FIT & STRONG! PLUS: DESCRIPTIVE DEMOGRAPHIC AND RISK CHARACTERISTICS IN A COMPARATIVE EFFECTIVENESS TRIAL FOR OLDER AFRICAN-AMERICAN ADULTS WITH OSTEOARTHRITIS

Objectives

The prevalence of osteoarthritis (OA) has increased in the US. We report on a comparative effectiveness trial that compares Fit & Strong!, an existing evidence-based physical activity (PA) program, to Fit & Strong! Plus, which combines the Fit & Strong! intervention with a weight management intervention.

Methods

Participants included 413 overweight/obese (BMI 25-50 kg/m²) adults with lower extremity (LE) OA. The majority of the sample was African-American and female. Both interventions met 3 times weekly for 8 weeks. Primary measures included diet and weight.

Results

The baseline mean BMI for all participants was 34.8 kg/m^², percentage of calories from fat was high, and self-reported PA was low.

Discussion

This sample of overweight/obese African-American adults had lifestyle patterns at baseline that were less than healthful, and there were differences between self-report and performance-based measures as a function of age.

Characterization of microsatellite loci for the critically endangered cactus Ariocarpus bravoanus

Ariocarpus bravoanus is common in trade but critically endangered in its natural habitat. With the ultimate aim of developing a certification scheme to aid in the conservation of this species, we have isolated A. bravoanus microsatellites from a nonenriched library. Fifty-four sequences contained a microsatellite array, of which eight were polymorphic among 23 individuals, 20 from one population and three plants from trade.

Hormonal responses to a 160-km race across frozen Alaska

BACKGROUND

Severe physical and environmental stress seems to have a suppressive effect on the hypothalamic-pituitary-gonadal (HPG) axis in men. Examining hormonal responses to an extreme 160-km competition across frozen Alaska provides a unique opportunity to study this intense stress.

OBJECTIVE

To examine hormonal responses to an ultra-endurance race.

METHODS

Blood samples were obtained from 16 men before and after racing and analyzed for testosterone, interleukin-6 (IL-6), growth hormone (GH) and cortisol. Six subjects (mean (SD) age 42 (7) years; body mass 78.9 (7.1) kg; height 1.78 (0.05) m raced by bicycle (cyclists) and 10 subjects (age 35 (9) years; body mass 77.9 (10.6) kg; height, 1.82 (0.05) m) raced by foot (runners). Mean (SD) finish times were 21.83 (6.27) and 33.98 (6.12) h, respectively.

RESULTS

In cyclists there were significant (p< or =0.05) mean (SD) pre-race to post-race increases in cortisol (254.83 (135.26) to 535.99 (232.22) nmol/l), GH (0.12 (0.23) to 3.21 (3.33) microg/ml) and IL-6 (2.36 (0.42) to 10.15 (3.28) pg/ml), and a significant decrease in testosterone (13.81 (3.19) to 5.59 (3.74) nmol/l). Similarly, in runners there were significant pre-race to post-race increases in cortisol (142.09 (50.74) to 452.21 (163.40) ng/ml), GH (0.12 (0.23) to 3.21 (3.33) microg/ml) and IL-6 (2.42 (0.68) to 12.25 (1.78) pg/ml), and a significant decrease in testosterone (12.32 (4.47) to 6.96 (3.19) nmol/l). There were no significant differences in the hormonal levels between cyclists and runners (p>0.05).

CONCLUSIONS

These data suggest a suppression of the hypopituitary-gonadal axis potentially mediated by amplification of adrenal stress responses to such an ultra-endurance race in environmentally stressful conditions.

Genetic mapping of the novel Turnip mosaic virus resistance gene TuRB03 in Brassica napus

A new source of resistance to the pathotype 4 isolate of Turnip mosaic virus (TuMV) CDN 1 has been identified in Brassica napus (oilseed rape). Analysis of segregation of resistance to TuMV isolate CDN 1 in a backcross generation following a cross between a resistant and a susceptible B. napus line showed that the resistance was dominant and monogenic. Molecular markers linked to this dominant resistance were identified using amplified fragment length polymorphism (AFLP) and microsatellite bulk segregant analysis. Bulks consisted of individuals from a BC(1) population with the resistant or the susceptible phenotype following challenge with CDN 1. One AFLP and six microsatellite markers were associated with the resistance locus, named TuRB03, and these mapped to the same region on chromosome N6 as a previously mapped TuMV resistance gene TuRB01. Further testing of TuRB03 with other TuMV isolates showed that it was not effective against all pathotype 4 isolates. It was effective against some, but not all pathotype 3 isolates tested. It provided further resolution of TuMV pathotypes by sub-dividing pathotypes 3 and 4. TuRB03 also provides a new source of resistance for combining with other resistances in our attempts to generate durable resistance to this virus.

Spoligotype diversity of Mycobacterium bovis strains isolated in France from 1979 to 2000

The molecular fingerprints of 1,349 isolates of Mycobacterium bovis received between 1979 and August 2000 at Agence Française de Sécurité Sanitaire des Aliments (Afssa) have been obtained by spoligotyping. The majority of the isolates (1,266) were obtained from cattle living in France. An apparently high level of heterogeneity was observed between isolates. One hundred sixty-one spoligotypes were observed in total, of which 153 were from French isolates. The two predominant spoligotypes, designated BCG-like and GB54, accounted for 26 and 12% of the isolates, respectively. In addition, 84% of the spoligotypes were found fewer than 10 times. Analysis of the results by clustering and parsimony-based algorithms revealed that the majority of the spoligotypes were closely related. The predominant spoligotype was identical to that of the vaccine strain Mycobacterium bovis BCG, which was isolated in France at the end of the 19th century. Some spoligotypes were closely associated with restricted geographical areas. Interestingly, some spoligotypes, which were frequently observed in France, were also observed in neighboring countries. Conversely, few spoligotypes were common to France and England, and those that were shared were observed at very different frequencies. This last point illustrates the potential role for an international data bank, which could help trace the spread of M. bovis across national borders.

