Soluble Receptor for Advanced Glycation End Products (sRAGE) Isoforms Predict Changes in Resting Energy Expenditure in Adults with Obesity during Weight Loss

Background

Accruing evidence indicates that accumulation of advanced glycation end products (AGEs) and activation of the receptor for AGEs (RAGE) play a significant role in obesity and type 2 diabetes. The concentrations of circulating RAGE isoforms, such as soluble RAGE (sRAGE), cleaved RAGE (cRAGE), and endogenous secretory RAGE (esRAGE), collectively sRAGE isoforms, may be implicit in weight loss and energy compensation resulting from caloric restriction.

Objectives

We aimed to evaluate whether baseline concentrations of sRAGE isoforms predicted changes (∆) in body composition [fat mass (FM), fat-free mass (FFM)], resting energy expenditure (REE), and adaptive thermogenesis (AT) during weight loss.

Methods

Data were collected during a behavioral weight loss intervention in adults with obesity. At baseline and 3 mo, participants were assessed for body composition (bioelectrical impedance analysis) and REE (indirect calorimetry), and plasma was assayed for concentrations of sRAGE isoforms (sRAGE, esRAGE, cRAGE). AT was calculated using various mathematical models that included measured and predicted REE. A linear regression model that adjusted for age, sex, glycated hemoglobin (HbA1c), and randomization arm was used to test the associations between sRAGE isoforms and metabolic outcomes.

Results

Participants (n = 41; 70% female; mean ± SD age: 57 ± 11 y; BMI: 38.7 ± 3.4 kg/m2) experienced modest and variable weight loss over 3 mo. Although baseline sRAGE isoforms did not predict changes in ∆FM or ∆FFM, all baseline sRAGE isoforms were positively associated with ∆REE at 3 mo. Baseline esRAGE was positively associated with AT in some, but not all, AT models. The association between sRAGE isoforms and energy expenditure was independent of HbA1c, suggesting that the relation was unrelated to glycemia.

Conclusions

This study demonstrates a novel link between RAGE and energy expenditure in human participants undergoing weight loss.This trial was registered at clinicaltrials.gov as NCT03336411.

Characterizing Intervention Opportunities among Home-Delivered Meals Program Participants: Results from the 2017 National Survey of Older Americans Act Participants and a New York City Survey

BACKGROUND

The Home Delivered Meals Program (HDMP) serves a vulnerable population of adults aged 60 and older who may benefit from technological services to improve health and social connectedness.

OBJECTIVE

The objectives of this study are (a) to better understand the needs of HDMP participants, and (b) to characterize the technology-readiness and the utility of delivering information via the computer.

DESIGN

We analyzed data from the 2017 NSOAAP to assess the health and functional status and demographic characteristics of HDMP participants. We also conducted a telephone survey to assess technology use and educational interests among NYC HDMP participants.

MEASUREMENTS

Functional measures of the national sample included comorbidities, recent hospitalizations, and ADL/IADL limitations. Participants from our local NYC sample completed a modified version of the validated Computer Proficiency Questionnaire. Technology readiness was assessed by levels of technology use, desired methods for receiving health information, and interest in learning more about virtual senior centers.

RESULTS

About one-third (32.4%) of national survey HDMP participants (n=902) reported insufficient resources to buy food and 17.1% chose between food or medications. Within the NYC HDMP participant survey sample (n=33), over half reported having access to the internet (54.5%), 48.5% used a desktop or laptop, and 30.3% used a tablet, iPad, or smartphone.

CONCLUSION

The HDMP provides an opportunity to reach vulnerable older adults and offer additional resources that can enhance social support and improve nutrition and health outcomes. Research is warranted to compare technological readiness of HDMP participants across urban and rural areas in the United States.

Community-Based Hemoglobin A1C Testing in Barbershops to Identify Black Men With Undiagnosed Diabetes

This cross-sectional study evaluates the use of hemoglobin A_1c testing at barbershops owned by black individuals for timely diagnosis of diabetes among black men and suggests appropriate methods for care.

Evaluating steady-state resting energy expenditure using indirect calorimetry in adults with overweight and obesity

BACKGROUND

Determining a period of steady state (SS) is recommended when estimating resting energy expenditure (REE) using a metabolic cart. However, this practice may be unnecessarily burdensome and time-consuming in the research setting.

AIM

The aim of the study was to evaluate the use of SS criteria, and compare it to alternative approaches in adults with overweight and obesity.

METHODS

In this cross-sectional, ancillary analysis, participants enrolled in a bariatric (study 1; n = 13) and lifestyle (study 2; n = 51) weight loss intervention were included. Indirect calorimetry was performed during baseline measurements using a metabolic cart for 25 min, including a 5-min stabilization period at the start. SS was defined as the first 5-min period with a coefficient of variation (CV) ≤10% for both VO₂ and VCO₂ (hereafter REE_5-SS). Body composition was measured using bioelectrical impedance analysis in study 2 participants only. REE_5-SS was compared against the lowest CV (REE_CV-lowest), 5-min time intervals (REE_6-10, REE_11-15, REE_16-20, REE_21-25), 4-min and 3-min SS intervals (REE_4-SS and REE_3-SS), and time intervals of 6-15, 6-20 and 6-25 min (REE_6-15, REE_6-20, and REE_6-25) using repeated measures ANOVA and Bland-Altman analysis to test for bias, limits of agreement and accuracy (±6% measured REE).

