The Prevalence of Cognitive Impairment Among Medicare Beneficiaries Who Use Outpatient Physical Therapy

OBJECTIVE

The objective of this study was to estimate the prevalence of cognitive impairment (including cognitive impairment no dementia [CIND] and dementia) among Medicare fee-for-service beneficiaries who used outpatient physical therapy and to estimate the prevalence of cognitive impairment by measures that are relevant to rehabilitation practice.

METHODS

This cross-sectional analysis included 730 Medicare fee-for-service beneficiaries in the 2016 wave of the Health and Retirement Study with claims for outpatient physical therapy. Cognitive status, our primary variable of interest, was categorized as normal, CIND, or dementia using a validated approach, and population prevalence of cognitive impairment (CIND and dementia) was estimated by sociodemographic variables and Charlson comorbidity index score. Age-, gender- (man/woman), race-/ethnicity-adjusted population prevalence of CIND and dementia were also calculated for walking difficulty severity, presence of significant pain, self-reported fall history, moderate-vigorous physical activity (MVPA) ≤1×/week, and sleep disturbance frequency using multinomial logistic regression.

RESULTS

Among Medicare beneficiaries with outpatient physical therapist claims, the prevalence of any cognitive impairment was 20.3% (CIND:15.2%, dementia:5.1%). Cognitive impairment was more prevalent among those who were older, Black, had lower education attainment, or higher Charlson comorbidity index scores. The adjusted population prevalence of cognitive impairment among those who reported difficulty walking across the room was 29.8%, difficulty walking 1 block was 25.9%, difficulty walking several blocks was 20.8%, and no difficulty walking was 16.3%. Additionally, prevalence of cognitive impairment among those with MVPA ≤1×/week was 27.1% and MVPA >1×/week was 14.1%. Cognitive impairment prevalence did not vary by significant pain, self-reported fall history, or sleep disturbance.

CONCLUSION

One in 5 older adults who use outpatient physical therapist services have cognitive impairment. Furthermore, cognitive impairment is more common in older physical therapist patients who report worse physical function and less physical activity.

IMPACT

Physical therapists should consider cognitive screening for vulnerable older adults to inform tailoring of clinical practice toward a patient's ability to remember and process rehabilitation recommendations.

Health care utilization and costs in the years preceding dementia identification

INTRODUCTION

There is evidence that health care utilization increases after incident dementia, particularly after dementia diagnosis and toward the end of life; however, less is known about utilization in the years before dementia identification.

METHODS

In this retrospective cohort study we obtained data on n = 5547 beneficiaries from the Health and Retirement Study (HRS)-Medicare linked sample (n = 1241 with and n = 4306 without dementia) to compare longitudinal trends in health care costs and utilization in the 6 years preceding dementia identification relative to a confounder-balanced reference group without dementia.

RESULTS

We found that persons with dementia had a greater prevalence of outpatient emergency department (ED), inpatient hospital, skilled nursing, and home health use, and total health care costs in the years preceding dementia identification compared to their similar counterparts without dementia across a comparable timespan in later life.

CONCLUSIONS

This study provides evidence to suggest greater healthcare burden may exist well before clinical manifestation and identification of dementia.

HIGHLIGHTS

Several studies have documented the tremendous healthcare-related costs of living with dementia, particularly toward the end of life. Dementia is a progressive neurodegenerative disease, which, for some, includes a prolonged pre-clinical phase. However, health services research to date has seldom considered the time before incident dementia. This study documents that health care utilization and costs are significantly elevated in the years before incident dementia relative to a demographically-similar comparison group without dementia.

Declines in Wealth Among US Older Adults at Risk of Dementia

This case-control study uses Health and Retirement Study data to examine the trajectories of wealth among US older adults at risk of dementia.

Paid Care for People with Functional Impairment and Serious Illness: Results from the Health and Retirement Study

BACKGROUND

Paid caregivers (e.g., home health aides) care for individuals living at home with functional impairment and serious illnesses (health conditions with high risk of mortality that impact function and quality of life).

OBJECTIVE

To characterize those who receive paid care and identify factors associated with receipt of paid care in the context of serious illness and socioeconomic status.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Community-dwelling participants ≥ 65 years enrolled in the Health and Retirement Study (HRS) between 1998 and 2018 with new-onset functional impairment (e.g., bathing, dressing) and linked fee-for-service Medicare claims (n = 2521).

MAIN MEASURES

Dementia was identified using HRS responses and non-dementia serious illness (e.g., advanced cancer, end-stage renal disease) was identified using Medicare claims. Paid care support was identified using HRS survey report of paid help with functional tasks.

KEY RESULTS

While about 27% of the sample received paid care, those with both dementia and non-dementia serious illnesses in addition to functional impairment received the most paid care (41.7% received ≥ 40 h of paid care per week). In multivariable models, those with Medicaid were more likely to receive any paid care (p < 0.001), but those in the highest income quartile received more hours of paid care (p = 0.05) when paid care was present. Those with non-dementia serious illness were more likely to receive any paid care (p < 0.001), but those with dementia received more hours of care (p < 0.001) when paid care was present.

CONCLUSIONS

Paid caregivers play a significant role in meeting the care needs of those with functional impairment and serious illness and high paid care hours are common among those with dementia in particular. Future work should explore how paid caregivers can collaborate with families and healthcare teams to improve the health and well-being of the seriously ill throughout the income spectrum.

Heart failure with comorbid dementia: Association with clinical characteristics and outcomes

BACKGROUND

Heart failure (HF) and dementia both have profound effects on function and mortality in older persons. However, we have limited knowledge about the impact of co-occurring HF and dementia. Our goal was to understand how often persons with HF have dementia and the impact of their co-occurrence.

METHODS

Retrospective analysis of participants (age > 65) in the 2015 wave of the nationally representative Health and Aging Trends Study (NHATS) with linkage to Medicare claims. 912 participants with HF (45% older than 80, 51% women) using Medicare claims. We used the validated NHATS dementia algorithm to identify those with probable dementia. Outcomes of interest included the need for help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) at baseline, functional decline, hospitalization over 1 year, and mortality over 2-years. Baseline functional status, functional decline, and hospitalization were compared using adjusted logistic regression, mortality was analyzed using adjusted Cox regression models adjusted for demographics, socio-economic status, baseline health, and baseline functional status.

RESULTS

200 (21%) of the participants with HF also had dementia. For each I/ADL, patients with both HF and dementia were more likely to need help than those with HF without dementia. 71.8% of participants with HF and dementia needed help with medications versus 16.6% with HF without dementia (p < 0.001). Having HF and dementia was associated with an increased risk of requiring help with additional ADLs after one year (aOR = 2.69, 95% CI 1.53, 4.73). Participants with HF and dementia had an increased risk of being hospitalized within one year (aOR = 2.02 95% CI 1.16, 3.54), or dying within two years (aHR = 1.52 95% CI 1.03, 2.26).

CONCLUSIONS

One-fifth of persons over age 65 with HF also have comorbid dementia. Co-occurring HF and dementia markedly increase functional impairment and subsequent ADL decline, hospitalization, and death. These results highlight the need for physician awareness for signs of dementia, and appropriate adjustments in the management of HF.

Caring for aging parents in the last years of life

BACKGROUND

Adult children provide a large portion of end-of-life caregiving for older adults and make up the majority of caregivers for adults with dementia. Yet research has been limited to the hours of care that primary caregivers provide, neglecting the other ways adult children provide caregiving support. This study aims to describe the caregiving support adult children provide to their parents at the end of life and characterize differences by race and ethnicity and dementia status.

METHODS

We conducted a retrospective study using survey responses from the Health and Retirement Study between 2002 and 2018. The sample population (n = 8040) included decedents aged 65 with at least one living adult child at their time of death. Caregiving support was defined as providing financial support, providing help with basic or instrumental activities of daily living (ADLs or IADLs), or coresiding with the care recipient. Respondents were stratified by self-identified race and ethnicity as Hispanic, non-Hispanic White, or non-Hispanic Black. Respondents were further stratified by dementia and marital status.

