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Association of Medicare eligibility with access to and affordability of care among older cancer survivors. J Cancer Surviv 2024:10.1007/s11764-024-01562-x. [PMID: 38520599 DOI: 10.1007/s11764-024-01562-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE Older cancer survivors have substantial needs for ongoing care, but they may encounter difficulties accessing care due to cost concerns. We examined whether near-universal insurance coverage through Medicare-a key source of health insurance coverage in this population-is associated with improvements in care access and affordability among older cancer survivors around age 65. METHODS In a nationally representative sample of cancer survivors (aged 50-80) from 2006-2018 National Health Interview Survey, we employed a quasi-experimental, regression discontinuity design to estimate changes in insurance coverage, delayed/skipped care due to cost, and worries about or problems paying medical bills at age 65. RESULTS Medicare coverage sharply increased from 8.3% at age 64 to 98.2% at age 65, ensuring near-universal insurance coverage (99.5%). Medicare eligibility at age 65 was associated with reductions in delayed/skipped care due to cost (discontinuity, - 5.7 percentage points or pp; 95% CI, - 8.1, - 3.3; P < .001), worries about paying for medical bills (- 7.7 pp; 95% CI, - 12.0, - 3.2; P = .001), and problems paying medical bills (- 3.2 pp; 95% CI, - 6.1, - 0.2; P = .036). However, a sizable proportion reported any access or affordability problems (29.7%) between ages 66 and 80. CONCLUSIONS Near-universal Medicare coverage at age 65 was associated with a reduction-but not elimination-of access and affordability problems among cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS These findings reaffirm the role of Medicare in improving access and affordability for older cancer survivor and highlight opportunities for reforms to further alleviate financial burden of care in this population.
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Supplemental Oxygen Therapy in Interstitial Lung Disease: A Narrative Review. Ann Am Thorac Soc 2023; 20:1541-1549. [PMID: 37590496 DOI: 10.1513/annalsats.202304-391cme] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/17/2023] [Indexed: 08/19/2023] Open
Abstract
Patients with interstitial lung diseases (ILD) often have hypoxemia at rest and/or with exertion, for which supplemental oxygen is commonly prescribed. The number of patients with ILD who require supplemental oxygen is unknown, although estimates suggest it could be as much as 40%; many of these patients may require high-flow support (>4 L/min). Despite its frequent use, there is limited evidence for the impact of supplemental oxygen on clinical outcomes in ILD, with recommendations for its use primarily based on older studies in patients with chronic obstructive pulmonary disease. Oxygen use in ILD is rarely included as an outcome in clinical trials. Available evidence suggests that supplemental oxygen in ILD may improve quality of life and some exercise parameters in patients whose hypoxemia is a limiting factor; however, oxygen therapy also places new burdens and barriers on some patients that may counter its beneficial effects. The cost of supplemental oxygen in ILD is also unknown but likely represents a significant portion of overall healthcare costs in these patients. Current Centers for Medicare and Medicaid reimbursement policies provide only a modest increase in payment for high oxygen flows, which may negatively impact access to oxygen services and equipment for some patients with ILD. Future studies should examine clinical and quality-of-life outcomes for oxygen use in ILD. In the meantime, given the current limited evidence for supplemental oxygen and considering cost factors and other barriers, providers should take a patient-focused approach when considering supplemental oxygen prescriptions in patients with ILD.
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Nursing Home Reform in the Context of National Long-Term Care Services and Policy: The Devil in the Details of the National Academies Report. J Am Geriatr Soc 2023; 71:357-361. [PMID: 36795631 DOI: 10.1111/jgs.18273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
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2022 NASEM Quality of Nursing Home Report: Moving Recommendations to Action. J Am Geriatr Soc 2023; 71:318-321. [PMID: 36795630 DOI: 10.1111/jgs.18274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
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Risk of hospitalization associated with different constellations of home & community based services. BMC Geriatr 2023; 23:36. [PMID: 36670350 PMCID: PMC9862558 DOI: 10.1186/s12877-022-03676-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/05/2022] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Identify the association between specific combinations of home and community-based services (HCBS) and risk of acute hospitalization. METHODS Data for this study came from Pennsylvania Medicaid claims and Medicare records. This was a retrospective, observational cohort study that examined hospitalization, HCBS service use and patient characteristics between July, 2014 and December, 2016. This analysis compared risk of inpatient hospitalization risk for community dwelling disabled older adults using a range of Medicaid financed HCBS. Twelve constellations of HCBS were identified representing different combinations of common services (personal assistive services [PAS], delivered meals, and adult day care). Since HCBS users are not randomly assigned to different combinations of services, we used logistic regression to estimate the predicted probability of experiencing hospitalization conditional on the constellation of services, and adjusting for demographics, health and level of disability. RESULTS The most common constellation was people who used under four hours of PAS per person per day. This group experienced a hospitalization rate of 13.7%. however, those individuals receiving more than 4 h per person per day experienced only a 10.2% hospitalization rate. Similar trends were seen for people who used PAS in combination with home delivered meals. However, those who used adult day care experienced higher hospitalization rates as the number of hours of personal assistive service increased: increasing from 6.8% among those with under 4 h, to 8.6% among those with 8 or more hours per person per day. CONCLUSION Using medium and high levels of PAS was associated with lower hospitalization risk for people who PAS alone or in combination with delivered meals. By contrast, higher levels of PAS was associated with increased hospitalization for adult day users (both alone or in combination). Policy makers should consider offering higher levels of PAS to offset potential risk of hospitalization. Future research is needed to explain the association between adult day care and risk.