RESULTS

Participants were 54 ± 13 years old, mostly women (75%) and had a BMI of 35 ± 5 kg/m². Overall, 54/63 (84%) of participants reached REE_5-SS, often (47/54, 87%) within the first 10-min (6-15 min). Alternative approaches to estimating REE had a relatively low bias (-16 to 13 kcals), narrow limits of agreement and high accuracy (83-98%) when compared to REE_5-SS, in particular, outperforming standard prediction equations (e.g., Mifflin St. Joer).

CONCLUSION

Indirect calorimetry measurements that utilize the 5-min SS approach to estimate REE are considered the gold-standard. Under circumstances of non-SS, it appears 4-min and 3-min SS periods, or fixed time intervals of atleast 5 min are accurate and practical alternatives for estimating REE in adults with overweight and obesity. However, future trials should validate alternative methods in similar populations to confirm these findings.

Congregate Meals: Opportunities to Help Vulnerable Older Adults Achieve Diet and Physical Activity Recommendations

BACKGROUND

Through diet and exercise interventions, community centers offer an opportunity to address health-related issues for some of the oldest, most vulnerable members of our society.

OBJECTIVES

The purpose of this investigation is to draw upon nationwide data to better characterize the population served by the congregate meals program and to gather more detailed information on a local level to identify opportunities for service enhancement to improve the health and well-being of older adults.

DESIGN

We examined community center data from two sources: 2015 National Survey of Older Americans Act and surveys from two New York City community centers. To assess nationwide service delivery, we analyzed participant demographics, functional status defined by activities of daily living, and perceptions of services received.

MEASUREMENTS

Participants from the two New York City community centers completed a four-day food record. Functional measures included the short physical performance battery, self-reported physical function, grip strength, and the Montreal Cognitive Assessment.

RESULTS

Nationwide (n=901), most participants rated the meal quality as good to excellent (91.7%), and would recommend the congregate meals program to a friend (96.0%). Local level data (n=22) were collected for an in-depth understanding of diet, physical activity patterns, body weight, and objective functional status measures. Diets of this small, local convenience sample were higher in fat, cholesterol, and sodium, and lower in calcium, magnesium, and fiber than recommended by current United States Dietary Guidelines. Average time engaged in moderate physical activity was 254 minutes per week (SD=227), exceeding the recommended 150 minutes per week, but just 41% (n=9) and 50% (n=11) of participants engaged in strength or balance exercises, respectively.

CONCLUSION

Research is warranted to test whether improvements in the nutritional quality of food served and access/supports for engaging in strength training within community centers could help older adults achieve diet and physical activity recommendations.

Physical activity counseling in overweight and obese primary care patients: Outcomes of the VA-STRIDE randomized controlled trial

The purpose of this 2-arm randomized clinical trial was to evaluate the effectiveness of a 12-month, expert system-based, print-delivered physical activity intervention in a primary care Veteran population in Pittsburgh, Pennsylvania. Participants were not excluded for many health conditions that typically are exclusionary criteria in physical activity trials. The primary outcome measures were physical activity reported using the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire and an accelerometer-based activity assessment at baseline, 6, and 12 months. Of the 232 Veterans enrolled in the study, 208 (89.7%) were retained at the 6-month follow-up and 203 (87.5%) were retained at 12 months. Compared to the attention control, intervention participants had significantly increased odds of meeting the U.S. recommended guideline of ≥ 150 min/week of at least moderate-intensity physical activity at 12 months for the modified CHAMPS (odds ratio [OR] = 2.86; 95% CI: 1.03-7.96; p = 0.04) but not at 6 months (OR = 1.54; 95% CI: 0.56-4.23; p = 0.40). Based on accelerometer data, intervention participants had significantly increased odds of meeting ≥ 150 min/week of moderate-equivalent physical activity at 6 months (OR = 6.26; 95% CI: 1.26-31.22; p = 0.03) and borderline significantly increased odds at 12 months (OR = 4.73; 95% CI: 0.98-22.76; p = 0.053). An expert system physical activity counseling intervention can increase or sustain the proportion of Veterans in primary care meeting current recommendations for moderate-intensity physical activity. Trial Registration Clinical trials.gov identifier: NCT00731094 URL: http://www.clinicaltrials.gov/ct2/show/NCT00731094.

Recruitment of veterans from primary care into a physical activity randomized controlled trial: the experience of the VA-STRIDE study

BACKGROUND

Much of the existing literature on physical activity (PA) interventions involves physically inactive individuals recruited from community settings rather than clinical practice settings. Recruitment of patients into interventions in clinical practice settings is difficult due to limited time available in the clinic, identification of appropriate personnel to efficiently conduct the process, and time-consuming methods of recruitment. The purpose of this report is to describe the approach used to identify and recruit veterans from the Veterans Affairs (VA) Pittsburgh Healthcare System Primary Care Clinic into a randomized controlled PA study.

METHODS

A sampling frame of veterans was developed using the VA electronic medical record. During regularly scheduled clinic appointments, primary care providers (PCPs) screened identified patients for safety to engage in moderate-intensity PA and willingness to discuss the study with research staff members. Research staff determined eligibility with a subsequent telephone screening call and scheduled a research study appointment, at which time signed informed consent and baseline measurements were obtained.

RESULTS

Of the 3,482 veterans in the sampling frame who were scheduled for a primary care appointment during the study period, 1,990 (57.2%) were seen in the clinic and screened by the PCP; moderate-intensity PA was deemed safe for 1,293 (37.1%), 871 (25.0%) agreed to be contacted for further screening, 334 (9.6%) were eligible for the study, and 232 (6.7%) enrolled.

