age-stratified survival analysis, the survival advantage in women was limited to those aged 75 years and older. CONCLUSIONS Despite lower subsequent mortality, women admitted to nursing home after stroke required more care than men. Pain and depression are two treatable symptoms that disproportionately affect women.
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Abstract
Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.
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Affiliation(s)
- Peter Appelros
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Signild Åsberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Friedman EM, Rodakowski J, Schulz R, Beach SR, Martsolf GR, James AE. Do Family Caregivers Offset Healthcare Costs for Older Adults? A Mapping Review on the Costs of Care for Older Adults With Versus Without Caregivers. THE GERONTOLOGIST 2019; 59:e535-e551. [PMID: 30945725 DOI: 10.1093/geront/gny182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Older adults face significant long-term care and health care costs. But some of these costs can potentially be offset through family caregivers who may serve as substitutes for formal care or directly improve the care recipient's health and reduce health care utilization and expenditures. This article reviews the current literature to determine whether it is possible through existing work to compare the costs of care for individuals with versus without family caregivers and, if not, where the data, measurement, and other methodological challenges lie. RESEARCH DESIGN AND METHODS A mapping review of published works containing information on health care utilization and expenditures and caregiving was conducted. A narrative approach was used to review and identify methodological challenges in the literature. RESULTS Our review identified 47 articles that met our criteria and had information on caregiving and health care costs or utilization. Although findings were mixed, for the most part, having a family caregiver was associated with reduced health care utilization and a decreased risk of institutionalization however, the precise difference in health care expenditures for individuals with caregivers compared to those without was rarely examined, and findings were inconsistent across articles reviewed. DISCUSSION AND IMPLICATIONS The number of family caregivers providing care to loved ones is expected to grow with the aging of the Baby Boomers. Various programs and policies have been proposed to support these caregivers, but they could be costly. These costs can potentially be offset if family caregivers reduce health care spending. More research is needed, however, to quantify the savings stemming from family caregiving.
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Affiliation(s)
| | - Juleen Rodakowski
- Department of Occupational Therapy, University of Pittsburgh, Pennsylvania
| | - Richard Schulz
- Department of Psychiatry, University of Pittsburgh, Pennsylvania
| | - Scott R Beach
- University Center for Social and Urban Research, University of Pittsburgh, Pennsylvania
| | - Grant R Martsolf
- RAND Corporation, Santa Monica, California.,School of Nursing, University of Pittsburgh, Pennsylvania
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Liu C, Marino V, Sheehan OC, Huang J, Roth DL, Haley WE. Association between caregiver engagement and patient-reported healthcare utilization after stroke: a mixed-methods study. Top Stroke Rehabil 2019; 27:1-7. [PMID: 31483738 DOI: 10.1080/10749357.2019.1659640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Caregivers (CGs) are critical in helping stroke survivors (SSs) retain function and receive adequate healthcare. Objectives: We aimed to identify the activities that CGs are engaged in over the course of stroke care from open-ended SS interviews and explore the association between CG engagement and SS healthcare utilization post-stroke.Methods: We qualitatively analyzed 9-month post-stroke interviews with 118 SSs about their experiences before, during and following acute care from the Caring for Adults Recovering from the Effects of Stroke (CARES) study. We classified each SS as having either an engaged or non-engaged CG based on whether the SS indicated CG involvement in any part of their stroke care. We compared differences between groups in self-reported use of outpatient therapy, home health care, ambulatory care, mental health services, and acute care.Results: SSs who were interviewed most often described CG involvement as driving the SS to the hospital or calling 911 (n = 48; 23.4%), coordinating medical appointments (n = 43; 21.0%) and monitoring recovery (n = 23; 11.2%). SSs with engaged CGs were more likely to see a speech-language pathologist and had more emergency room visits compared to those with non-engaged CGs. No differences were observed after adjusting for stroke severity.Conclusions: Higher rates of healthcare utilization by SSs with engaged CGs may be driven by greater stroke severity and greater need for services. Interestingly, the presence of an engaged CG did not facilitate more care for the SS after adjusting for stroke severity.
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Affiliation(s)
- Chelsea Liu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Victoria Marino
- School of Aging Studies, University of South Florida, Tampa, FL, USA
| | - Orla C Sheehan
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jin Huang
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - David L Roth
- Center on Aging and Health, Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - William E Haley
- School of Aging Studies, University of South Florida, Tampa, FL, USA
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