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Evidence Base for the Future of Nursing Homes: Special Issue. Innov Aging 2022; 6:igac039. [PMID: 35832203 PMCID: PMC9273401 DOI: 10.1093/geroni/igac039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Patterns of Home and Community Based Service Use by Beneficiaries Enrolled in the Pennsylvania Medicaid Aging Waiver. J Appl Gerontol 2022; 41:1870-1877. [PMID: 35593519 DOI: 10.1177/07334648221094578] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This study examines multiple services are used across a population and the association between type and amount of services use with level of disability and living arrangement. METHODS This is a descriptive cross-sectional analysis examining HCBS use among older Pennsylvanians from 2014 to 2016 enrolled in Pennsylvania's 1915(c) waiver program. Data were derived from Medicaid claims. Logistic regression and OLS regression were used to examine the association between service use and level of disability, controlling for age, gender, race, and other covariates. RESULTS People with Alzheimer's or a related dementia were more likely to use adult day care. People with higher ADL and IADL limitations were more likely to use higher amounts of PAS and less likely to have delivered meals. CONCLUSIONS These findings demonstrate HCBS is a complex package of services that are allocated regarding the level of need and resources available to individual program participants.
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The Gerontologist Adopts New Transparency and Openness Guidelines. THE GERONTOLOGIST 2022; 62:149-151. [PMID: 34972857 DOI: 10.1093/geront/gnab154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Workforce Issues in Long-Term Care: Is There Hope for a Better Way Forward? THE GERONTOLOGIST 2021; 61:483-486. [PMID: 33757125 DOI: 10.1093/geront/gnab040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Home- and Community-Based Provider Preparation for Pennsylvania's Managed Long-term Services and Supports. J Aging Soc Policy 2021; 33:268-284. [PMID: 33461429 DOI: 10.1080/08959420.2020.1824537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
As Pennsylvania implements its managed long-term services and supports program, we explore how home- and community-based providers are preparing for and perceiving the transition through an online survey. We summarize responses and conduct chi-square analysis to measure differences between select provider groups. Despite high levels of uncertainty about program impact, over 84% of respondents plan to participate. We found that providers in the first implementation phase had more strategic and operational discussions with MCOs than the other two phases (p < .03). As program rollout continues, we anticipate changes in MCO-provider conversation frequency and topics based upon implementation zone.
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The Importance of Ascertaining Participant Preferences: The Importance of What Is Important. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2021; 64:8-20. [PMID: 33390098 DOI: 10.1080/01634372.2020.1864799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/13/2020] [Accepted: 12/13/2020] [Indexed: 06/12/2023]
Abstract
Rosalie Kane made major contributions to research on ascertaining personal preferences. Her work influenced others and was part of a growing movement to place high priority on the voice and subjective experience of people who live with Long-Term Services and Supports (LTSS). This essay summarizes some highlights of Rosalie's research, and traces the idea of incorporating participant preferences through different programs, policies and measurement tools over the past three decades. The current policy environment takes as paramount the notion that participants in LTSS programs should have an active role in planning their own care. While language supporting preferences is not new, the technology to effectively and efficiently elicit preferences is relatively recent. Key milestones in the development of these policies are reviewed. Rosalie's influence on generations of researchers and policy makers cannot be understated. She challenged colleagues, state program agencies and program directors to consider "the art of the possible," pushing them to explore how LTSS could fully support the dignity, independence and autonomy of every participant. A remaining challenge for researchers, policy makers and program managers is to move beyond incorporating preferences and choices as outcomes, and develop methods to accountably and reliably measure and incorporate individual goals of care into LTSS care plans. As LTSS continues to shift more and more into home and community-based settings, the quality of care and the quality of life for people who rely on those services will demand more subtle and individualized measures of processes and outcomes.
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Celebrating Rosalie Kane (1940–2020). THE GERONTOLOGIST 2020; 60:1381-1383. [DOI: 10.1093/geront/gnaa117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Change in Functional Status After Prostate Cancer Treatment Among Medicare Advantage Beneficiaries. Urology 2019; 131:104-111. [PMID: 31181274 DOI: 10.1016/j.urology.2019.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/06/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine the relationship between treatment and subsequent functional status among prostate cancer patients. METHODS Using Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data, we identified men 65 years or older diagnosed with prostate cancer between 1998 and 2009 (follow-up through 2010) who were treated with conservative management, surgery, or radiation. Our primary outcome was functional status as measured by activities of daily living. Secondary outcomes included physical component summary and mental component summary scores, which are both calculated from the Short Form 36 (SF-36) and the Veterans RAND 12-item health survey (VR-12) questionnaires. We included patients who completed 2 surveys and performed propensity score analyses to match patients 1:5 with noncancer controls. We used generalized linear mixed effects models, accounting for clustering due to insurance plan. RESULTS We identified 408 patients of whom 143 (35%) underwent conservative management, 59 (14%) underwent surgery, and 206 (51%) underwent radiation. Among conservative management and radiation patients, changes in functional status mirrored that of their noncancer controls (all P > .05). Among surgery patients, changes in activities of daily living scores were not significant, but physical component summary (mean difference = 4.5, P < .001) and mental component summary (mean difference = 3.3, P = .01) scores declined slightly more than for their noncancer peers. CONCLUSION Surgery patients had a slight decline in their general functional status whereas conservative management and radiation patients had no differences in functional status compared with their noncancer peers. Although the functional status of surgery patients declined more than that of their noncancer peers, this difference may not be clinically significant.