CONCLUSIONS

Using a semiautomated screening approach that combined an electronically-derived sampling frame with paper and pencil prescreening by PCPs and research staff, VA-STRIDE was able to recruit 1 in 15 veterans in the sampling frame. Using this approach, a high proportion of potentially eligible veterans were screened by their PCPs.

TRIAL REGISTRATION

Clinical trials.gov identifier: NCT00731094.

The effect of electronic self-monitoring on weight loss and dietary intake: a randomized behavioral weight loss trial

Technology may improve self-monitoring adherence and dietary changes in weight loss treatment. Our study aimed to investigate whether using a personal digital assistant (PDA) with dietary and exercise software, with and without a feedback message, compared to using a paper diary/record (PR), results in greater weight loss and improved self-monitoring adherence. Healthy adults (N = 210) with a mean BMI of 34.01 kg/m(2) were randomized to one of three self-monitoring approaches: PR (n = 72), PDA with self-monitoring software (n = 68), or PDA with self-monitoring software and daily feedback messages (PDA+FB, n = 70). All participants received standard behavioral treatment. Self-monitoring adherence and change in body weight, waist circumference, and diet were assessed at 6 months; retention was 91%. All participants had a significant weight loss (P < 0.01) but weight loss did not differ among groups. A higher proportion of PDA+FB participants (63%) achieved ≥ 5% weight loss in comparison to the PR group (46%) (P < 0.05) and PDA group (49%) (P = 0.09). Median percent self-monitoring adherence over the 6 months was higher in the PDA groups (PDA 80%; PDA+FB 90%) than in the PR group (55%) (P < 0.01). Waist circumference decreased more in the PDA groups than the PR group (P = 0.02). Similarly, the PDA groups reduced energy and saturated fat intake more than the PR group (P < 0.05). Self-monitoring adherence was greater in the PDA groups with the greatest weight change observed in the PDA+FB group.

Cost-effectiveness of exercise and diet in overweight and obese adults with knee osteoarthritis

PURPOSE

The purpose of this study was to compare the cost-effectiveness of dietary and exercise interventions in overweight or obese elderly patients with knee osteoarthritis (OA) enrolled in the Arthritis, Diet, and Physical Activity Promotion Trial (ADAPT).

METHODS

ADAPT was a single-blinded, controlled trial of 316 adults with knee OA, randomized to one of four groups: Healthy Lifestyle Control group, Diet group, Exercise group, or Exercise and Diet group. A cost analysis was performed from a payer perspective, incorporating those costs and benefits that would be realized by a managed care organization interested in maintaining the health and satisfaction of its enrollees while reducing unnecessary utilization of health care services.

RESULTS

The Diet intervention was most cost-effective for reducing weight, at $35 for each percentage point reduction in baseline body weight. The Exercise intervention was most cost-effective for improving mobility, costing $10 for each percentage point improvement in a 6-min walking distance and $9 for each percentage point improvement in the timed stair climbing task. The Exercise and Diet intervention was most cost-effective for improving self-reported function and symptoms of arthritis, costing $24 for each percentage point improvement in subjective function, $20 for each percentage point improvement in self-reported pain, and $56 for each percentage point improvement in self-reported stiffness.

CONCLUSIONS

The Exercise and Diet intervention consistently yielded the greatest improvements in weight, physical performance, and symptoms of knee OA. However, it was also the most expensive and was the most cost-effective approach only for the subjective outcomes of knee OA (self-reported function, pain, and stiffness). Perceived function and symptoms of knee OA are likely to be stronger drivers of downstream health service utilization than weight, or objective performance measures and may be the most cost-effective in the long term.

Gender differences in morbidity and mortality related to depression: a review of the literature

In this review of the existing evidence regarding a gender-specific association of depression with major health outcomes in older adults, we were unable to confirm that relative risk of morbidity and/or mortality due to depression varies with respect to gender. Future researchers may wish to concentrate their efforts in the identification of possible biophysiologic mechanisms underlying the association between depression and a variety of health outcomes.

Ethics in adherence promotion and monitoring

In evaluating and intervening to increase adherence to medical treatments, clinicians and researchers must address ethical issues pertaining to best interest, autonomy, and privacy. "Best interest" refers to the notion that health-care practitioners act in a manner that produces benefits or good outcomes for the patients in their care. "Autonomy" refers to the patient's right to determine whether or not they will accept medical treatment or participate in a clinical study. "Nonmaleficence" refers to the clinician's or researcher's responsibility to "do no harm." "Privacy" refers to the notion that researchers and clinicians promise not to divulge personal information about the patients in their care. Adherence monitoring and promotion pose ethical challenges to researchers and clinicians, which are the topic of this paper. Control Clin Trials 2000;21:241S-247S

Dietary adherence: characteristics and interventions

This paper reviews issues regarding dietary adherence. Issues and barriers unique to dietary adherence, in contrast to adherence to physical activity or medication regimens, are discussed. These include decision making, social and cultural contexts, perceptions and preferences, and environmental barriers. We review factors known to increase adherence in dietary interventions, including education, motivation, behavioral skills, new and modified foods, and supportive interactions. We conclude with directions for future study, such as improved measurement of diet-related behavior and longitudinal, culturally sensitive interventions. Control Clin Trials 2000;21:206S-211S