Understanding costs of home and community based services

With detailed cost information, home and community-based services (HCBS) providers can make intelligent choices that reduce costs without compromising quality and outcomes. Using cost and utilization data from a large HCBS program, monthly costs are estimated and related to demographic and clinical variables. HCBS costs are positively related to disability and cognitive impairment, but not to available social support. Costs vary significantly across the nursing home-eligible population, indicating that caution is warranted when seeking to capitate HCBS services. Per capita costs are strongly related to program volume and experience, falling from $508 to $423 (16.7 percent) over the course of the program.

Effectiveness of team-managed home-based primary care: a randomized multicenter trial

CONTEXT

Although home-based health care has grown over the past decade, its effectiveness remains controversial. A prior trial of Veterans Affairs (VA) Team-Managed Home-Based Primary Care (TM/HBPC) found favorable outcomes, but the replicability of the model and generalizability of the findings are unknown.

OBJECTIVES

To assess the impact of TM/HBPC on functional status, health-related quality of life (HR-QoL), satisfaction with care, and cost of care.

DESIGN AND SETTING

Multisite randomized controlled trial conducted from October 1994 to September 1998 in 16 VA medical centers with HBPC programs.

PARTICIPANTS

A total of 1966 patients with a mean age of 70 years who had 2 or more activities of daily living impairments or a terminal illness, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD). Intervention Home-based primary care (n=981), including a primary care manager, 24-hour contact for patients, prior approval of hospital readmissions, and HBPC team participation in discharge planning, vs customary VA and private sector care (n=985).

MAIN OUTCOME MEASURES

Patient functional status, patient and caregiver HR-QoL and satisfaction, caregiver burden, hospital readmissions, and costs over 12 months.

RESULTS

Functional status as assessed by the Barthel Index did not differ for terminal (P=.40) or nonterminal (those with severe disability or who had CHF or COPD) (P=.17) patients by treatment group. Significant improvements were seen in terminal TM/HBPC patients in HR-QoL scales of emotional role function, social function, bodily pain, mental health, vitality, and general health. Team-Managed HBPC nonterminal patients had significant increases of 5 to 10 points in 5 of 6 satisfaction with care scales. The caregivers of terminal patients in the TM/HBPC group improved significantly in HR-QoL measures except for vitality and general health. Caregivers of nonterminal patients improved significantly in QoL measures and reported reduced caregiver burden (P=.008). Team-Managed HBPC patients with severe disability experienced a 22% relative decrease (0.7 readmissions/patient for TM/HBPC group vs 0.9 readmissions/patient for control group) in hospital readmissions (P=.03) at 6 months that was not sustained at 12 months. Total mean per person costs were 6.8% higher in the TM/HBPC group at 6 months ($19190 vs $17971) and 12.1% higher at 12 months ($31401 vs $28008).

CONCLUSIONS

The TM/HBPC intervention improved most HR-QoL measures among terminally ill patients and satisfaction among non-terminally ill patients. It improved caregiver HR-QoL, satisfaction with care, and caregiver burden and reduced hospital readmissions at 6 months, but it did not substitute for other forms of care. The higher costs of TM/HBPC should be weighed against these benefits.

The involvement of physicians in VA home care: results from a national survey

OBJECTIVES

To examine the role of physicians in the Veteran Affairs (VA) home-based primary care (HBPC) program and to identify variables that predict whether physicians make home visits and volume of home visits made.

DESIGN

Descriptive and regression analyses of responses from a mail survey.

PARTICIPANTS

Forty-five physicians affiliated with VA HBPC programs. MAIN SURVEY TOPICS: Self-reported work load, attitudes toward home care, reasons for home visits, administrative policies regarding physicians' role in patient care management, and time commitment to home care.

RESULTS

A majority of physicians believed strongly in the importance of home care and made home visits for reasons consistent with their training. Physician attitude toward home care and preoccupation with office or hospital practice were related to whether or not physicians made home visits. Degree of preoccupation with office practice and amount of salary support from VA HBPC were significant predictors of the number of visits made (R2 = 0.44).

CONCLUSIONS

These findings indicate that most physicians will make home visits if they believe that home care is valuable and if their time commitment is supported financially. Managed care plans that own and operate home care programs and have the capacity to transfer primary care management to physicians who derive financial support from the programs should find this information particularly relevant.

Home medical equipment receipt in a home care appropriate population

OBJECTIVES

This study examines home medical equipment (HME) receipt for 1,040 veterans considered appropriate for home health services.

METHODS

HME receipt was monitored for 12 months using the Department of Veterans Affairs' Prosthetics database.

RESULTS

Eighty-three percent received at least one item; averaging 7.4 items (SD = 6.8). The most common items included commodes/bath benches (9%), canes/walkers (7%), safety equipment (7%), liquid oxygen (6%), and wheelchairs (6%). Two functional status variables, home care use and race, correctly classified 69% of HME recipients. Logistic regressions were run for specific equipment; c-indices ranged from .64 to .75. Age, race, income, functional status, risk of hospital readmission, and home care use were significant predictors.