RESULTS

Black and Hispanic respondents without dementia were more likely to report receiving financial help from (28.0% and 25.9%) or coresiding with their adult children (38.9% and 49.7%) compared to White respondents (15.0% receiving financial help and 23.3% coresiding) (p < 0.05). Among respondents with dementia, 47.1% of both Black and Hispanic respondents reported coresiding with their adult children, compared to only 24.6% of White respondents (p < 0.05). Notably, married Black and Hispanic respondents reported significantly higher rates of all support types compared to married White respondents (p < 0.05).

CONCLUSIONS

The majority of older adults at the end of life receive some form of care and support from their adult children, with Black and Hispanic older adults receiving particularly high rates of care and support from their adult children regardless of dementia or marital status.

The heterogeneity of the homebound: A latent class analysis of a national sample of homebound older adults

BACKGROUND

Homebound status is a final common pathway for people with a variety of diseases and conditions. There are 7 million homebound older adults in the United States. Despite concerns regarding their high healthcare costs and utilization and limited access to care, the unique subsets within the homebound population are understudied. Better understanding of distinct homebound groups may enable more targeted and tailored approaches to care delivery. Therefore, in a nationally representative sample of homebound older adults we used latent class analysis (LCA) to examine distinct homebound subgroups based on clinical and sociodemographic characteristics.

MATERIALS AND METHODS

Using data from the National Health and Aging Trends Study (NHATS) 2011-2019, we identified 901 newly homebound persons (defined as never/rarely leaving home or leaving home only with assistance and/or difficulty). Sociodemographic, caregiving context, health and function, and geographic covariates were derived from NHATS via self-report. LCA was used to identify the existence of distinct subgroups within the homebound population. Indices of model fit were compared for models testing 1-5 latent classes. Association between latent class membership and 1 year mortality was examined using a logistic regression.

RESULTS

We identified four classes of homebound individuals differentiated by their health, function, sociodemographic characteristics, and caregiving context: (i) Resource constrained (n = 264); (ii) Multimorbid/high symptom burden (n = 216); (iii) Dementia/functionally impaired (n = 307); (iv) Older/assisted living (n = 114). One year mortality was highest among the older/assisted living subgroup (32.4%) and lowest among the resource constrained (8.2%).

CONCLUSIONS

This study identifies subgroups of homebound older adults characterized by distinct sociodemographic and clinical characteristics. These findings will support policymakers, payers, and providers in targeting and tailoring care to the needs of this growing population.

Complex Care Needs at the End of Life for Seriously Ill Adults With Multiple Chronic Conditions

Understanding the complex care needs of seriously ill adults with multiple chronic conditions with and without cancer is critical for the delivery of high-quality serious illness and palliative care at the end of life. The objective of this secondary data analysis of a multisite randomized clinical trial in palliative care was to elucidate the clinical profile and complex care needs of seriously ill adults with multiple chronic conditions and to highlight key differences among those with and without cancer at the end of life. Of the 213 (74.2%) older adults who met criteria for multiple chronic conditions (eg, 2 or more chronic conditions requiring regular care with limitations of daily living), 49% had a diagnosis of cancer. Hospice enrollment was operationalized as an indicator for severity of illness and allowed for the capture of complex care needs of those deemed to be nearing the end of life. Individuals with cancer had complex symptomatology with a higher prevalence of nausea, drowsiness, and poor appetite and end of life and lower hospice enrollment. Individuals with multiple chronic conditions without cancer had lower functional status, greater number of medications, and higher hospice enrollment. The care of seriously ill older adults with multiple chronic conditions requires tailored approaches to improve outcomes and quality of care across health care settings, particularly at the end of life.

Virtual Geritalk: Does Intensive Virtual Communication Skills Training Improve Use of Serious Illness Communication Skills?

Background: The COVID-19 pandemic presented a unique opportunity to adapt in-person communication skills training to a virtual format. Objective: Examine use of serious illness communication skills by learners after participating in an intensive virtual communication skills training. Design: Prospective cohort study. Setting/Subjects: Icahn School of Medicine at Mount Sinai, Clinical Fellows. Measurements: Family Meeting Communication Assessment Tool (FAMCAT) assessed fundamental and advanced communication skills. Results: As compared to a historical benchmark obtained after a prior in-person course, the virtual course showed equivalent or better use of communication skills across fundamental skills and advanced skills. Conclusions: Our findings suggest that a virtual communication skills training is associated with the use of serious illness communication skills in the clinical setting by learners.

The Trauma Dyad: The Role of Informal Caregivers for Older Adults After Traumatic Injury

OBJECTIVE

To investigate the association between higher injury severity and increased informal caregiving received by injured older adults.

SUMMARY OF BACKGROUND DATA

Injured older adults experience high rates of functional decline and disability after hospitalization. Little is known about the scope of caregiving received post-discharge, particularly from informal caregivers such as family.

METHODS

We used the National Health and Aging Trends Study 2011 to 2018 linked to Medicare claims to identify adults ≥65 with hospital admission for traumatic injury and a National Health and Aging Trends Study interview within 12 months pre- and post-trauma. Injury severity was assessed using the injury severity score (ISS, low 0-9; moderate 10-15; severe 16-75). Patients reported the types and hours of formal and informal help received and any unmet care needs. Multi variable logistic regression models examined the association between ISS and increase in informal caregiving hours after discharge.

RESULTS

We identified 430 trauma patients. Most were female (67.7%), non-Hispanic White (83.4%) and half were frail. The most common mechanism of injury was fall (80.8%) and median injury severity was low (ISS = 9). Those reporting receiving help with any activity increased post-trauma (49.0% to 72.4%, P < 0.01), and unmet needs nearly doubled (22.8% to 43.0%, P < 0.01). Patients had a median of 2 caregivers and most (75.6%) were informal, often family members. Median weekly hours of care received pre- versus post-injury increased from 8 to 14 (P < 0.01). ISS did not independently predict increase in caregiving hours; pre-trauma frailty predicted an increase in hours ≥8 per week.

CONCLUSIONS

Injured older adults reported high baseline care needs which increased significantly after hospital discharge and were mostly met by informal caregivers. Injury was associated with increased need for assistance and unmet needs regardless of injury severity. These results can help set expectations for caregivers and facilitate post-acute care transitions.

Examining annual transitions in healthcare spending among U.S. medicare beneficiaries using multistate Markov models: Analysis of medicare current beneficiary survey data, 2003-2019

Many studies have examined factors associated with individuals of high or low healthcare spending in a given year. However, few have studied how healthcare spending changes over multiple years and which factors are associated with the changes. In this study, we examined the dynamic patterns of healthcare spending over a three-year period, among a nationally representative cohort of Medicare beneficiaries in the U.S. and identified factors associated with these patterns. We extracted data for 30,729 participants from the national Medicare Current Beneficiary Survey (MCBS), for the period 2003-2019. Using multistate Markov (MSM) models, we estimated the probabilities of year-to-year transitions in healthcare spending categorized as three states (low (L), medium (M) and high (H)), or to the terminal state, death. The participants, 13,554 (44.1%), 13,715 (44.6%) and 3,460 (11.3%) were in the low, medium and high spending states at baseline, respectively. The majority of participants remained in the same spending category from one year to the next (L-to-L: 76.8%; M-to-M: 71.7%; H-to-H: 56.6 %). Transitions from the low to high spending state were significantly associated with older age (75-84, ≥85 years), residing in a long-term care facility, greater assistance with activities of daily living, enrollment in fee-for-service Medicare, not receiving a flu shot, and presence of specific medical conditions, including cancer, dementia, and heart disease. Using data from a large population-based longitudinal survey, we have demonstrated that MSM modelling is a flexible framework and useful tool for examining changes in healthcare spending over time.