Measuring adherence to behavioral and medical interventions

Measuring adherence to medical and behavioral interventions is important to clinicians and researchers since inadequate adherence can reduce the effectiveness of an intervention. Unfortunately, there is no gold standard for measuring adherence across health behaviors. Adherence needs to be defined situationally with parameters of acceptable adherence carefully delineated and appropriate to the health behavior being studied. Additionally, measurement methods must be valid, reliable, and sensitive to change; this paper reviews these criteria. Methods used to measure adherence to dietary interventions include 24-hour recalls, food diaries, and food frequency questionnaires. Direct and indirect calorimetry, doubly labeled water, and a variety of self-report methods can be used to measure adherence in physical activity interventions. Adherence to pharmacological interventions is assessed using self-report methods, biochemical measures, medication counts, and the automated pharmacy database review strategy. The strengths and weaknesses of these methods for measuring adherence to dietary, physical activity, and pharmacological interventions are reviewed. Control Clin Trials 2000;21:188S-194S

Factors related to sleep disturbance in older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis

OBJECTIVES

To describe the types and frequencies of sleep complaints and the biopsychosocial factors associated with sleep disturbance in a large community sample of older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis (OA).

DESIGN

Baseline analyses of an observational prospective study.

SETTING AND PARTICIPANTS

Participants were 429 men and women aged 65 years and older experiencing knee pain or knee pain with radiographic evidence of OA enrolled in the Observational Arthritis Study in Seniors (OASIS).

MEASUREMENTS

Demographic variables (age, gender, ethnicity, education), health (X-rays of knee rated for OA severity, medical conditions, medication use, smoking status, body mass index, self-rated health), physical functioning (self-rated physical functioning, physical performance), knee pain, and psychosocial functioning (social support, depression) were measured.

RESULTS

Problems with sleep onset, sleep maintenance, and early morning awakenings occurred at least weekly among 31%, 81%, and 51% of participants, respectively. Bivariate correlates of greater sleep disturbance in those with OA were less education, cardiovascular disease, more arthritic joints, poorer self-rated health, poorer physical functioning, poorer physical performance, knee pain, depression, and less social support. In regression analyses, each set of variables representing the domains of health, physical functioning, pain, and psychosocial functioning contributed to the prediction of sleep disturbance beyond the demographic set. Finally, in a simultaneous model, white race (trend, P = .06), poorer self-rated health, poorer physical functioning, and depressive symptoms were predictive of sleep disturbance.

CONCLUSIONS

Sleep disturbance is common in older adults experiencing knee pain or knee pain with radiographic evidence of OA and is best understood through the consideration of demographic, physical health, physical functioning, pain, and psychosocial variables. Interventions that take into account the multidetermined nature of sleep disturbance in knee pain or knee OA are most likely to be successful.

Cost-effectiveness of aerobic and resistance exercise in seniors with knee osteoarthritis

PURPOSE

The purpose of this study was to determine, in a randomized clinical trial of 439 individuals with knee osteoarthritis, the incremental cost-effectiveness of aerobic versus weight resistance training, compared with an education control intervention.

METHODS

Cost estimates of the intervention were based upon the cost of purchasing from the community similar services to provide exercise or health education. Effect at 18 months was measured using several variables, including: self-reported disability score, 6-min walking distance, stair climb, lifting and carrying task, car task, and measures of pain frequency and pain intensity on ambulation and transfer.

RESULTS

The total cost of the educational intervention was $343.98 per participant. The aerobic exercise intervention cost $323.55 per participant, and the resistance training intervention cost $325.20 per participant. On all but two of the outcome variables, the incremental savings per incremental effect for the resistance exercise group was greater than for the aerobic exercise group.

CONCLUSION

The data obtained from this study suggest that, compared with an education control, resistance training for seniors with knee osteoarthritis is more economically efficient than aerobic exercise in improving physical function. However, the magnitude of the difference in efficiency between the two approaches is small.

Cost-effectiveness of lifestyle and structured exercise interventions in sedentary adults: results of project ACTIVE

BACKGROUND

Project ACTIVE was a randomized clinical trial comparing two physical activity interventions, lifestyle and traditional structured exercise. The two interventions were evaluated and compared in terms of cost effectiveness and ability to enhance physical activity among sedentary adults.

DESIGN

This was a randomized clinical trial.

SETTING/ PARTICIPANTS

The study included 235 sedentary but healthy community-dwelling adults.

INTERVENTION

A center-based lifestyle intervention that consisted of behavioral skills training was compared to a structured exercise intervention that included supervised, center-based exercise.

MAIN OUTCOME MEASURES

The main outcome measures of interest included cost, cardiorespiratory fitness, and physical activity.

RESULTS

Both interventions were effective in increasing physical activity and fitness. At 6 months, the costs of the lifestyle and structured interventions were, respectively, $46.53 and $190.24 per participant per month. At 24 months these costs were $17.15 and $49.31 per participant per month. At both 6 months and 24 months, the lifestyle intervention was more cost-effective than the structured intervention for most outcomes measures.

CONCLUSIONS

A behaviorally-based lifestyle intervention approach in which participants are taught behavioral skills to increase their physical activity by integrating moderate-intensity physical activity into their daily lives is more cost-effective than a structured exercise program in improving physical activity and cardiorespiratory health. This study represents one of the first attempts to compare the efficiency of intervention alternatives for improving physical activity among healthy, sedentary adults.