DISCUSSION

HME accounted for $4.5 billion in sales (16% of total) for medical products in 1996. As the HME market continues to expand, the characteristics of HME recipients are necessary to project future HME needs in a growing, elderly population.

Relationship between caregiver burden and health-related quality of life

This study tested the cross-sectional relationship between caregiver burden and health-related quality of life (HRQOL) among 1,594 caregivers of veterans identified to qualify for formal home care. A two-stage model found that familial relationship, coresidence, and low income predicted objective burden. Coresidence also predicted subjective burden, whereas being African American was protective. In the full model, spousal relationship, low income, and burden were associated with poor HRQOL scores. Total variance explained in HRQOL ranged from 14% to 29%, with objective burden contributing more than subjective burden. These findings suggest a direct effect of objective burden on caregiver HRQOL, indicating a need among caregivers for assistance in caring for disabled family members.

Nursing facilities and managed care

OBJECTIVE

To examine the extent to which Illinois nursing facilities have developed relationships with other healthcare providers, particularly managed care organizations (MCOs).

STUDY DESIGN

A cross-sectional survey of nursing facilities designed to determine: 1) relationship objectives; 2) obstacles to developing relationships; 3) currently available services; 4) staffing for these services and; 5) nursing facility approaches to networking. The survey was sent to a census sample of 867 nursing facilities serving the elderly in Illinois. Descriptive and multivariate logistic regression analyses of relationships determined to be formal/risk-sharing were performed.

STUDY POPULATION

The sample included 523 Illinois nursing facilities. A total response rate of 60% was achieved (523/867).

RESULTS

Higher strategic goals, urban location, nonprofit ownership status, higher percentages of private pay and/or Medicare clients (vs Medicaid), and provision of home care and subacute services were all significant predictors of formal or risk-sharing relationships with MCOs.

CONCLUSIONS

Facilities with more relationships and higher goals have more formal/risk-sharing relationships with MCOs. Facilities in urban areas have more relationships, likely due to the fact that rural facilities have fewer options and operate in different markets. In addition, nursing facilities rely on Medicare referrals from hospitals, and these Medicare patients, especially those in urban areas, are increasingly controlled by MCOs.

Impact of joint impairment on disability-specific domains at four years

The objective of this study was to assess the longitudinal impact of joint impairment on overall disability and crossing domain-specific thresholds for physical activity, mobility, dexterity, instrumental activities of daily living (IADL), and activities of daily living (ADL) that are associated with use of long-term care. This 4-year longitudinal study observed 484 persons older than age 60. Logistic regression assessed the contribution of demographics, psychological mediators, lower- and upper-extremity joint impairment, and comorbidities to increased domain-specific self-reported disability above a threshold associated with use of long-term care. Lower-extremity joint impairment and age predicted crossing thresholds by year 4 in physical activity, mobility, IADL, and ADL disability that were associated with use of long-term care. Lower-extremity joint impairment is a strong risk factor for future disability that is associated with use of long-term care.

Impact of home care on hospital days: a meta analysis

OBJECTIVE

To examine the impact of home care on hospital days.

DATA SOURCES

Search of automated databases covering 1964-1994 using the key words "home care," "hospice," and "healthcare for the elderly." Home care literature review references also were inspected for additional citations.

STUDY SELECTION

Of 412 articles that examined impact on hospital use/cost, those dealing with generic home care that reported hospital admissions/cost and used a comparison group receiving customary care were selected (N = 20).

STUDY DESIGN

A meta-analytic analysis used secondary data sources between 1967 and 1992.

DATA EXTRACTION

Study characteristics that could have an impact on effect size (i.e., country of origin, study design, disease characteristics of study sample, and length of follow-up) were abstracted and coded to serve as independent variables. Available statistics on hospital days necessary to calculate an effect size were extracted. If necessary information was missing, the authors of the articles were contacted.

METHODS

Effect sizes and homogeneity of variance measures were calculated using Dstat software, weighted for sample size. Overall effect sizes were compared by the study characteristics described above.

PRINCIPAL FINDINGS

Effect sizes indicate a small to moderate positive impact of home care in reducing hospital days, ranging from 2.5 to 6 days (effect sizes of -.159 and -.379, respectively), depending on the inclusion of a large quasi-experimental study with a large treatment effect. When this outlier was removed from analysis, the effect size for studies that targeted terminally ill patients exclusively was homogeneous across study subcategories; however, the effect size of studies that targeted nonterminal patients was heterogeneous, indicating that unmeasured variables or interactions account for variability.

CONCLUSION

Although effect sizes were small to moderate, the consistent pattern of reduced hospital days across a majority of studies suggests for the first time that home care has a significant impact on this costly outcome.

Partial identification of spirochaetes from two dairy cows with digital dermatitis by polymerase chain reaction analysis of the 16S ribosomal RNA gene

Specimens taken postmortem from typical lesions of digital dermatitis in two dairy cows were tested by the polymerase chain reaction (PCR) for the presence of a spirochaetal 16S rRNA gene. Seven different assays detected the gene in the samples from both cows. Two of the PCR products were sequenced and a comparison of the nucleotide sequences revealed that the spirochaete belonged to the genus Treponema and was closely related to Treponema denticola. A PCR specific for the detection of the digital dermatitis-associated treponeme was developed.

Disability in activities of daily living: patterns of change and a hierarchy of disability

OBJECTIVES

This paper examines longitudinal data over 6 years to evaluate incidence rates of disability and the pattern of dependency in activities of daily living.