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The Patients Save Lives Program to Facilitate Organ Donor Designation in Primary Care Offices. Prog Transplant 2019; 29:204-212. [PMID: 31232179 DOI: 10.1177/1526924819853836] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are about 120 000 people on the US waiting list for a solid organ transplant; nearly 22 people die every day who could be helped through organ donation. Joining a donor registry and informing one's family of one's preferences increases recovery rates and can avoid misunderstandings during an emotionally difficult time. Although the vast majority of people support organ donation, only about half of adults have joined a state donor registry. Methods. A 3-group design was used. Primary care physician offices were randomly assigned to either web-based training, in-person training, or a control condition. The control condition consisted of a poster and traditional brochure and donor form placed in the waiting room. In the 2 intervention groups, the Patients Save Lives form was distributed during the check-in process in addition to the poster. RESULTS A total of 1521 physicians and office staff at 81 clinic sites (48 in-person and 33 web-based) received the training; there were 33 control locations. A total of 21 189 patients were exposed to the intervention over a 6-month period; 761 (8.1%) of 9428 people who were not already registered completed the designation form to be organ donors. There were no donor designations in the control group locations. CONCLUSION Organ donor designation can be incorporated into the office check-in procedure without disrupting the workflow or burdening clinicians. The program is available online and can be sustained inexpensively with cooperation between primary care offices and regional Organ Procurement Organizations.
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MEDICAID MANAGED LONG-TERM SERVICES AND SUPPORTS IN PENNSYLVANIA: POLICY CHANGE WITH A COMMITMENT TO EVALUATION. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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COMMUNITY HEALTHCHOICES: MANAGED LTSS FOR PENNSYLVANIA DUAL ELIGIBLE AND DISABLED ADULTS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Broad Consent for Research on Biospecimens: The Views of Actual Donors at Four U.S. Medical Centers. J Empir Res Hum Res Ethics 2018; 13:115-124. [PMID: 29390947 PMCID: PMC5869128 DOI: 10.1177/1556264617751204] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Commentators are concerned that broad consent may not provide biospecimen donors with sufficient information regarding possible future research uses of their tissue. We surveyed with interviews 302 cancer patients who had recently provided broad consent at four diverse academic medical centers. The majority of donors believed that the consent form provided them with sufficient information regarding future possible uses of their biospecimens. Donors expressed very positive views regarding tissue donation in general and endorsed the use of their biospecimens in future research across a wide range of contexts. Concerns regarding future uses were limited to for-profit research and research by investigators in other countries. These results support the use of broad consent to store and use biological samples in future research.
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Abstract
Hierarchical logistic regression was used with the results of a factorial vignette survey of a national sample of case managers for the disabled elderly in Medicaid home- and community-based services waiver programs. The effects of client, case manager, and agency factors on case managers’out-of-home placement decisions in response to hypothetical case studies were estimated. Results show that client preferences, workload, and division of labor affect the probability that a case manager will recommend an out-of-home placement, controlling for client’s physical and cognitive disability and the available resources. Significant variation among individuals was found. Implications of the findings are discussed.
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Association of functional status and treatment choice among older men with prostate cancer in the Medicare Advantage population. Cancer 2016; 122:3199-3206. [PMID: 27379732 DOI: 10.1002/cncr.30184] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 06/05/2016] [Accepted: 06/07/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND There are several effective treatments for prostate cancer. To what extent a patient's functional status influences the treatment decision is unknown. This study examined the association between functional status and treatment among older men with prostate cancer. METHODS Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey data were used to identify men who were 65 years old or older and were diagnosed with prostate cancer between 1998 and 2009. The primary outcome was treatment choice: conservative management, surgery, or radiation within 1 year of the diagnosis. The exposure was the functional status assessed as 4 measures within 3 domains: 1) physical function (activities of daily living [ADLs] and physical component summary score), 2) cognitive function (survey completer: self vs proxy), and 3) emotional well-being (mental component summary score). A multivariate, multinomial logistic regression was fitted with adjustments for several patient, tumor, and regional characteristics. RESULTS This study identified 508 conservative management patients, 195 surgery patients, and 603 radiation patients. Compared with men with no ADL dependency, those with any ADL dependency had lower odds of receiving surgery (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.38-0.99) or radiation (OR, 0.58; 95% CI, 0.43-0.78) versus conservative management. ADL dependency did not differ when surgery and radiation were compared. Patients with a proxy survey response were less likely to receive surgery or radiation versus conservative management. CONCLUSIONS Functional status is associated with treatment choice for men with prostate cancer. Future research should examine whether this is due to physician recommendations, patient preferences, or a combination. Cancer 2016;122:3199-206. © 2016 American Cancer Society.
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Variations Among Medicare Beneficiaries Living in Different Settings: Demographics, Health Status, and Service Use. Res Aging 2016; 38:602-16. [PMID: 26269562 PMCID: PMC4752425 DOI: 10.1177/0164027515598557] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Older people with complex health issues and needs for functional support are increasingly living in different types of residential care environments as alternatives to nursing homes. This study aims to compare the demographics and health-care expenditures of Medicare beneficiaries by the setting in which they live: nursing homes, residential care settings, and at home using data from the 2002 to 2010 Medicare Current Beneficiary Study (MCBS), a nationally representative survey of the Medicare population. All Medicare beneficiaries aged 65 years or older who participated in the fall MCBS interview (years 2002-2010) and were alive for the full year (N = 83,507) were included in the sample. We found that there is a gradient in health status, physical and cognitive functioning, and health-care use and spending across settings. Minority elderly are overrepresented in facilities and underrepresented in alternative living settings.