Cost-effectiveness analysis methods for the REACT Study

The Reconditioning Exercise and Chronic Obstructive Pulmonary Disease Trial (REACT) is a two-arm randomized clinical trial designed to compare short-term versus long-term exercise intervention in terms of physical function, acute exacerbation of chronic obstructive pulmonary disease, health-related quality of life, and cost-effectiveness. Clinical trials such as REACT are now routinely paired with economic analyses, and nurses can expect to play a growing role in the conduct of these studies. This article describes a model that is useful for structuring economic evaluations of health care interventions, and illustrates a cost-effectiveness analysis that is being conducted in conjunction with the REACT study. An in-depth description of collection methods and procedures is provided, as well as a summary of recruitment and retention experience to date.

Cost-benefit of a nursing telephone intervention to reduce preterm and low-birthweight births in an African American clinic population

BACKGROUND

A cost-benefit analysis was performed to estimate the cost-savings obtained from a nursing telephone intervention delivered to pregnant women identified as being at risk for preterm or low-birthweight births.

METHODS

After being screened for eligibility, a total of 1,554 women receiving prenatal care in a clinic located in Winston-Salem, North Carolina were randomized to intervention and control groups. Women in the intervention group received telephone calls from a registered nurse one or two times each week from the 24th through the 37th week of gestation.

RESULTS

No clinical benefits were realized by Caucasian participants. The intervention reduced preterm and low-birthweight births, and resulted in cost savings, for African-American mothers ages 19 and over. No significant differences were seen in the rates of low-birthweight or preterm births and no cost savings were realized from intervention with women ages 18 and younger.

CONCLUSIONS

A prenatal nursing support intervention in a clinic population of pregnant African American women was cost-beneficial for these adults (< or =19 years of age).

Challenges faced in recruiting patients from primary care practices into a physical activity intervention trial. Activity Counseling Trial Research Group

BACKGROUND

Special challenges are encountered when clinical trial recruitment targets a physician practice-based population, as opposed to recruiting from the community. Since most published information about recruitment has focused on the latter group, summation of successful primary-care-based recruitment strategies could prove useful for future trials recruiting from this population.

METHODS

The Activity Counseling Trial (ACT) is a multicenter, randomized clinical trial that evaluated approaches to primary care-based interventions to increase physical activity in sedentary adults 35-75 years of age. Fifty-four clinicians from eight practices recruited 874 participants from three U.S. sites. Recruitment challenges that related, in great part, to the primary care setting included: (1) focusing on patients from ACT physician practices who had regularly scheduled or intend-to-schedule appointments within the next year; (2) placing trial staff in the clinical offices for recruitment purposes; and (3) placing trial interventionists in the physicians' offices. Other challenges were related to recruitment of minorities and men.

RESULTS

Patient mailing yielded 43.4% of all randomized participants, followed by office-based questionnaires (32.5%) and direct telephone contact (21.6%). Based on a retrospective cost-effective analysis (indirect costs excluded), the self-administered office-based questionnaire was the least costly strategy for one site ($14/randomized participant), followed by patient mailing at another site ($58). The direct telephone contact method utilized at one site serving primarily a minority population yielded a per randomized participant cost of $80.

CONCLUSIONS

Recruitment of clinical trial participants from practice-based populations requires modification of the strategies used to recruit from the community. Multiple strategies should be employed, followed closely for their respective yields, and adapted as needed.

Measurement of continuous ambulatory peritoneal dialysis prescription adherence using a novel approach

OBJECTIVE

The purpose of the study was to test a novel approach to monitoring the adherence of continuous ambulatory peritoneal dialysis (CAPD) patients to their dialysis prescription.

DESIGN

A descriptive observational study was done in which exchange behaviors were monitored over a 2-week period of time.

SETTING

Patients were recruited from an outpatient dialysis center.

PARTICIPANTS

A convenience sample of patients undergoing CAPD at Piedmont Dialysis Center in Winston-Salem, North Carolina was recruited for the study. Of 31 CAPD patients, 20 (64.5%) agreed to participate.

MEASURES

Adherence of CAPD patients to their dialysis prescription was monitored using daily logs and an electronic monitoring device (the Medication Event Monitoring System, or MEMS; APREX, Menlo Park, California, U.S.A.). Patients recorded in their logs their exchange activities during the 2-week observation period. Concurrently, patients were instructed to deposit the pull tab from their dialysate bag into a MEMS bottle immediately after performing each exchange. The MEMS bottle was closed with a cap containing a computer chip that recorded the date and time each time the bottle was opened.

RESULTS

One individual's MEMS device malfunctioned and thus the data presented in this report are based upon the remaining 19 patients. A significant discrepancy was found between log data and MEMS data, with MEMS data indicating a greater number and percentage of missed exchanges. MEMS data indicated that some patients concentrated their exchange activities during the day, with shortened dwell times between exchanges. Three indices were developed for this study: a measure of the average time spent in noncompliance, and indices of consistency in the timing of exchanges within and between days. Patients who were defined as consistent had lower scores on the noncompliance index compared to patients defined as inconsistent (p = 0.015).

CONCLUSIONS

This study describes a methodology that may be useful in assessing adherence to the peritoneal dialysis regimen. Of particular significance is the ability to assess the timing of exchanges over the course of a day. Clinical implications are limited due to issues of data reliability and validity, the short-term nature of the study, the small sample, and the fact that clinical outcomes were not considered in this methodology study. Additional research is needed to further develop this data-collection approach.