METHODS

The Longitudinal Study of Aging (n = 5151) was used to evaluate incidence of disability in activities of daily living; biennial interview data from 1984 through 1990 were used. The median age to disability onset for individual activities was estimated from survival analysis. A prevalent ordering of incident disability was identified from patterns of disability onset within individuals.

RESULTS

The progression of incident disability among the elderly supported by longitudinal data, based on both the ordering of median ages to disability onset and patterns of incident disability, was as follows: walking, bathing, transferring, dressing, toileting, feeding. Gender differences were found in disability incidence rates.

CONCLUSIONS

This study provides a mathematical picture of physical functioning as people age. These findings, based on longitudinal data, indicate a different hierarchical structure of disability than found in previous reports using cross-sectional data. Furthermore, the study documents gender differences in incident impairment, which indicate that although women outlive men, they spend more time in a disabled state.

Evaluation of a prospective payment system for VA contract nursing homes

An evaluation of a pilot program for community nursing home care reimbursement by Department of Veterans Affairs Medical Centers (VAMCs) was undertaken. Eight VAMCs began using the Enhanced Prospective Payment System (EPPS) in 1992. These sites were compared to eight customary payment sites in a pretest/posttest quasi-experimental design. Outcomes included access to care, administrative workload, quality of care, and cost. As expected, per diem costs were significantly higher for EPPS than customary reimbursement patients ($106 vs. $87). However, EPPS sites placed veterans more quickly (81 days vs. 113 days; p < .01) than comparison sites and reduced administrative workload associated with placement. EPPS sites also increased the number of Medicare-certified homes under contract (76% vs. 54%) and placed significantly more veterans who received therapy (20% vs. < 1%). Savings in hospital days more than offset the increased cost of nursing home placement. Because the findings were attributed largely to a few veterans with long lengths of hospital stay, the early success of EPPS may diminish as the backlog of these long-stay patients decreases.

The prevalence and impact of arthritis in older persons

OBJECTIVE

To review that what is known about the prevalence and impact of arthritis on disability and health care expenditures incurred by older persons.

METHODS

The current prevalence estimates of osteoarthritis and osteoporosis in the US are examined, and what is known about the relationship of arthritis, broadly defined to disability, and the impact of arthritis-specific disability on home care and nursing home use by older persons are reviewed.

RESULTS

Arthritis is a major contributor to disability among older people and is especially disabling for older women, who have higher prevalence rates and greater disability than their male counterparts. Studies of the relationship of arthritis to long-term care use indicate that arthritis can be a risk factor insofar as it can cause disability that results in homeboundedness, which, in turn is a risk factor for nursing home use. It is possible that previous analyses that included arthritis and disability as competing risk factors for nursing home use underestimate the contribution of arthritis because arthritis is a risk factor for disability; thus, the two variables may be strongly correlated.

CONCLUSIONS

More study is needed to understand the contribution of sex to prevalence of arthritis and severity of arthritis-specific disability. The route through which arthritis affects long-term care use also needs careful longitudinal study. If arthritis is confirmed to be a major risk factor for disability that leads to long-term care use, the development and testing of interventions to prevent/minimize arthritis-specific disability should be a major research priority.

Organizational characteristics, client characteristics, and the delivery of home care services

This research examines the extent to which organizational professional orientation, client perceived needs, and client characteristics jointly determine long-term care service delivery to a frail elderly population. The study uses primary data collected from 16 community networks that were part of a national demonstration of the Living at Home Program, conducted from 1986 to 1989. Data include baseline assessments of individuals enrolled at each site, subsequent utilization data, and data on community network characteristics. Site professional orientation has a significant role in determining services provided to clients, with social service agencies more likely to provide nonmedical services and less likely to provide skilled-care services. Despite systematic site variation in the services provided to individuals, sites appear to reasonably allocate resources among individuals with differing levels of functional disability.

Epizootic bovine abortion in a dairy herd: characterization of a Chlamydia psittaci isolate and antibody response

A chlamydial agent was recovered from the placental cotyledons of an aborting cow from a 100-cow dairy herd in Cumbria. Immunoblotting analysis of purified elementary bodies of the isolate revealed a reactivity pattern typical of serotype I Chlamydia psittaci strains. Nucleotide sequencing of the major outer membrane protein (MOMP) gene further confirmed the isolate, BA1, as a serotype I strain. The sequence was identical to that of the type strain of ovine enzootic abortion, B577. In both the antigenic and MOMP sequencing analyses BA1 was distinguishable from serotype II C. pecorum strains. A sequential series of sera obtained from the aborting cow, from which BA1 was recovered, was analysed by immunoblotting against the homologous isolate, and demonstrated reactivity to major chlamydial antigens over a 110-day period. Close contact between ruminant species on the farm suggested that the C. psittaci strain may have been transmitted to cattle from infected sheep.

An empirical typology of subjects within stage of change

The transtheoretical model of behavior change postulates five distinct, well-defined stages of change: Precontemplation, Contemplation, Preparation, Action, and Maintenance. Each stage has been regarded as reflecting a motivational posture and treated as if it is homogenous with respect to membership. This paper reports the results of four cluster analytic studies, one within each of the first four stages of change. The cluster analysis was based on three constructs of the model. Four distinct subtypes were found within Contemplation, Preparation, and Action, and three subtypes were found within Precontemplation. External validation for the clusters was provided using the 10 Processes of Change and 8 behavioral measures as dependent measures. At least one subtype corresponded to the existing stage definition but the other subtypes suggested alternative intervention strategies.