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Development of an Applied Framework for Understanding Health Information Technology in Nursing Homes. J Am Med Dir Assoc 2016; 17:434-40. [PMID: 26975206 DOI: 10.1016/j.jamda.2016.02.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 11/28/2022]
Abstract
There is growing evidence that Health Information Technology (HIT) can play a role in improving quality of care and increasing efficiency in the nursing home setting. Most research in this area, however, has examined whether nursing homes have or use any of a list of available technologies. We sought to develop an empirical framework for understanding the intersection between specific uses of HIT and clinical care processes. Using the nominal group technique, we conducted a series of focus groups with different types of personnel who work in nursing homes (administrators, directors of nursing, physicians, mid-level practitioners, consultant pharmacists, and aides). The resulting framework identified key domain areas that can benefit from HIT: transfer of data, regulatory compliance, quality improvement, structured clinical documentation, medication use process, and communication. The framework can be used to guide both descriptive and normative research.
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Effect of web-based training for Department of Motor Vehicle staff on donor designation rates: results of a statewide randomized trial. Am J Transplant 2015; 15:1376-83. [PMID: 25777987 DOI: 10.1111/ajt.13117] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 11/12/2014] [Accepted: 11/13/2014] [Indexed: 01/25/2023]
Abstract
On approach to addressing the continual shortage of organ donors is to encourage people to join a state donor registry. Joining the registry saves time and assures family members that organ donation is what their loved one would want. However, fewer than half of adults have taken this step. We tested a brief, web-based training program for department of motor vehicles (DMV) staff that educates them about organ and tissue donation and also models the correct way to interact with customers. The intervention was developed with extensive input and active participation from DMV staff. After a small-scale pilot test, all DMV offices across the state of West Virginia (WV) were randomized to receive the training or serve as a comparison group. The results showed that customers of DMV staff who had received the training were 7.5% more likely to register as organ donors. A conservative estimate is that this generates approximately 800 additional donor designations per month. An important aspect of web-based training is that once it has been deployed, it can continue to be used without incurring additional cost; the state of WV currently requires all new employees to complete the training program. This type of training can be adopted nationwide.
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Knowledge, attitudes, and preferences of healthy young adults regarding advance care planning: a focus group study of university students in Pittsburgh, USA. BMC Public Health 2015; 15:197. [PMID: 25885778 PMCID: PMC4349677 DOI: 10.1186/s12889-015-1575-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To date, research and promotion regarding advance care planning (ACP) has targeted those with serious illness or the elderly, thereby ignoring healthy young adults. The purpose of this study was to explore young adults' knowledge, attitudes, and preferences regarding advance care planning (ACP) and medical decision-making. Further, we aimed to understand the potential role of public health to encourage population-based promotion of ACP. METHODS Between February 2007 and April 2007, we conducted six focus groups comprising 56 young adults ages 18-30. Topics explored included (1) baseline knowledge regarding ACP, (2) preferences for ACP, (3) characteristics of preferred surrogates, and (4) barriers and facilitators to completing ACP specific to age and individuation. We used a qualitative thematic approach to analyze transcripts. RESULTS All participants desired more information regarding ACP. In addition, participants expressed (1) heterogeneous attitudes regarding triggers to perform ACP, (2) the opinion that ACP is a marker of individuation, (3) the belief that prior exposure to illness plays a role in prompting ACP, and (4) an appreciation that ACP is flexible to changes in preferences and circumstances throughout the life-course. CONCLUSION Young adults perceive ACP as a worthwhile health behavior and view a lack of information as a major barrier to discussion and adoption. Our data emphasize the need for strategies to increase ACP knowledge, while encouraging population-level, patient-centered, healthcare decision-making.
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Effect of dementia on the use of drugs for secondary prevention of ischemic heart disease. J Aging Res 2014; 2014:897671. [PMID: 24719764 PMCID: PMC3955600 DOI: 10.1155/2014/897671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 01/06/2014] [Indexed: 01/19/2023] Open
Abstract
Background. Dementia and cardiovascular disease (CVD) are frequently comorbid. The presence of dementia may have an effect on how CVD is treated. Objective. To examine the effect of dementia on the use of four medications recommended for secondary prevention of ischemic heart disease (IHD): angiotensin-converting enzyme inhibitors, beta-blockers, lipid-lowering medications, and antiplatelet medications. Design. Retrospective analysis of data from the Cardiovascular Health Study: Cognition Study. Setting and Subjects. 1,087 older adults in four US states who had or developed IHD between 1989 and 1998. Methods. Generalized estimating equations to explore the association between dementia and the use of guideline-recommended medications for the secondary prevention of IHD. Results. The length of follow-up for the cohort was 8.7 years and 265 (24%) had or developed dementia during the study. Use of medications for the secondary prevention of IHD for patients with and without dementia increased during the study period. In models, subjects with dementia were not less likely to use any one particular class of medication but were less likely to use two or more classes of medications as a group (OR, 0.60; 95% CI, 0.36-0.99). Conclusions. Subjects with dementia used fewer guideline-recommended medications for the secondary prevention of IHD than those without dementia.