Prevalence of unpaid caregiving, pain, and depression in older seriously ill patients undergoing elective surgery

INTRODUCTION

Serious illness is a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes.

METHODS

Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES-D < 3, or yes, CES-D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in-hospital outcomes, including hospital days (days admitted between discharge date and one-year post-discharge), in-hospital complications (no or yes), and discharge destination (home or non-home).

RESULTS

Of the 1343 patients, 55.0% were female and 81.6% were non-Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre-admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non-home discharge (OR 1.6, 95% CI 1.2-2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in-hospital or post-acute outcomes in multivariable analysis.

CONCLUSIONS

Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter.

The devil's in the details: Variation in estimates of late-life activity limitations across national cohort studies

BACKGROUND

Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS).

METHODS

We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing.

RESULTS

NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% [95% confidence interval (CI) 11.5%-13.4%] of the cohort received help with dressing, while in HRS this figure was 6.4% [95% CI 5.7%-7.2%] and MCBS 5.3% [95% CI 4.7%-5.8%]. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability.

CONCLUSIONS

In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked.

Functional and clinical needs of older hospice enrollees with coexisting dementia

BACKGROUND

The Medicare Hospice Benefit increasingly serves people dying with dementia. We sought to understand characteristics, hospice use patterns, and last-month-of-life care quality ratings among hospice enrollees with dementia coexisting with another terminal illness as compared to enrollees with a principal hospice diagnosis of dementia, and enrollees with no dementia.

METHODS

We conducted a pooled cross-sectional study among decedent Medicare beneficiaries age 70+ using longitudinal data from the National Health and Aging Trends Study (NHATS) (last interview before death; after-death proxy interview) linked to Medicare hospice claims (2011-2017). We used unadjusted and adjusted regression analyses to compare characteristics of hospice enrollees with coexisting dementia to two groups: (1) enrollees with a principal dementia diagnosis, and (2) enrollees with no dementia.

RESULTS

Among 1105 decedent hospice enrollees age 70+, 40% had coexisting dementia, 16% had a principal diagnosis of dementia, and 44% had no dementia. In adjusted analyses, enrollees with coexisting dementia had high rates of needing help with 3-6 activities of daily living, similar to enrollees with principal dementia (62% vs. 67%). Enrollees with coexisting dementia had high clinical needs, similar to those with no dementia, for example, 63% versus 61% had bothersome pain. Care quality was worse for enrollees with coexisting dementia versus principal dementia (e.g., 61% vs. 79% had anxiety/sadness managed) and similar to those with no dementia. Enrollees with coexisting dementia had similar hospice use patterns as those with principal diagnoses and higher rates of problematic use patterns compared to those with no dementia (e.g., 16% vs. 10% live disenrollment, p = 0.004).

CONCLUSIONS

People with coexisting dementia have functional needs comparable to enrollees with principal diagnoses of dementia, and clinical needs comparable to enrollees with no dementia. Changes to hospice care models and policy may be needed to ensure appropriate dementia care.

Role of Home Health for Community-Dwelling Older Adults Near the End of Life: A Resource Beyond Hospice?

Background: Medicare home health could be leveraged to care for those near the end of life (EOL), especially for those who cannot access nor desire the Medicare hospice benefit. It is unknown what role home health currently has either preceding or as an alternative to hospice use. Objective: The aim of this study is to compare populations served and visit patterns of Medicare beneficiaries receiving home health/hospice/both near the EOL. Design: Nationally representative cohort study of National Health and Aging Trends Study (NHATS) respondents. Setting/Subjects: A total of 1,057 U.S. decedents in NHATS from 2012 to 2017 with linked Medicare claims were included in this study. Measurements: Measurements included the proportion of decedents who received home health/hospice/both/neither (yes/no) in the last six months of life (EOL) and mean number of visits by discipline (nurse/therapist [physical/occupational speech-language pathologist]/social worker/home health aide) per 30 eligible days at home for home health/hospice/both at the EOL. The primary independent variable was the clinician discipline providing services (nurse/therapist/social worker/aide). Results: In our sample, 19.9% received home health only, 25.8% hospice only, 18.8% both, and 35.6% neither at the EOL. These populations varied in their demographic, region, and clinical characteristics. Decedents who received home health only compared with hospice only were younger (44.1% over age 85 vs. 58.4%), members of a racially/ethnically diverse group (19.7% vs. 10.9%), and with less disability (37.2% required no assistance with activities of daily living vs. 22.7%), all p values <0.05. In adjusted models, those receiving home health versus hospice received similar numbers of visits per 30 days (average 5.4/30 vs. 6.6/30), while those receiving both received more visits (10.5/30). Home health provided more therapy visits, while hospice provided more social work and aide visits. Conclusions: More than one in three Medicare decedents nationwide received home health at the EOL. Home health has the potential to serve a population not reached by hospice and improve the quality of end-of-life care.

The burden of pre-admission pain, depression, and caregiving on palliative care needs for seriously ill trauma patients

INTRODUCTION

Increasing numbers of individuals admitted to hospitals for trauma are older adults, many of whom also have underlying serious illnesses. Older adults with serious illness benefit from palliative care, but the palliative care needs of seriously ill older adults with trauma have not been elucidated. We hypothesize that older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours before trauma admission.

METHODS

Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients 66 years or older who met an established definition of serious illness in surgery and were admitted with trauma. Descriptive analyses were performed for baseline patient characteristics, pre-admission pain (dichotomized as none/mild vs. moderate/severe), depression (dichotomized as no, Center for Epidemiologic Studies Depression scale [CES-D] < 3 vs. yes, CES-D ≥ 3), and unpaid caregiving hours (dichotomized as low (<30 h/month), high (≥30 h/month)).

RESULTS

We identified 1741 patients, 67.4% were female and 86.8% White. Mean age was 83 (SD 7.5), and 60.3% had ≥4 comorbidities. The majority (62.9%) were admitted due to falls, 33.5% had isolated hip fracture. The prevalence of baseline moderate/severe pain and depression were 38.1% and 42.6%, respectively. Among the cohort, 42.2% had unpaid caregiving, of those 27.7% had ≥30 h/week of unpaid caregiving hours.

CONCLUSIONS

Prior to trauma admission, older adults with serious illness have a high prevalence of pain, depression, and unpaid caregiving hours. These findings may inform targeted palliative care interventions to reduce symptom burden and post-discharge healthcare utilization.

Multiple Chronic Conditions among Seriously Ill Adults Receiving Palliative Care

The objective of this study was to characterize multiple chronic conditions (MCCs) among seriously ill adults receiving palliative care at the end of life. A latent class analysis was conducted to identify latent subgroups of seriously ill older adults based on a baseline Charlson comorbidity index (CCI) measurement, a measure of comorbidity burden, and mortality risk. The three latent subgroups were: (1) low to moderate CCI with MCC, (2) high CCI with MCC, and (3) high CCI and metastatic cancer. The "low to moderate CCI and MCC" subgroup included older adults with chronic obstructive pulmonary disease (COPD), cardiovascular disease, congestive heart failure, myocardial infarction, dementia, diabetes, and lymphoma. A "high CCI and MCC" subgroup included individuals with severe illness including liver or renal disease among other MCCs. A "high CCI and metastatic cancer" included all participants with metastatic cancer. This study sheds light on the MCC profile of seriously ill adults receiving palliative care.

Symptom Management Experience of End-of-Life Family Caregivers: A Population-Based Study

CONTEXT

In the United States, 30% of all deaths occur at home. Effective symptom management is integral to quality end-of-life (EOL) care. Family caregivers play a major role in EOL symptom management. Recent federal policies emphasize the need to improve training and support for family caregivers.