Predicting agency participation in interorganizational networks providing community care

In response to health care reform, health care providers have begun to develop interorganizational networks. At present, however, relatively little is known about factors facilitating participation in networks. To this end, organizational characteristics and views were obtained from key informants from both "Lead" and "Affiliate" Agencies participating in the networks for the Living-at-Home Program (LAHP) Demonstration (N = 131) using an Organizational Change Survey. Logistic regression analysis was used to examine factors related to network member agencies' participation. Significant relationships were found between decreased participation and lack of agreement between network agencies regarding expectations (P = 0.02), membership in a network with a Medical Lead Agency (P < 0.01), and Lead Agency inexperience (P < 0.01). Agencies with lower ratings of the impact that LAHP had on their community were more likely to decrease their participation (P = 0.01). The number of unoccupied nursing home beds in the community was positively and significantly related to decreased participation (P < 0.001). These results suggest that leadership skills of the Lead Agency, and in particular, experience, may be among the chief requirements for the creation and development of successful networks, and confirm that inexperienced Lead Agencies may face an uphill battle in terms of recruiting and maintaining network members.

Predictors of hand function in older persons: a two-year longitudinal analysis

OBJECTIVE

To validate a hierarchical model of hand function in older persons, using longitudinal data.

DESIGN

Longitudinal observational study (2-year data from an ongoing longitudinal study).

SUBJECTS

689 persons older than age 60, including Continuing Care Retirement Community (n = 230), homebound (n = 204), and ambulatory (n = 255) respondents. Mean age at baseline 76.6 (SD = 8.8).

MEASUREMENT

Independent variables included sociodemographics, physician measures of upper joint impairment, self-reported comorbidity, arthritis pain, depression, and anxiety. The dependent variables included grip strength and a timed manual performance test.

MAIN RESULTS

Using generalized estimated equations (GEE) to test our hierarchial model, we found that gender and upper extremity joint impairment were the strongest predictors of a longitudinal measure of grip strength. Grip strength, in turn, along with demographics, comorbidity, and a measure of psychological status, was significantly related to timed manual performance.

CONCLUSIONS

The longitudinal analyses confirmed a previous cross-sectional finding that upper extremity joint impairment contributes significantly to reduced grip strength, which, in turn, contributes to reduced hand performance on a timed test.

A profile of Department of Veterans Affairs hospital based home care programs

This paper describes the Department of Veterans Affairs (VA) home care program and compares it to community-based programs. Structure and process data were collected on hospital based home care programs in VA facilities nationwide (n=75). Supplemental data were obtained on staffing and patient attributes. Although the VA provides program guidelines, some variability was noted. The characteristics of VA programs and patients were then compared to National Center for Health Statistics survey data. This comparison revealed that VA programs provide a more comprehensive array of services to patients including physician home visits than most community-based programs.

Impact of joint impairment on longitudinal disability in elderly persons

Recent longitudinal data indicating that arthritis is a major contributor to disability in elderly persons are based on self-reported diagnostic information. This longitudinal study included baseline physical examinations of joints of 541 persons over age 60. Previous results from a cross-sectional multivariate model of disability in this sample found that joint impairment (and, its absence, arthritis pain) explained a significant proportion of variance in overall disability. We have retested this model using generalized estimation equations (GEE) analysis to estimate the effect of joint impairment and arthritis pain on baseline and Year 2 disability. Findings indicate that baseline joint impairment contributes substantially to longitudinal disability. If direct measures of baseline joint impairment are unavailable, concurrent self-reported arthritis pain also predicts longitudinal disability well. These findings indicate that longitudinal studies should monitor arthritis pain and that symptomatic arthritis is a risk factor for future disability.

Estimates and determinants of valid self-reports of musculoskeletal disease in the elderly

This study examined the extent and nature of bias associated with self-reported versus standardized physician-examination/assessment-based accounts of musculoskeletal disease in a sample of 406 persons chosen to represent an aging and dependency continuum. Prevalence of musculoskeletal disease based on standardized physician examination/assessments was 97%. Using the standardized findings as the criterion, the self-report underestimated prevalence by 16%. Overall, the results indicated that self-reports of musculoskeletal conditions by the elderly capture the vast majority of persons with painful or functionally significant disease and are most valid for persons from ages 65 to 74 but do not reflect the presence of asymptomatic joint pathology. Standardized physician examinations/assessments would more accurately determine the presence of risk factors in epidemiological studies of musculoskeletal disability.

Classification of adult day care: a cluster analysis of services and activities

Using data from a 1986 national census survey of 774 adult day care (ADC) centers, this study (a) determined whether distinct classes of ADC could be identified based on measures of program services and activities, and (b) delineated the distinguishing characteristics of such classes on other available measures of structure, process, and client population. A cluster analysis of 10 "process" measures of services and activities identified 6 classes of ADC centers: Alzheimer's Family Care, Rehabilitation, High Intensity Clinical/Social, Moderate Intensity Clinical/Social, General Purpose, and Low Scoring. Validity was examined by developing a set of expectations for pairs of classes on other available variables. Of 12 expectations, 11 were supported by the statistical tests. Finally, profiles of the 6 classes were developed to describe the classes on 30 other characteristics. The findings clarify the settings to which previous ADC studies are generalizable and indicate a need for effectiveness studies on special classes of ADC.