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Early hospital readmission is a predictor of one-year mortality in community-dwelling older Medicare beneficiaries. J Gen Intern Med 2012; 27:1467-74. [PMID: 22692634 PMCID: PMC3475824 DOI: 10.1007/s11606-012-2116-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 04/18/2012] [Accepted: 04/25/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hospital readmission within thirty days is common among Medicare beneficiaries, but the relationship between rehospitalization and subsequent mortality in older adults is not known. OBJECTIVE To compare one-year mortality rates among community-dwelling elderly hospitalized Medicare beneficiaries who did and did not experience early hospital readmission (within 30 days), and to estimate the odds of one-year mortality associated with early hospital readmission and with other patient characteristics. DESIGN AND PARTICIPANTS A cohort study of 2133 hospitalized community-dwelling Medicare beneficiaries older than 64 years, who participated in the nationally representative Cost and Use Medicare Current Beneficiary Survey between 2001 and 2004, with follow-up through 2006. MAIN MEASURE One-year mortality after index hospitalization discharge. KEY RESULTS Three hundred and four (13.7 %) hospitalized beneficiaries had an early hospital readmission. Those with early readmission had higher one-year mortality (38.7 %) than patients who were not readmitted (12.1 %; p<0.001). Early readmission remained independently associated with mortality after adjustment for sociodemographic factors, health and functional status, medical comorbidity, and index hospitalization-related characteristics [HR (95 % CI) 2.97 (2.24-3.92)]. Other patient characteristics independently associated with mortality included age [1.03 (1.02-1.05) per year], low income [1.39 (1.04-1.86)], limited self-rated health [1.60 (1.20-2.14)], two or more recent hospitalizations [1.47 (1.01-2.15)], mobility difficulty [1.51 (1.03-2.20)], being underweight [1.62 (1.14-2.31)], and several comorbid conditions, including chronic lung disease, cancer, renal failure, and weight loss. Hospitalization-related factors independently associated with mortality included longer length of stay, discharge to a skilled nursing facility for post-acute care, and primary diagnoses of infections, cancer, acute myocardial infarction, and heart failure. CONCLUSIONS Among community-dwelling older adults, early hospital readmission is a marker for notably increased risk of one-year mortality. Providers, patients, and families all might respond profitably to an early readmission by reviewing treatment plans and goals of care.
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End-of-life and formal and informal care use of community-dwelling older adults with different levels of physical disability. J Am Geriatr Soc 2012; 59:1983-4. [PMID: 22091523 DOI: 10.1111/j.1532-5415.2011.03610_15.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Physician Follow-Up Visits After Acute Care Hospitalization for Elderly Medicare Beneficiaries Discharged to Noninstitutional Settings. J Am Geriatr Soc 2011; 59:1947-54. [DOI: 10.1111/j.1532-5415.2011.03572.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
RATIONALE Studies of long-term functional outcomes of elderly survivors of mechanical ventilation (MV) are limited to local samples and biased retrospective, proxy-reported preadmission functional status. OBJECTIVES To assess the impact on disability of hospitalization with MV, compared with hospitalization without MV, accounting for prospectively assessed prior functional status. METHODS Retrospective population-based longitudinal cohort study of Medicare beneficiaries age 65 and older enrolled in the Medicare Current Beneficiary Survey, 1996-2003. MEASUREMENTS AND MAIN RESULTS Premeasures and postmeasures of disability included mobility difficulty and weighted activities of daily living disability scores ranging from 0 (not disabled) to 100 (completely disabled) based on self-reported health and functional status collected 1 year apart. Among 54,771 person-years (PY) of observation over 7 calendar years of data, 42,890 PY involved no hospitalization, 11,347 PY involved a hospitalization without MV, and 534 PY included a hospitalization with MV. Mortality at 1 year was 8.9%, 23.9%, and 72.5%, respectively. The level of disability at the postassessment was substantially higher for a prototypical patient who survived after hospitalization with MV (adjusted activities of daily living disability score [95% confidence interval] 14.9 [12.2-17.7]; adjusted mobility difficulty score [95% confidence interval] 25.4 [22.4-28.4]) compared with an otherwise identical patient who survived hospitalization without MV (11.5 [11.1-11.9] and 22.3 [21.8-22.9]) or who was not hospitalized (8.0 [7.9-8.1] and 13.4 [13.3-13.6]). CONCLUSIONS The greater marginal increase in disability among survivors of MV compared with survivors of hospitalization without MV is larger than would be predicted from prior functional status.
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Biopsychosocial characteristics of community-dwelling older adults with limited ability to walk one-quarter of a mile. J Am Geriatr Soc 2010; 58:539-44. [PMID: 20210817 DOI: 10.1111/j.1532-5415.2010.02727.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To establish nationally representative estimates of the prevalence of self-reported difficulty and inability of older adults to walk one-quarter of a mile and to identify the characteristics independently associated with difficulty or inability to walk one-quarter of a mile. DESIGN Cross-sectional analysis of data from the 2003 Cost and Use Medicare Current Beneficiary Survey. SETTING Community. PARTICIPANTS Nine thousand five hundred sixty-three community-dwelling Medicare beneficiaries aged 65 and older, representing an estimated total population of 34.2 million older adults. MEASUREMENTS Self-reported ability to walk one-quarter of a mile, sociodemographics, chronic conditions, body mass index, smoking, functional status. RESULTS In 2003, an estimated 9.5 million older Medicare beneficiaries had difficulty walking one-quarter of a mile, and 5.9 million were unable to do so. Of the 20.2 million older adults with no difficulty in activities of daily living (ADLs) or instrumental activities of daily living (IADLs), an estimated 4.3 million (21%) had limited ability to walk one-quarter of a mile. Having difficulty or being unable to walk one-quarter of a mile was independently associated with older age, female sex, non-Hispanic ethnicity, lower educational level, Medicaid entitlement, most chronic medical conditions, current smoking, and being overweight or obese. CONCLUSION Almost half of older adults and 20% of those reporting no ADL or IADL limitations report limited ability to walk one-quarter of a mile. For functionally independent older adults, reported ability to walk one-quarter of a mile can identify vulnerable older adults with greater medical problems and fewer resources and may be a valuable clinical marker in planning their care. Future work is needed to determine the association between ability to walk one-quarter of a mile walk and subsequent functional decline and healthcare use.