Costs and benefits of respiratory syncytial virus immunoglobulin to prevent hospitalization for lower respiratory tract illness in very low birth weight infants

BACKGROUND

Respiratory syncytial virus immunoglobulin intravenous (RSV-IGIV) has been shown to reduce the risk of lower respiratory illness (LRI) hospitalization in preterm infants and infants with bronchopulmonary dysplasia (BPD). The purpose of this analysis was to estimate the economic costs and benefits of prophylaxis with RSV-IGIV in these groups.

METHODS

The analysis was performed from a payer's perspective and therefore included only costs and cost savings that would be realized by an insurer. Estimates of the direct costs of prophylaxis and the risk and cost of LRI hospitalization were based on data about preterm very low birth weight infants cared for at our medical center. Estimates of the reduction in risk of LRI hospitalization associated with RSV-IGIV were based on data from a randomized trial (the PREVENT Study).

RESULTS

The range of cost for a five-dose course of RSV-IGIV was estimated to be $3280 to $8800 for infants weighing 1.2 to 10.0 kg at the time of the initial dose. Risks of LRI hospitalization were estimated to be 12, 17 and 28%, respectively, for preterm infants without BPD, with mild BPD and with moderate to severe BPD. Estimates of duration and per diem cost of LRI hospitalizations were, respectively, 5 days and $971. The estimated net cost of prophylaxis per infant ranged between $5415 for a 6-kg infant without BPD to $1689 for an infant with BPD and age < or =3 months.

CONCLUSIONS

The cost of RSV-IGIV typically exceeds the cost of hospitalizations prevented by several thousand dollars. Cost minus benefit is lower for infants with BPD and infants 3 months of age or younger.

The Kidney Outcomes Prediction and Evaluation (KOPE) study: a prospective cohort investigation of patients undergoing hemodialysis. Study design and baseline characteristics

PURPOSE

The purpose of the Kidney Outcomes Prediction and Evaluation (KOPE) study, was to more fully characterize the end-stage renal disease (ESRD) population with respect to social, psychological, and clinical characteristics, and to prospectively study the biomedical, social, and psychological factors that influence a range of ESRD outcomes in a large observational study of black and white patients on hemodialysis. This paper focuses on the KOPE study design as well as characteristics of patients at baseline.

METHODS

KOPE was a prospective cohort investigation of patients treated at four dialysis centers in Forsyth County, North Carolina. Participants were interviewed at the dialysis centers, semi-annually over a 3 1/2 year period. Prevalent cases who were being treated with hemodialysis at the initiation of the study were enrolled into KOPE. Incident cases were subsequently enrolled as they presented to the participating units for hemodialysis. A total of 304 prevalent and 162 incident cases were enrolled into the study. The baseline health and sociodemographic characteristics of KOPE participants reported in this paper were obtained from medical records and Southeast Kidney Council data. Laboratory values taken within a 30-day interval around the baseline interview are also reported.

RESULTS

KOPE participants differ from national statistics on race, age, and gender. Differences between KOPE participants and patients living in the region, but who did not participate in the study, can be explained by our recruitment criteria.

CONCLUSIONS

KOPE will enable the characterization of the ESRD population, identification of factors related to poor outcomes, and identification of opportunities for interventions to prevent death and morbidity.

Health-related physical function and quality of well-being prior to and following cardiomyoplasty. A preliminary report

OBJECTIVE

The purpose of this study was to obtain preliminary data regarding the effects of cardiomyoplasty on health-related physical function and quality of well-being.

EXPERIMENTAL DESIGN

Quasi-experimental with repeated measures. Patients were interviewed prior to surgery, with post-surgical follow-up interviews at 6 weeks, 6 months, and 12 months.

SETTING

Interviews were usually conducted by telephone with patients who were at home at the time of data collection.

PATIENTS OR PARTICIPANTS

Four patients receiving cardiomyoplasty at Allegheny General Hospital in Pittsburgh, Pennsylvania.

INTERVENTIONS

Patients received cardiomyoplasty between November 1992 and April 1993. Cardiomyoplasty using the right latissimus dorsi muscle was performed on the first patient. A left muscle-wrap was performed on the subsequent three patients.

MEASURES

Self-reported function and well-being were measured using the Sickness Impact Profile (SIP), the Quality of Well-Being Scale (QWB), and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36).

RESULTS

Patient responses on the SF-36 demonstrated general improvement in cardiomyoplasty survivors. Results on the QWB and SIP are mixed.

CONCLUSIONS

Due to the small, incomplete sample and lack of any comparison group, extreme caution must be used in drawing any clinical conclusions from this preliminary data. Future randomized clinical trials of cardiomyoplasty need to include quality of life and health-related physical function as dependent variables. Further psychometric study is necessary which compares the usefulness of these various methods for assessing the value of outcomes for patients with end-stage heart disease.

A confirmatory factor analysis of the Caregiving Appraisal Scale for caregivers of home-based ventilator-assisted individuals

OBJECTIVE

To confirm the underlying dimensions of the Caregiving Appraisal Scale (CAS) with use of data collected from caregivers of home-based ventilator-assisted individuals (VAIs).

DESIGN

Cross-sectional survey.

SETTING

Residences of home-based VAIs.

SAMPLE

Two hundred seventy-seven primary family caregivers of VAIs.

MEASURES

Twenty-eight-item CAS developed by Lawton et al. (1989), and an investigator-developed instrument to assess physical health and sociodemographic characteristics of both VAIs and their caregivers.

INTERVENTION

None.