Cognitive predictors of suicide risk among hospitalized psychiatric patients: a prospective study

This prospective study examined the utility of several cognitive variables as predictors of suicide risk among 79 hospitalized psychiatric patients. These variables included pessimism (measured by the Hopelessness Scale), perceived and actual problem-solving ability (indexed by the Problem-Solving Inventory and Means-End Problem-Solving test, respectively), and polarized thinking, self-negativity, and construct system constriction and differentiation (derived from a repertory grid). Suicide risk was operationalized in terms of subsequent self-report of suicide ideation and staff records of time spent on suicide precautions. Results indicated that hopelessness, self-negativity, and poor problem-solving performance functioned as reliable predictors of suicide risk, whereas self-evaluated problem-solving ability did not. Interestingly, constriction emerged as a significant inverse predictor across.

Joint impairment and self-reported disability in elderly persons

Recent findings indicating that arthritis is a major contributor to disability in elderly persons are based on self-reported diagnostic information. We conducted physical examinations of the joints at baseline on 541 older persons. We then tested a multivariate model of total/generic disability which included respondent group, demographic and chronic disease variables (joint impairment and comorbid conditions), arthritis pain, and psychological status. Hierarchical multiple regression found that the model explained 55 percent (adjusted R2 = .55) of the variance in baseline disability with joint impairment accounting for 15 percent (change in R2 = .15) of the variance. When joint impairment was removed from the model, arthritis pain worked well as a surrogate. Together, these findings strongly support the importance of musculoskeletal disease in explaining disability in the elderly population.

A medicare adult day care model: proposed criteria and available supply

The study on which this article is based addressed the issue of the proportion of adult day care centers (ADCs) existing in 1986 that would qualify for Medicare funding under the 1989 U.S. Senate Medicare Adult Day Care Amendments. It also estimated the impact of the criteria on two policy-relevant subgroups of ADCs-that is, Alzheimer's vs. non-Alzheimer's and rural vs. urban-using data from a 1986 national census survey of ADCs. The five proposed Medicare criteria and the percentage of ADCs meeting them were: services to be provided directly, 14.6%; multi-disciplinary team, 20%; services to be provided directly or indirectly, 16%; program activities, 42%; and other, 53%. Only 3% met all five criteria while 13% met four out of five. Alzheimer's centers met the criteria more often than non-Alzheimer's centers, while urban centers qualified more often than rural centers. Based on the findings, implications for Medicare funding policy are discussed.

Program factors that influence utilization of adult day care

Health planners, policymakers, and providers urgently require methods and information that explain the factors that affect health services utilization. This information is especially critical for planning programs that are effective in maintaining the burgeoning elderly population in community care. In this study, correlation and regression analyses examined the characteristics of adult day care (ADC) centers that were associated with utilization as operationalized by demand for and actual attendance in 822 centers. Community, client population, services and activities, and structural characteristics were associated with demand per center whereas the social environment of the ADC center was not. The attendance rate was most strongly affected by services and activities and structural characteristics. The significance of the study, its limitations, and future directions for research are discussed.

Joint impairment and hand function in the elderly

OBJECTIVE

To test the contribution of joint impairment to observed hand function (grip strength and Williams Test) in the elderly, using a multivariate model.

DESIGN

Cross-sectional observational data (baseline data from an ongoing longitudinal study).

SUBJECTS

Five hundred forty-one persons over age 60, including continuing care retirement community (n = 222), homebound (n = 72), and ambulatory (n = 247) respondents. Mean age at assessment 76.7, (SD = 9.0).

MEASUREMENT

Independent variables included sociodemographics, physician measures of upper joint impairment, an index of comorbidities derived from physical examination or chart abstract, self-assessed arthritis pain, depression, and anxiety. The dependent variables included grip strength and a modified Williams Test [Williams Test (M)].

MAIN RESULTS

The multiple regression explained 59% (Adjusted R2 = .59) of the variance in grip strength, with joint impairment accounting for a change in R2 of .07. Upper joint impairment and grip strength accounted for 3% and 5%, respectively, of the variance in the Williams Test (M) (total amount of explained variance = 45%).

CONCLUSIONS

Demographics explain most of the variance in grip strength and performance on the Williams Test (M). Controlling for demographics, musculoskeletal disease represented by joint impairment is associated with diminished grip strength. Reduced grip strength is associated with poorer performance on the Williams Test (M).

Self-reported functional status predicts change in level of care in independent living residents of a continuing care retirement community

OBJECTIVE

To test the hypothesis that self-reported functional status predicts change in level of care from independent to dependent in residents of a continuing care retirement community (CCRC).

DESIGN

Two-year longitudinal descriptive study of change in level of care and survival.

SUBJECTS

One hundred fifty-two residents in the independent-living unit of a non-profit CCRC. Mean age at initial evaluation was 82.3 years, SD 6.2.

MEASUREMENT

Predictor variables assessed at baseline were age, sex, physician estimate of functionally significant disease, self-reported functional status, and performance-based hand function. Criterion variables collected at 2-year follow-up were level of care (independent/dependent) and survival (alive/dead).

MAIN RESULTS

Self-reported functional status (P less than 0.01) and age (P less than 0.05) were significant predictors of change in level of care in a logistic regression analysis containing all predictor variables. No variable predicted survival.

CONCLUSIONS

Self-reported functional status may help to predict dependency in older adults in good health who have few markers of dependency risk.