OBJECTIVES

In a nationally representative sample: 1) Characterize the population of caregivers assisting with and reporting difficulty in symptom management at the end of life; and 2) Assess caregiver and care recipient characteristics associated with caregiver report of difficulty.

METHODS

Cross-sectional analysis of data from the National Health and Aging Trends Study and National Study of Caregiving. Multivariable logistic regression to assess association between care recipient and caregiver characteristics and caregiver report of difficulty.

RESULTS

Caregivers (n = 214) were mean age 57.1 years, 74% female, and 86% white non-Hispanic. Over 2 million family caregivers provided assistance with symptom management in the last month of life in 2017; 78% reported difficulty. Non-Hispanic Black caregivers (aOR 0.24, 95% CI 0.08-0.75), Hispanic caregivers (0.13, 0.03-0.56), and caregivers with lower than high school education (0.26, 0.11-0.63) were less likely to report difficulty. Caregivers of care recipients who received paid care (3.37, 1.30-8.69) were more likely to report difficulty. Receipt of training and support services (1.80, 0.83-3.93) and hospice (1.83, 0.82-4.07) were not associated with caregiver report of difficulty.

CONCLUSION

These findings underscore the need to improve training and support for family caregivers in EOL symptom management.

Comparing the association between multiple chronic conditions, multimorbidity, frailty, and survival among older patients with cancer

INTRODUCTION

The high prevalence of multiple chronic conditions (MCC), multimorbidity, and frailty may affect treatment and outcomes for older adults with cancer. The goal of this study was to use three conceptually distinct measures of morbidity to examine the association between these measures and mortality.

MATERIALS AND METHODS

Using Medicare claims data linked with the 2012-2016 Ohio Cancer Incidence Surveillance System we identified older adults with incident primary cancer sites of breast, colorectal, lung, or prostate (n = 29,140). We used claims data to identify their Elixhauser comorbidities, Multimorbidity-Weighted Index (MWI), and Claims Frailty Index (CFI) as measures of MCC, multimorbidity, and frailty, respectively. We used Cox proportional hazard models to examine the association between these measures and survival time since diagnosis.

RESULTS

Lung cancer patients had the highest levels of MCC, multimorbidity, and frailty. There was a positive association between all three measures and a greater hazard of death after adjusting for age, sex (colorectal and lung only), and stage. Breast cancer patients with 5+ comorbidities had an adjusted hazard ratio (aHR) of 1.63 (95% confidence interval [CI]: 1.38, 1.93), and those with mild frailty had an aHR of 3.38 (95% CI; 2.12, 5.41). The C statistics for breast cancer were 0.79, 0.78, and 0.79 for the MCC, MWI, and CFI respectively. Similarly, lung cancer patients who were moderately or severely frail had an aHR of 1.82 (95% CI: 1.53, 2.18) while prostate cancer patients had an aHR of 3.39 (95% CI: 2.12, 5.41) and colorectal cancer patients had an aHR of 4.51 (95% CI: 3.23, 6.29). Model performance was nearly identical across the MCC, multimorbidity, and frailty models within cancer type. The models performed best for prostate and breast cancer, and notably worse for lung cancer. The frailty models showed the greatest separation in unadjusted survival curves.

DISCUSSION

The MCC, multimorbidity, and frailty indices performed similarly well in predicting mortality among a large cohort of older cancer patients. However, there were notable differences by cancer type. This work highlights that although model performance is similar, frailty may serve as a clearer indicator in risk stratification of geriatric oncology patients than simple MCCs or multimorbidity.

National End-of-Life-Treatment Preferences are Stable Over Time: National Health and Aging Trends Study

CONTEXT

Advance Care Planning is a process of understanding and sharing preferences regarding future medical care.

OBJECTIVE

To explore individual and national stability of end-of-life treatment preferences among a sample of older adults.

METHODS

National Health and Aging Trends Study is a nationally representative sample of older adults. In 2012, a random sample, and in 2018, the entire sample were queried on end-of-life treatment preferences defined as acceptance or rejection of life prolonging treatment (LPT) if they had a serious illness and were at the end of their life and in severe pain or had severe disability. Using a cohort design, we explored individual trends in preferences for LPT among those with responses in both waves (pain scenario: N = 606, disability scenario: N = 628) and, using a serial cross-sectional design, national trends in LPT among the entire sample (1702 older adults in wave 2 and 4342 in wave 8).

RESULTS

In the cohort study, individual preferences were stable over time (overall percent agreement = 86% for disability and 76% for pain scenarios), particularly for older adults who would reject LPT in wave 2 (overall agreement 92% for disability and 86% for pain). In the serial cross-sectional study, national trends in preferences for receipt of LPT were stable over time in the pain (27.4% vs. 27.0%, P = 0.80) and disability (15.8% vs. 15.7%, P = 0.99) scenarios.

CONCLUSIONS

We found that national trends in preferences for end-of-life treatment did not substantially change over time and may be stable within individual older adults.

Use of hospitals in the New York City Metropolitan Region, by race: how separate? How equal in resources and quality?

BACKGROUND

Although racial and ethnic minorities disproportionately use some hospitals, hospital-based racial and ethnic composition relative to geographic region and its association with quality indicators has not been systematically analyzed.

METHODS

We used four race and ethnicity categories: non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Asian/Pacific Islander/Alaskan Native/American Indian (API/AIAN), as well as a combined non-NHW category, from the 2010 (latest year publicly available) Medicare Institutional Provider & Beneficiary Summary public use file for 84 hospitals in the New York City region. We assessed the relative distribution of race and ethnicity across hospitals grouped at different geographic levels (region, county, hospital referral region [HRR], or hospital service areas [HSA]) using the dissimilarity index. Hospital characteristics included quality star ratings, essential professional services and diagnostic/treatment equipment, bed size, total expenses, and patients with dual Medicare and Medicaid enrollment. We assessed Spearman's rank correlation between hospital-based racial and ethnic composition and quality/structural measures.

RESULTS

Dissimilarity Index decreases from region (range 30.3-40.1%) to county (range 13.7-23.5%), HRR (range 10.5-27.5%), and HSA (range 12.0-16.9%) levels. Hospitals with larger non-NHW patients tended to have lower hospital ratings and higher proportions of dually-enrolled patients. They were also more likely to be safety net hospitals and non-federal governmental hospitals.

CONCLUSIONS

In the NYC metropolitan region, there is considerable hospital-based racial and ethnic segregation of Medicare patients among non-NHW populations, extending previous research limited to NHB. Availability of data on racial and ethnic composition of hospitals should be made publicly available for researchers and consumers.

Assessing Health Care Use Trajectories After the Onset of Functional Disability: Application of a Group-Based Trajectory Model

OBJECTIVES

While older adults with activity limitations have high levels of health care use, we do not know how this varies over time. We aimed to assess trajectories of Emergency Department (ED) use and hospitalization after the onset of receipt of help with self-care or mobility.

METHODS

We used the 2011-2017 National Health Aging Trends Study (NHATS) linked to Medicare claims to identify a cohort of older adults who began to receive help with self-care or mobility in the past year. Primary outcome was the quarterly rates of ED use and/or hospitalization over the 24 months following the onset of receiving help. We fit a Group-Based Trajectory Model to identify the trajectories of ED use or hospitalization and assessed the association of characteristics preceding and concurrent to the onset of help with trajectory group membership.

RESULTS

Among 1,687 NHATS respondents newly receiving help with self-care/mobility, health care use escalated and then immediately fell. We found distinct trajectories of ED use and hospitalization: delayed rise (13.5%), falling (26.2%), and persistent (60.4%). Trajectory group membership was predicted by clinical, economic, and regional characteristics; and the individuals in each group differed in terms of concurrent new illnesses and degree of disability.

DISCUSSION

While activity limitations are a strong predictor of health care use among older adults, trajectories of health care use are heterogeneous. Along with clinical characteristics, potentially modifiable household and regional factors shaped health care trajectories, indicating that addressing these factors could potentially shift health care use patterns.