ANALYSIS

Confirmatory factor analysis with principal components extraction. An oblique (oblimin) solution was used for rotation of the factor matrices. The number of common factors needed to obtain the best fit of the factor model was determined with use of maximum-likelihood estimation. Confirmatory factor analysis with linear structural equation modeling was also performed.

RESULTS

Confirmatory factor analysis did not fully replicate the factor structure proposed by Lawton et al.

CONCLUSIONS

The model proposed by Lawton et al. provides a useful foundation for examining the appraisal of family caregivers of home-based VAIs. Additional development work is needed for the CAS.

Cost-utility of lung transplantation: a pilot study

BACKGROUND

The purpose of this study was to conduct a pilot investigation of the cost-utility of lung transplantation. With this study we provide a threshold analysis to estimate the survival gains that must be achieved for lung transplantation to be considered a beneficial use of society's resources.

METHODS

A cross-sectional cohort design was used. All patients having undergone lung transplantation at the University of Pittsburgh Medical Center between March 1 and August 31, 1994, were identified via roster of transplant recipients (n = 20). Surviving patients were interviewed, by telephone, at their 1-year anniversary date. Utility was assessed by use of the quality of well-being scale. Direct cost of care was estimated from adjusted charges for the surgical admission, plus physician fees per the Medicare Physician Fee Schedule.

RESULTS

The mean quality of well-being score for this group was 0.54 +/- 0.198 SD (median = 0.599, range 0 to 0.728). Summing the physician cost and the adjusted charges for the inpatient operative admission, the average cost of lung transplantation was $153,921 +/- $133,981 SD (median $94,324, range $63,405 to $598,482). At a cost of $94,324 and a utility of 0.599, the survival gain from surgery must be 2.7 years for the cost of the procedure to be justified from a societal perspective.

CONCLUSIONS

Because of the many limitations in this pilot study, no firm policy implication may be drawn from these data. Directions for future research are discussed.

Economic value of caregiver effort in maintaining long-term ventilator-assisted individuals at home

OBJECTIVE

To estimate the economic value of caregivers' efforts in maintaining ventilator-assisted individuals at home.

DESIGN

Nonexperimental, cross-sectional survey.

SETTING

Households of home-based ventilator-assisted individuals residing in 37 states.

PARTICIPANTS

Caregivers of 1404 ventilator-assisted individuals; 277 (19.7%) responses were received.

OUTCOME MEASURES

The Home Ventilator Care Cost and Utilization Survey and the Modified Katz Index.

METHODS

The economic value of caregiver effort was estimated deterministically by opportunity cost, aggregated market value, and aggregated replacement cost and estimated stochastically by ordinary least squares regression. Cost of formal home care services was estimated with the Medicare Schedule of Limits for Home Health Agency Costs. Estimates of total cost of home care for each method of valuing caregiver effort were calculated by summing the cost of formal home care services with the value of caregiver effort.

RESULTS

The average monthly cost of formal home care services was estimated to be $6411 (SD, $8490; median, $2006; range, $0 to $38,607). After adding various values of caregiver effort to the cost of formal home care services, the average cost of home care increases by $960 to $12,483, depending on the method used to calculate the value of the caregiver's time; the median total cost of home care increased by $1403 to $17,793. Data also showed that, depending on the figure used to estimate the cost of long-term care and which method was used to calculate caregiver value, home care was more expensive for at least 4.6% of ventilator-assisted individuals and for as many as 36.7%.

CONCLUSIONS

The incorporation of the caregiver's time value into cost estimates did not substantially reduce the proportion of patients for whom home care was the least expensive alternative, except when caregiver effort was valued at a registered nurse's wage rate. However, the methods used to place an economic value on caregiver effort did not take into consideration the long-term economic impact on caregivers who reduce their work hours or forego employment or educational opportunities, nor did they take into account the lost wages of the ventilator-assisted individual or the extent to which the caregiver was financially dependent on the ventilator-assisted individual.

Economic cost of home-based care for ventilator-assisted individuals: a preliminary report

STUDY OBJECTIVE

To measure the direct and indirect costs of maintaining a ventilator-assisted individual (VAI) at home.

DESIGN

A cross-sectional survey was conducted of primary family caregivers of VAIs residing in 37 states.

SETTING

Surveys were delivered to the homes of VAIs.

PARTICIPANTS

Two hundred seventy-seven (19.7%) of 1,404 primary family caregivers of patients who were ventilator-dependent and who were living at home. Interventions. None.

MEASURES

Participants received the modified Katz Index and an investigator-developed Home Ventilator Care Cost and Utilization Survey (HVCCUS).

RESULTS

Total cost of care was determined by summing total direct medical and nonmedical costs of home care and lost wages. Using LPN rates for private duty care, the average total cost of care was estimated to be $7,642 per month (median=$5,406). Using RN rates for private duty care, the average total cost of home care was estimated to be $8,596 per month (median=$5,911). Variation with VAI characteristics is discussed.

CONCLUSIONS

Home care of VAIs is a labor-intensive and an economically costly undertaking. The development of policies and programs to support home placement requires additional investigation regarding factors affecting the cost-effectiveness of various placement settings, as well as the ability and/or willingness of family members to accept the cost and responsibility of home care.

Home-based ventilator-dependent patients: measurement of the emotional aspects of home caregiving

OBJECTIVE

To explore the concept of caregiving appraisal with the primary family caregivers of home-based ventilator-dependent patients and test the internal consistency of instruments to measure functional dependency of the patient and caregiving appraisal.

DESIGN

Nonexperimental, cross-sectional survey. Respondents were reimbursed $25 for the return of a completed questionnaire.