A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill

All admissions to a 1,100-bed Department of Veterans Affairs (VA) hospital were screened to identify 171 terminally ill patients with informal caregivers who were then randomly assigned to VA hospital-based team home care (HBHC, N = 85) or customary care (N = 86). Patient functioning, and patient and caregiver morale and satisfaction with care were measured at baseline, one month, and six months. Health services utilization was monitored over the six-month study period and converted to cost. Findings included no differences in patient survival, activities of daily living (ADL), cognitive functioning, or morale, but a significant increase in patient (p = .02) and caregiver (p = .005) satisfaction with care at one month. A substitution effect of HBHC was seen. Those in the experimental group used 5.9 fewer VA hospital days (p = .03), resulting in a $1,639 or 47 percent per capita saving in VA hospital costs (p = .02). As a result, total per capita health care costs, including HBHC, were $769 or 18 percent (n.s.) lower in the HBHC sample, indicating that expansion of VA HBHC to serve terminally ill veterans would increase satisfaction with care at no additional cost.

The GERI-AIMS. Reliability and validity of the arthritis impact measurement scales adapted for elderly respondents

We adapted the Arthritis Impact Measurement Scales (AIMS) for use with frail elderly respondents. The new instrument, called the GERI-AIMS, generates both generic and arthritis-specific impairment scores, to control for comorbid conditions that are commonly found in an older population. An analysis of scores obtained on 438 elderly persons (mean age 76) indicated that more than half of the total disability measured by the generic GERI-AIMS scores is related to arthritis. The GERI-AIMS scales have standardized-item alpha levels greater than 0.70 and correlate well with clinical measures of arthritis severity. Information gained by using the GERI-AIMS has important public policy implications, insofar as information on both generic and disease-specific functional impairment is needed to establish priorities for basic research, epidemiologic, and intervention studies.

Self report and performance-based hand function tests as correlates of dependency in the elderly

Preventing or minimizing functional dependency in older adults rests, in part, upon the ability to predict who is at risk. The purpose of this study was to compare the ability of five tests of hand function to discriminate the degree of dependency in older adults. Seven hundred sixty four subjects were assessed for hand function on performance-based (Williams Test of Hand Function, a test of Williams Board items only, Jebsen Test of Hand Function, grip strength), and self-reported (Dexterity Scale of the Geriatrics-Arthritis Impact Measurement Scale (GERI-AIMS] measures of hand function, and self-reported multidimensional functional status (GERI-AIMS). A trichotomous variable representing a continuum of dependency based upon living site (independent living, home-bound, institutional) was used as the measure of dependency. Sixty-two cases were dropped for incomplete data. Discriminant function analyses of the 702 subjects (age X = 76.78 years, SD = 8.79) showed that basic demographic variables explain 40.8% of the variance in dependency; all hand function tests significantly correlated with dependency; the Williams Board correlated best (additional 12.5% variance explained). However, a multidimensional functional status measure explains substantially more variance in dependency (16.9%) after controlling for demographic variables and performance on the Williams Board. This comparison of methods and tests available for measuring hand function was made to provide criteria for selecting an instrument for a given setting.

Screening elderly veterans for alcoholism

OBJECTIVE

To determine the sensitivity and specificity of an alcoholism screening test not previously tested in the elderly.

DESIGN

Cross-sectional study, face-to-face interviews.

SETTING

Veterans Administration (VA) outpatient facility.

PATIENTS/PARTICIPANTS

Men greater than or equal to 70 years old seeking care in a newly established VA outpatient facility were invited to participate in a health assessment program. Of 109 participants who enrolled, 96 completed both interviews.

INTERVENTIONS

The screening test was administered by an internist as part of a medical history. The Michigan Alcoholism Screening Test (MAST), used as the "gold standard," was administered by a trained interviewer as part of a longer structured interview.

MEASUREMENTS AND MAIN RESULTS

The screening test had a sensitivity of 0.52 and a specificity of 0.76 in this sample.

CONCLUSIONS

The sensitivity and specificity of the screening test were lower in this sample in comparison with previously reported results in a younger population. Differences in the test performance may be related to differences in attitudes and drinking behaviors of elderly veterans when compared with those of younger men and women.

Cost-effectiveness of Veterans Administration hospital-based home care. A randomized clinical trial

A randomized design was used to examine the cost-effectiveness of a Veterans Administration hospital-based home care program that case managed inpatient and outpatient care. Patients (N = 419) with two or more functional impairments or a terminal illness were randomized to hospital-based home care (n = 211) or customary care (n = 208). Functional status, satisfaction with care, and morale were measured at baseline and at 1 and 6 months after discharge from the hospital; health care utilization was tracked for 6 months. Findings included significantly higher (0.1 on a three-point scale) patient and caregiver satisfaction with care at 1 month and lower Veterans Administration and private sector hospital costs ($3000 vs $4245) for the experimental group. Net per person health care costs were also 13% lower in the experimental group. We conclude that this model of hospital-based home care is cost-effective and that its expansion to cover these two patient groups throughout the Veterans Administration system can improve patient care at no additional cost.

Survey of adult day care in the United States. National and regional findings

Before attempting to understand how a relatively new treatment modality such as adult day care (ADC) works, it is useful to understand what it is. To this end, this article describes the structural characteristics of ADC centers and the characteristics of ADC users in the United States and across the four U.S. census regions. A 1986 national census survey of 1,347 ADC centers yielded 974 usable responses (72.3%). Findings indicated that there is great variability in characteristics of ADC across the country. In general, ADC's are well-staffed, well-linked to other agencies, and well-equipped. However, demand and enrollment appeared low. A need for improved oversight and staff in-service training was indicated for a substantial proportion of centers. These and other findings provide the most detailed and comprehensive national and regional descriptions of ADC available to date.