Determinants of Total End-of-Life Health Care Costs of Medicare Beneficiaries: A Quantile Regression Forests Analysis

BACKGROUND

To identify and rank the importance of key determinants of end-of-life (EOL) health care costs, and to understand how the key factors impact different percentiles of the distribution of health care costs.

METHOD

We applied a principled, machine learning-based variable selection algorithm, using Quantile Regression Forests, to identify key determinants for predicting the 10th (low), 50th (median), and 90th (high) quantiles of EOL health care costs, including costs paid for by Medicare, Medicaid, Medicare Health Maintenance Organizations (HMOs), private HMOs, and patient's out-of-pocket expenditures.

RESULTS

Our sample included 7 539 Medicare beneficiaries who died between 2002 and 2017. The 10th, 50th, and 90th quantiles of EOL health care cost are $5 244, $35 466, and $87 241, respectively. Regional characteristics, specifically, the EOL-Expenditure Index, a measure for regional variation in Medicare spending driven by physician practice, and the number of total specialists in the hospital referral region were the top 2 influential determinants for predicting the 50th and 90th quantiles of EOL costs but were not determinants of the 10th quantile. Black race and Hispanic ethnicity were associated with lower EOL health care costs among decedents with lower total EOL health care costs but were associated with higher costs among decedents with the highest total EOL health care costs.

CONCLUSIONS

Factors associated with EOL health care costs varied across different percentiles of the cost distribution. Regional characteristics and decedent race/ethnicity exemplified factors that did not impact EOL costs uniformly across its distribution, suggesting the need to use a "higher-resolution" analysis for examining the association between risk factors and health care costs.

Fragmentation of care in the last year of life: Does dementia status matter?

Background

Care at the end of life is commonly fragmented; however, little is known about commonly used measures of fragmentation of care in the last year of life (LYOL). We sought to understand differences in fragmentation of care by dementia status among seriously ill older adults in the LYOL.

Methods

We analyzed data from adults ≥65 years in the National Health and Aging Trends Study who died and had linked 2011–2017 Medicare fee‐for‐service claims for ≥12 months before death. We categorized older adults as having serious illness due to dementia (hereafter dementia), non‐dementia serious illness or no serious illness. For outpatient fragmentation, we calculated the Bice–Boxerman continuity of care index (COC), which measures care concentration, and the known provider of care index (KPC), which measures the proportion of clinicians who were previously seen. For acute care fragmentation, we divided the number of hospitals and emergency departments visited by the total number of visits. We built separate multivariable quantile regression models for each measure of fragmentation.

Results

Of 1793 older adults, 42% had dementia, 53% non‐dementia serious illness and 5% neither. Older adults with dementia had fewer hospitalizations than older adults with non‐dementia serious illness but more than older adults without serious illness (mean 1.9 vs 2.3 vs 1, p = 0.002). In adjusted models, compared to older adults with non‐dementia serious illness, those with dementia had significantly less fragmented care across all quantiles of COC (range 0.016–0.110) but a lower predicted 90th percentile of KPC, meaning more older adults with dementia had extremely fragmented care on the KPC measure. There was no significant difference in acute care fragmentation.

Conclusions

In the LYOL, older adults with dementia have fewer healthcare encounters and less fragmentation of care by the COC index than older adults with non‐dementia serious illness.

Prospective assessment of dementia on transitions in homeboundness using multistate Markov models

BACKGROUND

One in 20 older adults in the United States is homebound and rarely/never leaves home. Although being homebound decreases the quality of the lived experience of individuals with serious illnesses, little is known about the frequency or likelihood of transitions in or out of homebound status. The objective of this study was to characterize the probability of transitions to and from homebound status among older adults and examine the relationship between dementia status and homebound transitions.

METHODS

Using 2011-2018 data from the National Health and Aging Trends Study (NHATS), a nationally representative longitudinal study of aging in the United States, we identified 6375 community-dwelling Medicare beneficiaries. Homebound status (independent, semi-homebound (leaving home but with difficulty or help), homebound (rarely or never leaving home), nursing home resident, dead) was assessed annually via self-report. Transition probabilities across states were assessed using a multistate Markov model.

RESULTS

Less than half of homebound individuals remain homebound (probability = 41.5% [95% CI: 39.2%, 43.5%]) after 1 year. One out of four dies (24% [22.3%, 26.0%]) and there is a low probability (3.2% [2.5%, 4.1%]) of transition to a nursing home. Dementia status was associated with increased risk of progression from independence to homebound status (HR: 1.83 [1.01, 3.34]). Dementia was consistently associated with increased probabilities of transitions to death including a two-fold increased hazards of progression from homebound to death (HR: 2.18 [1.69, 2.81]). Homebound individuals with dementia have a 34.2% [25.8%, 48.1%] probability of death in 5 years, compared with 17.4% [13.7%, 24.3%] among those without dementia.

DISCUSSION

Dementia is associated with greater risk of transitioning across homebound states. There is a greater need to support home-based care for patients with dementia, especially as the ongoing COVID pandemic has raised concerns about the need to invest in alternative models to nursing home care.

Latent Class Analysis of Symptom Burden Among Seriously Ill Adults at the End of Life

BACKGROUND

Serious illness is characterized by high symptom burden that negatively affects quality of life (QOL). Although palliative care research has highlighted symptom burden in seriously ill adults with cancer, symptom burden among those with noncancer serious illness and multiple chronic conditions has been understudied. Latent class analysis is a statistical method that can be used to better understand the relationship between severity of symptom burden and covariates, such as the presence of multiple chronic conditions. Although latent class analysis has been used to highlight subgroups of seriously ill adults with cancer based on symptom clusters, none have incorporated multiple chronic conditions.

OBJECTIVES

The objectives of this study were to (a) describe the demographic and baseline characteristics of seriously ill adults at the end of life in a palliative care cohort, (b) identify latent subgroups of seriously ill individuals based on severity of symptom burden, and (c) examine variables associated with latent subgroup membership, such as QOL, functional status, and the presence of multiple chronic conditions.

METHODS

A secondary data analysis of a palliative care clinical trial was conducted. The latent class analysis was based on the Edmonton Symptom Assessment System, which measures nine symptoms on a scale of 0-10 (e.g., pain, fatigue, nausea, depression, anxiousness, drowsiness, appetite, well-being, and shortness of breath). Clinically significant cut-points for symptom severity were used to categorize each symptom item in addition to a categorized total score.

RESULTS

Three latent subgroups were identified (e.g., low, moderate, and high symptom burden). Lower overall QOL was associated with membership in the moderate and high symptom burden subgroups. Multiple chronic conditions were associated with statistically significant membership in the high symptom burden latent subgroup. Older adults between 65 and 74 years had a lower likelihood of moderate or high symptom burden subgroup membership compared to the low symptom burden class.

DISCUSSION

Lower QOL was associated with high symptom burden. Multiple chronic conditions were associated with high symptom burden, which underlines the clinical complexity of serious illness. Palliative care at the end of life for seriously ill adults with high symptom burden must account for the presence of multiple chronic conditions.

Prevalence of Memory-Related Diagnoses Among U.S. Older Adults With Early Symptoms of Cognitive Impairment

BACKGROUND

Early diagnosis of cognitive impairment may confer important advantages. Yet the prevalence of memory-related diagnoses among older adults with early symptoms of cognitive impairment is unknown.

METHODS

A retrospective, longitudinal cohort design using 2000-2014 Health and Retirement Survey-Medicare linked data. We leveraged within-individual variation to examine the relationship between incident cognitive impairment and receipt of diagnosis among 1225 individuals aged 66 or older. Receipt of a memory-related diagnosis was determined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Incident cognitive impairment was defined as the first assessment wherein the participant's modified Telephone Interview for Cognitive Status score was less than 12.