SETTING

Caregivers of home-based ventilator-dependent patients residing in southwestern Pennsylvania.

SAMPLE

Caregivers of 39 home-based ventilator-dependent patients, 27 responses (69%) were received.

MEASURES

Modified Katz Index, Modified Caregiving Appraisal Scale, investigator-developed instrument to assess the health and sociodemographic characteristics of both patients and their caregivers.

INTERVENTION

None.

RESULTS

The needs of ventilator-dependent patients, as reported by their primary family caregivers, are extensive. Patients require considerable assistance with activities of daily living, with many patients having total care requirements in many functional domains. Caregivers are responsible for numerous pieces of high-tech equipment, as well as other special care requirements unrelated to the patient's ventilatory insufficiency. Although caregivers reportedly spend an average of 8.4 hours each day caring for their family member, the majority continue to maintain full- or part-time employment. Despite the considerable demands placed on caregivers, responses to the Modified Caregiving Appraisal Scale indicate that home placement is not perceived to be a negative experience. Internal consistency of instruments was determined by use of Cronbach's alpha, yielding the following correlation coefficients on the Modified Caregiving Appraisal Scale: burden subscale, 0.87; satisfaction subscale, 0.71; mastery subscale, 0.73; impact subscale, 0.70; and ideology subscale, 0.65. Alpha coefficients for the Katz Indexes measuring patient functional dependence, and consequent caregiver responsibility, were 0.95 and 0.90, respectively.

Health care professionals' characterizations of the system of care for long-term ventilator-dependent patients: a preliminary study

The purpose of this study was to characterize, from multiple professional perspectives, current management approaches and systems of care for long-term ventilator-dependent patients. This study was preliminary in nature and served to generate questions to be explored with subsequent research. A focus group methodology was used. Three focus sessions were held, with participants representing nursing, social services, and respiratory therapy. Field notes were recorded by two independent observers. The primary themes arising from the narrative data were: (i) caregiver impact, (ii) system barriers to appropriate care, (iii) communication difficulties among professionals and between patients and professionals, (iv) ethical concerns, and (v) patient characteristics that influence medical management and patient outcomes. Implications include the need for systematic research regarding caregiver impact, ethical practice of health care professionals, and the epidemiology of ventilator dependency, as well as evaluative studies of different system approaches to caring for these patients.

Characteristics and health service utilization patterns of ventilator-dependent patients cared for within a vertically integrated health system

OBJECTIVE: To describe the characteristics and service utilization patterns of long-term ventilator-dependent patients. DESIGN: Using medical records, a cohort of ventilator-dependent patients was identified and followed. SETTING: A vertically integrated healthcare system in southwestern Pennsylvania. PATIENTS: Forty-nine adults requiring prolonged ventilatory assistance. MEASURES: Demographics, admission date, admission diagnosis, discharge diagnosis, reason for ventilator dependency, level of care to which the patient was admitted, dates of all transfer orders, dates of all transfers between levels of care, discharge destination and subsequent readmissions. RESULTS: The major reason for long-term ventilator dependency was progressive debilitating disease of either a pulmonary or nonpulmonary nature. The mean length of stay within the system was 72.6 days +/- 42.55 (median = 59 days, range = 24 to 267 days). Patients had an average of 3.3 transfers +/- 2.53 within the system (median = 3, range = 0 to 10). No delays in transfer to lower levels of care were found. Health utilization variables were largely unrelated to reason for ventilator dependency. Almost half of the patients (n = 24 or 49.0%) died in the system. Patients who died in the system were significantly older than patients for whom discharge home was possible. CONCLUSIONS: Additional studies are necessary to describe the prevalence, etiology, health status and functional status of ventilator patients at all levels of care; the impact of different system approaches on patient well-being and cost of care; and the process of medical decision making. Economic analyses of costs and outcomes for ventilator-dependent patients using a cost-utility approach are also needed.

Characteristics and health service utilization patterns of ventilator-dependent patients cared for within a vertically integrated health system

OBJECTIVE

To describe the characteristics and service utilization patterns of long-term ventilator-dependent patients.

DESIGN

Using medical records, a cohort of ventilator-dependent patients was identified and followed.

SETTING

A vertically integrated healthcare system in southwestern Pennsylvania.

PATIENTS

Forty-nine adults requiring prolonged ventilatory assistance.

MEASURES

Demographics, admission date, admission diagnosis, discharge diagnosis, reason for ventilator dependency, level of care to which the patient was admitted, dates of all transfer orders, dates of all transfers between levels of care, discharge destination and subsequent readmissions.

RESULTS

The major reason for long-term ventilator dependency was progressive debilitating disease of either a pulmonary or nonpulmonary nature. The mean length of stay within the system was 72.6 days +/- 42.55 (median = 59 days, range = 24 to 267 days). Patients had an average of 3.3 transfers +/- 2.53 within the system (median = 3, range = 0 to 10). No delays in transfer to lower levels of care were found. Health utilization variables were largely unrelated to reason for ventilator dependency. Almost half of the patients (n = 24 or 49.0%) died in the system. Patients who died in the system were significantly older than patients for whom discharge home was possible.

CONCLUSIONS

Additional studies are necessary to describe the prevalence, etiology, health status and functional status of ventilator patients at all levels of care; the impact of different system approaches on patient well-being and cost of care; and the process of medical decision making. Economic analyses of costs and outcomes for ventilator-dependent patients using a cost-utility approach are also needed.