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Using Audio Computer-Assisted Self-Interviewing and Interactive Voice Response to Measure Elder Mistreatment in Older Adults: Feasibility and Effects on Prevalence Estimates. JOURNAL OF OFFICIAL STATISTICS 2010; 26:507-533. [PMID: 21113391 PMCID: PMC2990982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Demographic trends indicate an aging population, highlighting the importance of collecting valid survey data from older adults. One potential issue when surveying older adults is use of technology to collect data on sensitive topics. Survey technologies like A-CASI and IVR have not been used with older adults to measure elder mistreatment. We surveyed 903 adults age 60 and older in Allegheny County, Pennsylvania (U.S.) with random assignment to one of four survey modes: (1) CAPI, (2) A-CASI, (3) CATI; and (4) IVR. We assessed financial, psychological, and physical mistreatment, and examined feasibility of A-CASI and IVR, and effects on prevalence estimates relative to CAPI and CATI. Approximately 83% of elders randomized to A-CASI/IVR used each technology, although 28% of respondents in the A-CASI condition refused to use headphones and read the questions instead. A-CASI produced higher six month prevalence rates of financial and psychological mistreatment than CAPI. IVR produced higher six month prevalence rates of psychological mistreatment than CATI. We conclude that, while IVR may be useful, A-CASI offers a more promising approach to the measurement of elder mistreatment.
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Abstract
BACKGROUND Hierarchical modeling (HM) is a statistical technique that has gained in popularity in health care research. It has been used for analysis of secondary data, performance profiles or benchmarking studies, and in prospective trials. The technique is used in situations in which traditional regression analysis might lead to incorrect conclusions. Specifically, data drawn from nested settings such as hospital units or hospice providers may be correlated, thus violating an assumption required for ordinary least squares regression. OBJECTIVE This article provides a description of HM, reviews two recent articles in palliative care that have used the technique, and presents an illustrative case study to further illuminate the potential of the method. CONCLUSION When used appropriately, HM allows researchers to specify and test hypotheses that would not otherwise be possible, and avoid incorrect conclusions from nested data.
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Estimating the Quantity and Economic Value of Family Caregiving for Community-Dwelling Older Persons in the Last Year of Life. J Am Geriatr Soc 2009; 57:1654-9. [DOI: 10.1111/j.1532-5415.2009.02390.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE The purpose of this study was to determine the relationship between nursing home staffing level, care received by individual residents, and resident quality-related care processes and functional outcomes. DESIGN AND METHODS Nurses recorded resident care time for 5,314 residents on 156 units in 105 facilities in four states (Colorado, Indiana, Minnesota, and Mississippi). We linked residents' care times to their measures of health and functioning from Minimum Data Set assessments. Major variables were unit- and resident-specific minutes of care per day, process measures (physical restraints, range of motion, toileting program, and training in activities of daily living [ADLs]), outcome measures (ADL decline, mobility decline, and worsening behavior between the time study and 90-day follow-up), and covariates such as unit type and resident health status. We used multilevel analysis to examine staffing and quality relationships. RESULTS Residents with toileting programs, range of motion or ADL training, and restraints received significantly more care from unlicensed but not from licensed staff. However, functional outcomes were not significantly related to care received from licensed or unlicensed staff, except for ADL decline, which was greatest for residents receiving more unlicensed minutes of care. Unit staffing level (licensed and unlicensed) was unrelated to any of the care processes or outcome measures, although higher overall staffing was associated with more time devoted to direct resident care. IMPLICATIONS Future research into nursing home quality should focus on organization and delivery rather than simply the amount of care available.
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Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program. J Am Geriatr Soc 2007; 55:832-9. [PMID: 17537082 DOI: 10.1111/j.1532-5415.2007.01169.x] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the effects of a small-house nursing home model, THE GREEN HOUSE (GH), on residents' reported outcomes and quality of care. DESIGN Two-year longitudinal quasi-experimental study comparing GH residents with residents at two comparison sites using data collected at baseline and three follow-up intervals. SETTING Four 10-person GHs, the sponsoring nursing home for those GHs, and a traditional nursing home with the same owner. PARTICIPANTS All residents in the GHs (40 at any time) at baseline and three 6-month follow-up intervals, and 40 randomly selected residents in each of the two comparison groups. INTERVENTION The GH alters the physical scale environment (small-scale, private rooms and bathrooms, residential kitchen, dining room, and hearth), the staffing model for professional and certified nursing assistants, and the philosophy of care. MEASUREMENTS Scales for 11 domains of resident quality of life, emotional well-being, satisfaction, self-reported health, and functional status were derived from interviews at four points in time. Quality of care was measured using indicators derived from Minimum Data Set assessments. RESULTS Controlling for baseline characteristics (age, sex, activities of daily living, date of admission, and proxy interview status), statistically significant differences in self-reported dimensions of quality of life favored the GHs over one or both comparison groups. The quality of care in the GHs at least equaled, and for change in functional status exceeded, the comparison nursing homes. CONCLUSION The GH is a promising model to improve quality of life for nursing home residents, with implications for staff development and medical director roles.