RESULTS

The unadjusted prevalence of memory-related diagnosis at cognitive impairment was 12.0%. Incident cognitive impairment was associated with a 7.3% (95% confidence interval [CI], 5.6% to 9.0%; p < .001) higher adjusted probability of any memory-related diagnosis overall, yielding 9.8% adjusted prevalence of diagnosis. The increase in likelihood of diagnosis associated with cognitive decline was significantly higher among non-Hispanic Whites than non-Hispanic Blacks (8.2% vs -0.7%), and among those with at least a college degree than those with a high school diploma or less (17.4% vs 6.8% vs 1.6%). Those who were younger, had below-median wealth, or without a partner had lower probability of diagnosis than their counterparts.

CONCLUSIONS

We found overall low prevalence of early diagnosis, or high rate of underdiagnosis, among older adults showing symptoms of cognitive impairment, especially among non-Whites and socioeconomically disadvantaged subgroups. Our findings call for targeted interventions to improve the rate of early diagnosis, especially among vulnerable populations.

Virtual Geritalk: Improving Serious Illness Communication of Clinicians Who Care for Older Adults

CONTEXT

High quality communication is essential to older adults' medical decision-making, quality of life, and adjustment to serious illness. Studies have demonstrated that Geritalk, a two day (16 hours total) in-person communication skills training improves self-assessed preparedness, skill acquisition, and sustained practice of communication skills. Due to the COVID-19 pandemic, Geritalk was adapted to a virtual format (four days, 10 hours total).

OBJECTIVES

Our study evaluated the change in participants' self-assessed preparedness for serious illness communication before and after the virtual course and satisfaction with the course, and compared these findings to responses from a prior in-person Geritalk course.

METHODS

Geriatrics and Palliative Medicine fellows at three urban academic medical centers completed surveys, which employed five-point Likert scales, before and after the virtual course to assess satisfaction with the course and preparedness for serious illness communication.

RESULTS

Of the 20 virtual Geritalk participants, 17 (85%) completed the pre-course assessment, and 14 (70%) completed the post-course assessment. Overall, satisfaction with the course was high (mean 4.9 on a 5-point scale). Compared to in-person Geritalk participants, virtual course participants reported comparable and significant (P < 0.01) improvements in mean self-reported preparedness across all surveyed communication skills.

CONCLUSION

We show that a virtual communication skills training is feasible and effective. Our findings suggest that the innovative virtual Geritalk course has the potential to increase access to communication skills training, improve serious illness communication skills, and in improve the quality of care received by older adults with serious illness.

The Serious Illness Population: Ascertainment via Electronic Health Record or Claims Data

CONTEXT

Palliative care can improve the lives of people with serious illness, yet clear operational definitions of this population do not exist. Prior efforts to identify this population have not focused on Medicare Advantage (MA) and commercial health plan enrollees.

OBJECTIVES

We aimed to operationalize our conceptual definition of serious illness to identify those with serious medical conditions (SMC) among commercial insurance and MA enrollees, and to compare the populations identified through electronic health record (EHR) or claims data sources.

METHODS

We used de-identified claims and EHR data from the OptumLabs Data Warehouse (2016-2017), to identify adults age ≥18 with SMC and examine their utilization and mortality. Within the subset found in both data sources, we compared the performance of claims and EHR data.

RESULTS

Within claims, SMC was identified among 10% of those aged ≥18 (5.4% ages 18-64, 27% age ≥65). Within EHR, SMC was identified among 9% of those aged ≥18 (5.6% ages 18-64, 21% ages ≥65). Hospital, emergency department and mortality rates were similar between the EHR and claims-based groups. Only 50% of people identified as having SMC were recognized by both data sources.

CONCLUSION

These results demonstrate the feasibility of identifying adults with SMC in a commercially insured population, including MA enrollees; yet separate use of EHR or claims result in populations that differ. Future research should examine methods to combine these data sources to optimize identification and support population management, quality measurement, and research to improve the care of those living with serious illness.

Trends of hospitalizations among patients with both cancer and dementia diagnoses in New York 2007-2017

BACKGROUND

Cancer and dementia have often been studied in isolation. We aimed to examine the spatiotemporal trend of inpatient admissions with both cancer and dementia diagnoses.

METHODS

Using state-wide inpatient claims data, we identified all hospital admissions for patients aged ≥50 years with both cancer and dementia diagnoses in New York State, 2007-2017. We examined the spatiotemporal trend of the admission using a novel Bayesian hierarchical model adjusting for socioeconomic factor, as measured by Yost index.

RESULTS

Admissions with the presence of both cancer and dementia diagnoses represented 8.5% of all admissions with a cancer diagnosis, and the proportion increased from 7.1% in 2007 to 9.7% in 2017. The median admission rate was 3.5 (interquartile range: 2.2-5.2) hospitalizations per 1000 population aged ≥50 years, which increased from 2.9 in 2007 to 3.7 in 2017. The admission rate peaked first in 2010 followed by a smaller peak in 2014, before stabilizing at a level higher than the pre-2010 period. Taking into account the spatiotemporal heterogeneity, we found that hospitalizations among those with both cancer and dementia diagnoses were associated with a higher socioeconomic status (the posterior median relative risk for Yost index = 1.046 (95% credible interval: 1.033-1.058)).

CONCLUSIONS

Hospitalizations of patients with both cancer and dementia increased over time. Cancer care providers and healthcare systems should be prepared to provide prevention and management strategies and engage in complex medical decision-making for this increasingly common patient population comprised of individuals with cancer and dementia.

Family Caregiving for Those With and Without Dementia in the Last 10 Years of Life

This cohort study compares family caregiver hours provided to those with vs without dementia during the last 10 years of life.

Population-Based Screening for Functional Disability in Older Adults

BACKGROUND AND OBJECTIVES

Screening for functional disability is a promising strategy to identify high-need older adults. We compare 2 disability measures, activities of daily living (ADLs), and life space constriction (LSC), in predicting hospitalization and mortality in older adults.

RESEARCH DESIGN AND METHODS

We used the nationally representative National Health and Aging Trends Study of 30,885 observations of adults aged 65 years and older. Outcomes were 1-year mortality and hospitalization. Predictors were ADLs (receiving help with bathing, eating, dressing, toileting, getting out of bed, walking inside) and LSC (frequency of leaving home).

RESULTS

Of respondents, 12.4% reported 3 or more ADLs and 10.8% reported rarely/never leaving home. ADL disability and LSC predicted high rates of 1-year mortality and hospitalization: of those with 3 or more ADLs, 46.4% died and 41.0% were hospitalized; of those who never/rarely left home, 40.7% died and 37.0% were hospitalized. Of those with both 3 or more ADLs and who never/rarely left home, 58.4% died. ADL and LSC disability combined was more predictive of 1-year mortality and hospitalization than either measure alone. ADL disability and LSC screens identified overlapping but distinct populations. LSC identified more women (72.6% vs 63.8% with ADL disability), more people who live alone (40.7% vs 30.7%), fewer who were White (71.7% vs 76.2%) with cancer (27.6% vs 32.4), and reported pain (67.1% vs 70.0%).

DISCUSSION AND IMPLICATIONS

LSC and ADLs both independently predicted mortality and hospitalization but using both screens was most predictive. Routine screening for ADLs and LSC could help health systems identify those at high risk for mortality and health care use.