A randomized trial of Veterans Administration home care for severely disabled veterans

This randomized study screened hospital admissions to all wards except Psychiatry and Spinal Cord Injured during a 3-year period to identify 233 severely disabled patients (2 impairments on the Katz Index of ADL) and caregivers who were willing to participate in a pretest-multiple posttest trial of the Hines VA Hospital-based Home Care (HBHC) Program. Patient functional status, morale, and satisfaction with care were measured at baseline, 1 month and 6 months post discharge. Caregiver satisfaction and morale were assessed at the same time periods. All health care services used by both groups were tracked over the 6-month period and converted to cost. Findings include improved 1-month satisfaction with care (P = 0.04) and improved 6-month cognitive functioning (P = 0.04) among HBHC patients and improved 1-month (P = 0.04) and 6-month satisfaction with care (P less than 0.01) among their caregivers. A nonsignificant 10% decrease in net cost of care, was found in the treatment group, largely due to lower use of private sector hospital care.

Impact of long-term home care on mortality, functional status, and unmet needs

This article reports the outcomes of a four-year follow-up evaluation of the Five Hospital Program, a long-term home care program in Chicago. Outcomes assessed include the mortality, comprehensive functional status, and perceived unmet needs of its frail elderly clientele (mean age 81 years at entry). The evaluation utilized a pretest, multiple posttest design with a comparison group consisting of similarly elderly and impaired individuals receiving OAA Title III-C home-delivered meals. Consecutively accepted treatment (N = 157) and comparison group clients (N = 156) were interviewed using the OARS Multidimensional Functional Assessment Questionnaire at baseline, 9 months, and 48 months after acceptance to care. A multivariate analysis of mortality rates revealed no between-group differences attributable to treatment on this outcome. Major findings included significantly better cognitive functioning and reduced unmet needs in the treatment group at nine months. A longer-range, continued beneficial effect of treatment on cognitive status was also observed at 48 months. We conclude that long-term home care provided important benefits to clients at both 9 and 48 months, with no effect on mortality. However, we suggest that the four-year findings be interpreted with caution, since only a small percentage of clients (18 percent) were still alive and receiving active care in the community at that time.

Impact of long-term home care on hospital and nursing home use and cost

This article reports the long-range impact of a long-term home care program in Chicago on hospital and nursing home use and on overall health care costs over four client-years of observation. The evaluation utilized a quasi-experimental design with a comparison group composed of clients who received home-delivered meals. The health services utilization experience of consecutively accepted treatment (N = 157) and comparison group (N = 156) subjects was monitored for 48 client-months following acceptance to care. Imputed costs were then assigned to each type of care measured. Findings include a significantly lower risk of permanent admission to sheltered and intermediate-level nursing home care in the treatment group but no difference in risk of permanent admission to skilled-level nursing home care. Despite savings in low-intensity nursing home days, preliminary findings indicate that total costs of care were 25 percent higher in the treatment group. However, these costs are accompanied by significant quality-of-life benefits in the treatment group (reported elsewhere).

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans. Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 +/- 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p less than .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p less than .05). Penetrating injury did not increase the risk of sinusitis (p greater than .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.

Diversification of health care services: the effects of ownership, environment, and strategy

The present findings suggest that the trend toward greater diversification of hospital services is likely to be most strongly influenced by state Medicaid policies and certain hospital characteristics. Increasing Medicaid eligibility and payment levels is likely to have a positive effect on services diversification. Growth in the number of inpatient services provided and a more severe case mix are also likely to be involved with greater service diversification. Affiliation with a not-for-profit hospital system is likely to be associated with more diversified hospital services but not affiliation with an investor-owned system. There is also some indication that the overall portfolio of services which a hospital offers in regard to market share and market growth characteristics influences diversification. Specifically, a low market share portfolio is likely to be associated with less diversification. Competition is likely to be associated with more diversification; particularly for hospitals belonging to systems. The effect of competition on hospital strategy and services diversification is a particularly important area for further investigation. Increasing Medicaid payment and eligibility levels are also likely to have a positive effect on the provision of services which are usually unprofitable. Raising such levels is likely to be particularly beneficial to inner-city hospitals who are already providing a greater number of such services. However, the present data suggest that investor-owned hospitals are least likely to provide such services. Increasing Medicaid eligibility levels is also likely to be associated with fewer services for which charity care has to be provided. State regulation in the form of rate review and certificate of need is likely to be associated with more services for which hospitals provide some charity care. But such policies alone do not deal with the larger issue of how to finance care for the medically indigent. Present data suggest the charity care issue may be particularly salient in markets characterized by a relatively high degree of competition. Finally, investor-owned hospitals provide as many services involving charity care as not-for-profit system hospitals, although investor-owned system hospitals provide fewer such services than not-for-profit freestanding hospitals. Throughout, the findings indicate the importance of distinguishing between ownership and system affiliation. Previous research has failed to make a distinction between ownership form and system affiliation, thus attributing to ownership form differences which, as present findings suggest, appear to be more associated with system affiliation.(ABSTRACT TRUNCATED AT 400 WORDS)

Use of nursing homes by a high-risk long-term care population

Limited information exists concerning lifetime use of nursing home services by the aged. This article examines the longitudinal experience, over four years, of elderly individuals at high risk of institutionalization, and develops a simple model of nursing home use based on these observations. This model allows us to predict future lifetime use under alternative assumptions. The main observations drawn from this sample are that high-risk elderly tend to move from the community to nursing homes, but not back to the community except for short, transitional stays. Further, despite high overall mortality rates, the expected nursing home use by these high-risk elderly is very high, due to long average stays by a minority of the sample that enters a nursing home and remains there longer than six months.