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Identifying elderly at greatest risk of inadequate health literacy: A predictive model for population-health decision makers. Res Social Adm Pharm 2007; 3:70-85. [PMID: 17350558 DOI: 10.1016/j.sapharm.2006.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2006] [Revised: 06/03/2006] [Accepted: 06/03/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite concern that inadequate functional health literacy (FHL) is a widely prevalent problem and is associated with a variety of adverse health consequences, there is an absence of tools that population-health decision makers can use to efficiently identify those at risk of inadequate FHL. OBJECTIVES The objective of this study was to develop and validate a predictive model for estimating FHL in the elderly, generate a national estimate of FHL, and assess the construct validity of the national estimate. METHODS Using data from the largest study of FHL in the elderly, a multiple regression model to estimate FHL was developed and validated using common demographic predictors. Subsequently, the model was used to estimate FHL in the 65-year or older subgroup of the 1992 National Adult Literacy Survey (NALS). Construct validity of the FHL estimate was assessed by evaluating the direction, magnitude, and significance of association with reported general functional literacy (GFL) proficiency in the 1992 NALS. RESULTS A 20-variable model was derived (R2 = 0.365). The model correctly classified 73.2% of the sample into the appropriate FHL category. National prevalence of inadequate and marginal FHL was estimated to be 39.2% and 5.2%, respectively. FHL was significantly correlated with prose, document, and quantitative dimensions of GFL at r = 0.58 or higher (P<.0001). CONCLUSIONS This study was the first to quantitatively model and substantiate the high national prevalence of inadequate FHL in the elderly. The proposed quantitative model can be used in subsequent research to efficiently risk-stratify individuals by FHL level in large data sets to assess the relationships between FHL and health status, utilization, expenditures, and satisfaction. Furthermore, the model can be used to identify individuals at high risk of inadequate FHL, which will enable targeting of educational interventions that address FHL deficiencies.
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Abstract
PURPOSE A newly developed brief measure of nursing facility (NF) resident self-reported quality of life (QOL) has been proposed for inclusion in a modified version of the minimum data set (MDS). There is considerable interest in determining whether it is possible to develop indicators of QOL that are more convenient and less expensive than direct, in-person interviews with residents. DESIGN AND METHODS QOL interview data from 2,829 residents living in 101 NFs using a 14-item version of a longer instrument were merged with data from the MDS and the Online Survey and Certification Automated Record (OSCAR). Bivariate and multivariate hierarchical linear modeling were used to assess the association of QOL with potential resident and facility level indicators. RESULTS Resident and facility level indicators were associated with self-reported QOL in the expected direction. At the individual resident level, QOL is negatively associated with physical function, visual acuity, continence, being bedfast, depression, conflict in relationships, and positively associated with social engagement. At the facility level, QOL is negatively associated with citations for failing to accommodate resident needs or providing a clean, safe environment. The ratio of activities staff to residents is positively associated with QOL. This study did not find an association between QOL and either use of restraints or nurse staff levels. Approximately 9 percent of the total variance in self-reported QOL can be attributed to differences among facilities; 91 percent can be attributed to differences among residents. Resident level indicators explained about 4 percent of the variance attributable to differences among residents, and facility factors explained 49 percent of the variance attributable to differences among NFs. However, the different variables explained only 10 percent of the variance in self-reported QOL. IMPLICATIONS A brief self-report measure of NF resident QOL is consistently associated with measures that can be constructed from extant data sources. However, the level of prediction possible from these data sources does not justify reliance on external indicators of resident QOL for policy purposes.
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Assessing and Comparing Physical Environments for Nursing Home Residents: Using New Tools for Greater Research Specificity. THE GERONTOLOGIST 2006; 46:42-51. [PMID: 16452283 DOI: 10.1093/geront/46.1.42] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We developed and tested theoretically derived procedures to observe physical environments experienced by nursing home residents at three nested levels: their rooms, the nursing unit, and the overall facility. Illustrating with selected descriptive results, in this article we discuss the development of the approach. DESIGN AND METHODS On the basis of published literature, existing instruments, and expert opinion about environmental elements that might affect quality of life, we developed separate observational checklists for the room and bath environment, unit environment, and facility environment. We trained 40 interviewers without specialized design experience to high interrater reliability with the room-level assessment. We used the three checklists to assess 1,988 resident room and bath environments, 131 nursing units, and 40 facilities in five states. From the data elements, we developed quantitative indices to describe the facilities according to environmentally relevant constructs such as function-enhancing features, life-enriching features, resident environmental controls, and personalization. RESULTS We reliably gathered data on a large number of environmental items at three environmental levels. Environments varied within and across facilities, and we noted many environmental deficits potentially relevant to resident quality of life. IMPLICATIONS This research permits resident-specific data collection on physical environments and resident-level research using hierarchical analysis to examine the effects of specific environmental constellations. We describe practice and research implications for this approach.
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Do managed care plans reduce racial disparities in preventive care? J Health Care Poor Underserved 2005; 16:139-51. [PMID: 15741715 DOI: 10.1353/hpu.2005.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study was designed to determine whether managed care plans reduce racial disparities in use of influenza vaccination, mammography, and prostate-specific antigen screening. The study analyzed the use of three types of preventive care in a population-based sample of adults who were 65 years or older and were enrolled in a Medicare managed care (MMC) or fee-for-service (FFS) plan in Allegheny County, Pennsylvania. The study sample included 463 African Americans and 592 whites. Fewer African Americans than whites reported having had an influenza vaccination (64.4% versus 76.5%; p < 0.01) or a prostate-specific antigen test (64% versus 71.2%; p = 0.09) during the previous year. Slightly more African Americans than white women reported having had a mammogram (66.1% versus 63.8%). Logistic regression showed that, regardless of health plan type, African Americans were significantly less likely than whites to have an influenza vaccination (p < 0.05). A MMC plan did not narrow racial differences in preventive care. Reducing disparities may require interventions developed for specific racial/ethnic groups.