Impact of a Novel Goals-of-Care Communication Skills Coaching Intervention for Practicing Oncologists

Background: Oncologists routinely have opportunities for goals-of-care (GoC) discussions with patients. GoC discussions increase the likelihood that patients receive care consistent with their values. However, oncologists often feel ill-equipped to discuss end-of-life care. Objective: To assess the impact of a communication training and coaching intervention (INT) for oncologists during GoC discussions. Design: We randomized oncologists to usual care (UC) or a communication skills training INT, which consisted of an interactive training session and four joint visits with communication coaches. Setting/Subjects: Solid tumor oncologists seeing advanced cancer patients at four hospitals in New York and Connecticut. Measurements: Three blinded coders evaluated recorded encounters before and after INT using a validated tool to assess skill attainment. Results: Oncologists (n = 22) were 32% female and averaged 46 years of age. In baseline visits, INT oncologists (n = 11) and UC oncologists (n = 11) had no difference in the number of mean skills employed out of 8 GoC skills (INT 3.5, UC 2.4; p = 0.18). Post-INT, INT oncologists were significantly more likely to elicit patient values (55% vs. 0%; p = 0.01). There was no significant difference in overall mean skills employed (INT 3.4, UC 2.2; p = 0.14). Assessing for understanding, offering "I wish" statements, and providing prognosis were the least utilized skills among all oncologists. Conclusion: Our real-time communication skills coaching INT resulted in a significant increase in oncologists' ability to elicit patient values during GoC discussions, suggesting that skill acquisition can occur in the face of less intensive training. Future studies can highlight gaps leading to the lack of differences in utilization of other skills.

The Association Between Income and Incident Homebound Status Among Older Medicare Beneficiaries

IMPORTANCE

A large and growing population of older adults with multimorbidity, cognitive impairment, and functional disability live in the community, but many never or rarely leave their homes. Being homebound is associated with decreased access to medical services, poor health outcomes, and increased mortality. Yet, it is unknown what factors, in particular socioeconomic factors, are associated with new onset of homebound status.

OBJECTIVE

To evaluate the association between income and risk of becoming homebound.

DESIGN

Observational cohort study using 2011 to 2018 data from the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries aged 65 years and older.

SETTING

Population-based study in the United States.

PARTICIPANTS

A total of 7,042 initially nonhomebound community-dwelling older adults.

EXPOSURE

Total annual household income at baseline (in 2011) measured via self-report.

OUTCOME

Annual measure of homebound status, defined as leaving home an average of 1 d/wk or less.

RESULTS

Over 7 years, 15.81% of older adults in the lowest income quartile (≤$15,003) became homebound, compared with only 4.64% of those in the highest income quartile (>$60,000). In a competing risks analysis accounting for risks of death and nursing home admission, and adjusted for clinical and demographic characteristics, those in the lowest income quartile had a substantially higher subhazard of becoming homebound than those in the highest income quartile (1.65; 95% confidence interval = 1.20-2.29). Moreover, we see evidence of a gradient in risk of homebound status by income quartile.

CONCLUSION AND RELEVANCE

Our work demonstrates that financial resources shape the risk of becoming homebound, which is associated with negative health consequences. In the context of existing income disparities, more support is needed to assist older adults with limited financial resources who wish to remain in the community.

Family and Friend Perceptions of Quality of End-of-Life Care in Medicare Advantage vs Traditional Medicare

IMPORTANCE

Medicare Advantage (MA) insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare.

OBJECTIVE

To determine if there is a difference in quality of care reported by family and friends of individuals who died while insured by MA vs traditional Medicare at the end of life.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research representing 8 668 829 Medicare enrollees. Included individuals were 2119 enrollees who died when aged 65 years or older, with quality of care reported by a family member or close friend familiar with the individual's last month of life. Analysis was conducted in July 2020.

EXPOSURES

MA enrollment at the time of death or before hospice enrollment.

MAIN OUTCOMES AND MEASURES

Perception of end-of-life care was measured with 9 validated items, with the primary outcome variable being overall care rated not excellent. We conducted a propensity score-weighted multivariable model to examine the association of each item with MA vs traditional Medicare enrollment. The propensity score and multivariable model included covariates capturing demographic and socioeconomic factors, function and health, and relationship of the respondent to the individual who died. The sample was then stratified by hospice enrollment and setting of care in the last month.

RESULTS

Of 2119 people in the sample, 670 individuals were enrolled in MA at the time of death or prior to hospice (32.7%) and 1449 were enrolled in traditional Medicare (67.3%). In survey-weighted percentages, 53.6% (95% CI, 51.0% to 56.1%) were women and 43.4% (95% CI, 41.5% to 45.3%) were older than 85 years at the time of death. In the adjusted model, family and friends of individuals in MA were more likely to report that care was not excellent (odds ratio, 1.28; 95% CI, 1.01 to 1.61; P = .04) and that they were not kept informed (odds ratio, 1.48; 95% CI, 1.06 to 2.05; P = .02). For those in nursing homes, there was an estimated probability of 57.2% of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 77.9% of respondents for individuals with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32; P = .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare. These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.

Spousal Caregivers Are Caregiving Alone In The Last Years Of Life

Caregiving in the last years of life is associated with increased depression and negative health outcomes for surviving spouses, many of whom are themselves in poor health. Yet it is unclear how often spouses are caregiving alone, how they differ from supported spouses, and whether lack of support affects postbereavement outcomes. We hypothesized that spouses who were solo caregivers-that is, the only caregivers (paid or unpaid) who provided assistance with a spouse's self-care or household activities-would experience more depression after bereavement than supported spouses would. Using information from the Health and Retirement Study, we found that 55 percent of the spouses of community-dwelling married people with disability were solo caregivers. Solo caregiving was even common among people who cared for spouses with dementia and those with adult children living close by. Bereavement outcomes did not differ between solo and supported caregiving spouses. Caregiving spouses are often isolated and may benefit from greater support, particularly during the final years before bereavement. While some state and federal policy proposals aim to systematically recognize and assess caregivers, further innovations in care delivery and reimbursement are needed to adequately support seriously ill older adults and their caregivers. Ultimately, the focus of serious illness care must be expanded from the patient to the family unit.

Estimation of the Incident Homebound Population in the US Among Older Medicare Beneficiaries, 2012 to 2018

This cohort study examines the incidence of becoming homebound, being placed in a nursing home, and death in the US from 2012 to 2018 among Medicare beneficiaries aged 65 years and older.

Lifetime history of traumatic brain injury is associated with increased loneliness in adults: A US nationally representative study

BACKGROUND/OBJECTIVES

An estimated 55 million individuals worldwide live with chronic disability associated with traumatic brain injury (TBI), which may include cognitive, behavioral, and social impairments. Reduced participation in social activities is common after TBI; however, few studies have evaluated loneliness among survivors of TBI. The current study aimed to evaluate the association between history of TBI and loneliness and to identify mediators of this association.

METHODS/DESIGN

Retrospective cohort study. Nationally representative sample of N = 724 adults over age 50 years (Health and Retirement Study). Loneliness was evaluated using the 11-item Revised University of California Los Angeles (R-UCLA) Loneliness Scale (range 11-33). Lifetime history of TBI evaluated retrospectively using the Ohio State University TBI Identification Method. We included the following covariates: age, sex, race, and education; and mediators: depressive symptoms, number of comorbidities, chronic pain, difficulty with activities of daily living, and social network index.

RESULTS

History of TBI was associated with a 1.28-point (95% CI, 0.46-2.11; P < .05; Cohen's D = 0.284) increase in R-UCLA Loneliness Scale scores after covariate adjustment. Individuals with more recent injuries (within 10 years) and multiple lifetime TBIs reported the highest loneliness scores. In the structural equation model, depressive symptoms partially mediated the relationship between TBI and loneliness. All models were adjusted for US population sampling weights.

CONCLUSIONS

History of TBI was associated with greater loneliness compared with individuals without TBI in a representative sample of US adults. Managing depressive symptoms and medical consequences of TBI may be a target to ameliorate reporting of loneliness in this population.

Switching Between Medicare Advantage And Traditional Medicare Before And After The Onset Of Functional Disability

Medicare Advantage (MA) plans have increasing flexibility to provide nonmedical services to support older adults aging in place in the community. However, prior research has suggested that enrollees with functional disability (hereafter, "disability") were more likely than those without disability to leave MA plans. This indicates that MA plans might not meet the needs of older adults with disability. We used data for 2011-16 from the National Health and Aging Trends Study linked to Medicare claims to measure and characterize switches in either direction between Medicare Advantage and traditional Medicare in the twelve months before and after onset of disability. While the rate of switches from Medicare Advantage to traditional Medicare increased slightly after disability onset, people with greater levels of disability were more likely to switch to traditional Medicare, compared to those with lower levels: 36 percent of those who switched from Medicare Advantage to traditional Medicare needed help with two or more activities of daily living, compared to 14.3 percent of those who switched from traditional Medicare to Medicare Advantage. This indicates the potential benefit of including functional measures in MA plan risk adjustment and quality measures. Furthermore, the highest-need older adults with disability may experience lower-quality care in Medicare Advantage and thus leave before accessing the program's expanded benefits.

Residential Setting and the Cumulative Financial Burden of Dementia in the 7 Years Before Death

OBJECTIVES

Care for older adults with dementia during the final years of life is costly, and families shoulder much of this burden. We aimed to assess the financial burden of care for those with and without dementia, and to explore differences across residential settings.

DESIGN

Using the Health and Retirement Study (HRS) and linked claims, we examined total healthcare spending and proportion by payer-Medicare, Medicaid, out-of-pocket, and calculated costs of informal caregiving-over the last 7 years of life, comparing those with and without dementia and stratifying by residential setting.

SETTING

The HRS is a nationally representative longitudinal study of older adults in the United States.

PARTICIPANTS

We sampled HRS decedents from 2004 to 2015. To ensure complete data, we limited the sample to those 72 years or older at death who had continuous fee-for-service Medicare Parts A and B coverage during the 7-year period (n = 2909).

MEASUREMENTS

We compared decedents with dementia at last HRS assessment with those without dementia across annual and cumulative 7-year spending measures, and personal characteristics. We present annual and cumulative spending by payer, and the changing proportion of spending by payer over time, comparing those with and without dementia and stratifying results by residential setting.

RESULTS

We found that, consistent with prior studies, people with dementia experience significantly higher costs, with a disproportionate share falling on patients and families. This pattern is most striking among community residents with dementia, whose families shoulder 64% of total expenditures (including $176,180 informal caregiving costs and $55,550 out-of-pocket costs), compared with 43% for people with dementia residing in nursing homes ($60,320 informal caregiving costs and $105,590 out-of-pocket costs).

CONCLUSION

These findings demonstrate disparities in financial burden shouldered by families of those with dementia, particularly among those residing in the community. They highlight the importance of considering the residential setting in research, programs, and policies. J Am Geriatr Soc 68:1319-1324, 2020.

The Epidemiology of Depressive Symptoms in the Last Year of Life

BACKGROUND/OBJECTIVE

Depression impacts quality of life at all life stages, but the epidemiology of depression in the last year of life is unknown. This study's objectives were to document the epidemiology of depressive symptoms in the year prior to death and to assess how the trajectory of depressive symptoms varies by sociodemographic and clinical factors.

DESIGN

Observational, cross-sectional, cohort study using the Health and Retirement Study.

SETTING

Population-based survey.

PARTICIPANTS

A total of 3274 individuals who died within 12 months after assessment.

MEASURES

Primary outcome: eight-item Center for Epidemiologic Studies Depression Scale (CESD-8). Covariates included sociodemographics, self-reported illnesses, and activity of daily living (ADL) limitations.

RESULTS

Average CESD-8 score increased over the last year of life, with 59.3% screening positive for depression in the last month before death. Depression symptoms increased gradually from 12 to 4 months before death (increase of 0.05 points/month; 95% confidence interval [CI] = 0.01-0.08 points/month) and then escalated from 4 to 1 months before death (increase of 0.29 points/month; 95% CI = 0.16-0.39 points/month). Women, younger adults, and nonwhite adults all demonstrated higher rates of depressive symptoms. Individuals with cancer reported escalating rates of depressive symptoms at the end of life, while individuals with lung disease and ADL impairment demonstrated persistently high rates throughout the year before death.

CONCLUSIONS

This study revealed high rates of depressive symptoms in the last year of life as well as differences in the burden of depressive symptoms. A public health approach must be taken to screen for and appropriately treat symptoms of depression across the lifespan. J Am Geriatr Soc 68:321-328, 2020.

Development and Validation of the ACP-CAT for Assessing the Quality of Advance Care Planning Communication

CONTEXT

High-quality advance care planning (ACP) discussions are important to ensure patient receipt of goal-concordant care; however, there is no existing tool for assessing ACP communication quality.

OBJECTIVES

The objective of this study was to develop and validate a novel instrument that can be used to assess ACP communication skills of clinicians and trainees.

METHODS

We developed a 20-item ACP Communication Assessment Tool (ACP-CAT) plus two summative items. Randomized rater pairs assessed residents' performances in video-recorded standardized patient encounters before and after an ACP training program using the ACP-CAT. We tested the tool for its 1) discriminating ability, 2) interrater reliability, 3) concurrent validity, 4) feasibility, and 5) raters' satisfaction.

RESULTS

Fifty-eight pre/post-training video recordings from 29 first-year internal medicine residents at Mount Sinai Hospital were evaluated. ACP-CAT reliably discriminated performance before and after training (median score 6 vs. 11, P < 0.001). For both pre/post-training encounters, interrater reliability was high for ACP-CAT total scores (intraclass correlation coefficient or ICC = 0.83 and 0.82) and the summative items Overall impression of ACP communication skills (ICC = 0.73 and 0.80) and Overall ability to respond to emotion (ICC = 0.83 and 0.82). Concurrent validity was shown by the strong correlation between ACP-CAT total score and both summative items. Raters spent an average of 4.8 minutes to complete the ACP-CAT, found it feasible, and were satisfied with its use.

CONCLUSION

ACP-CAT provides a validated measure of ACP communication quality for assessing video-recorded encounters and can be further studied for its applicability with clinicians in different clinical contexts.

Defining Serious Illness Among Adult Surgical Patients

CONTEXT

Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context.

OBJECTIVES

The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts.

METHODS

We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement.

RESULTS

All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V.

CONCLUSION

We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.

One-Year Mortality After Dialysis Initiation Among Older Adults

This cohort study examines the incidence of mortality 1 year after the start of hemodialysis in patients 65 years and older.

Identifying Older Adults With Serious Illness: Transitioning From ICD-9 to ICD-10

CONTEXT

Identifying the seriously ill population is integral to improving the value of health care. Efforts to identify this population using existing data are anchored to a list of severe medical conditions (SMCs) using diagnostic codes. Published approaches have used International Classification of Diseases, Ninth Revision (ICD-9) codes, which has since been replaced by ICD-10.

OBJECTIVES

We translated SMCs from ICD-9 to ICD-10 using a refined code list. We aimed to test the hypothesis that people identified by ICD-9 or ICD-10 codes would have similar Medicare costs, health care utilization, and mortality.

METHODS

Using data from the National Health and Aging Trends Study linked to Medicare claims, we compared samples from periods using ICD-9 (2014) and ICD-10 (2016). We included participants with six-month fee-for-service Medicare data before their interview date who had an SMC identified within that period. We compared the groups' demographic, functional, and medical characteristics and followed up them for six months to compare outcomes.

RESULTS

Among subjects in the 2016 (ICD-10) sample, 19.9% were hospitalized, 24.6% used the emergency department, 7.2% died, and average Medicare spending totaled $9902.04 over six months of follow-up. We observed no significant differences between the 2014 and 2016 samples (P > 0.05); both samples represent 18% of Medicare fee-for-service beneficiaries.

CONCLUSION

Identifying the seriously ill population using currently available data requires using ICD-10 to define SMCs. Routine measurement of function, quality of life, and caregiver strain will further enhance the identification process and efficiently target palliative care services and appropriate quality measures.