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Abstract
BACKGROUND Living wills, a type of advance directive, are promoted as a way for patients to document preferences for life-sustaining treatments should they become incompetent. Previous research, however, has found that these documents do not guide decision making in the hospital. OBJECTIVE To test the hypothesis that people with living wills are less likely to die in a hospital than in their residence before death. DESIGN Secondary analysis of data from a nationally representative longitudinal study. SETTING Publicly available data from the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. PATIENTS People older than 70 years of age living in the community in 1993 who died between 1993 and 1995. MEASUREMENTS Self-report and proxy informant interviews conducted in 1993 and 1995. RESULTS Having a living will was associated with lower probability of dying in a hospital for nursing home residents and people living in the community. For people living in the community, the probability of in-hospital death decreased from 0.65 (95% CI, 0.58 to 0.71) to 0.52 (CI, 0.42 to 0.62). For people living in nursing homes, the probability of in-hospital death decreased from 0.35 (CI, 0.23 to 0.49) to 0.13 (CI, 0.07 to 0.22). LIMITATIONS Retrospective survey data do not contain detailed clinical information on whether the living will was consulted. CONCLUSION Living wills are associated with dying in place rather than in a hospital. This implies that previous research examining only people who died in a hospital suffers from selection bias. During advance care planning, physicians should discuss patients' preferences for location of death.
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Abstract
BACKGROUND Quality of life (QOL) is a goal for nursing home residents, but measures are needed to tap this phenomenon. METHODS In-person QOL interviews were attempted for 1988 residents, stratified by cognitive functioning, from 40 nursing homes in five states. Likert-type response options were used with reversion to dichotomous responses when necessary; z-score transformations were used to combine the formats. Tests of internal consistency and confirmatory factor analysis were performed; cluster analysis was used to shorten the scales. Correlations between domain scores were examined, and tests of convergent validity performed. Analyses were repeated for subgroups based on cognitive functioning levels. RESULTS Long QOL scales were constructed for 1316 of the 1988 residents, including many with substantial cognitive impairment. Confirmatory factor analysis confirmed 10 QOL domains. Cronbach alphas ranged from.76 to.52. The majority (93%) of the 45 possible interscale correlations among domains were below.l4 and the rest were between.4 and.5. QOL scales were correlated with, but distinct from, residents' emotions ratings and overall satisfaction, and each was correlated with a corresponding summary rating for the domain. CONCLUSIONS QOL can be feasibly measured from resident self-report for much of the nursing home population, including cognitively impaired residents. Additional research is suggested on the measures, but the approach has promise for regulation, continuous quality improvement, and public information.
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Abstract
Employing the National Institute of Mental Health-funded Prevention of Suicide in Primary Care Elderly Collaborative Trial as a case study, we discuss 2 sets of ethical issues: obtaining informed consent for a clinic-based intervention study and using treatment as usual (TAU) as the control condition. We then address these ethical issues in the context of the debate about the quality improvement efforts of health care organizations. Our analysis reveals the tension between ethics and scientific integrity involved with using TAU as a control condition and the difficulty in designing high-quality research in a community-based setting.
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Abstract
This paper analyzes the association between race and the presence of advance care plan documents (living wills, do not resuscitate (DNR) orders, and do not hospitalize (DNH) orders) in nursing home residents. We conducted secondary analysis of publicly available survey data from the 1996 Medical Expenditure Panel Survey-Nursing Home Component, a nationally representative survey of nursing home residents in the United States. There were 3,747 participants in the survey, weighted to represent 1.56 million nursing home residents in the United States. We found that 20% of U.S. nursing home residents in 1996 had documentation of living wills, 48% had DNR orders, and 4% had DNH orders. African Americans are about one-third as likely as Caucasians to have living wills and one-fifth as likely as Caucasians to have DNR orders; Hispanics are about one-third as likely as Caucasians to have DNR orders and just as likely as Caucasians to have living wills. In conclusion, we found that the presence of advance care plans is related to race, even after controlling for health and other demographic factors. These findings call attention to an area where further research is needed to determine whether residents' (and their families') preferences are being elicited and documented.
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Book Review. HEALTH EDUCATION & BEHAVIOR 2002. [DOI: 10.1177/109019810202900112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Book Review: Health and Human Rights, Jonathan M. Mann, Sofia Gruskin, Michael A. Grodin, and George J. Annas (eds.). New York: Routledge, 1999, 505 pp. HEALTH EDUCATION & BEHAVIOR 2002. [DOI: 10.1177/1090198102029001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Adding values: an experiment in systematic attention to values and preferences of community long-term care clients. J Gerontol B Psychol Sci Soc Sci 1999; 54:S109-19. [PMID: 10097781 DOI: 10.1093/geronb/54b.2.s109] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We tested the effects of providing case managers with tools to assess and respond to client values and preferences on their subsequent knowledge of clients' values and their practices in arranging long-term care. METHOD Using a quasi-experimental design with newly enrolled, cognitively intact clients, we compared case managers, clients, and care plans at the experimental and control agency. RESULTS Three weeks after enrollment, experimental clients were significantly more likely to report that case managers had asked them about their own preferences and offered them choices about services. Actual client values reported at the 3-month follow-up were similar for the two groups, with experimental case managers only slightly more accurate judges of their clients' responses to values questions. At follow-up, experimental case managers reported more case activity tailoring plans to client preferences, a finding confirmed by record reviews. Client acuity, measured by ADL functioning and prior hospital use, was associated with less perceived discussion of client preferences during the initial care planning process, but more case activity related to client preferences during the first three months. DISCUSSION The study suggests it is possible to sensitize case managers to the importance of assessing and acting on client values. Getting them to do so consistently, however, may require changes in the practice environment.
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