Nationwide Trends in Osteoporosis in Koreans With Disabilities From 2008 to 2017

This study examined the 10-year trends in the prevalence of osteoporosis according to disability grade and type compared with those without disabilities in South Korea. We linked national disability registration data with the National Health Insurance claims data. Age- and sex-standardized prevalence of osteoporosis were analyzed from 2008 to 2017 according to sex, disability type, and disability grade. Adjusted odds ratios for osteoporosis according to disability characteristics in the most recent years' data were also confirmed by multivariate analysis. Over the past decade, the prevalence of osteoporosis has increased in people with disabilities compared with people without disabilities, and the gap has gradually widened from 7% to 15%. By analysis of the most recent year data, both male and female individuals with disabilities had a higher risk of osteoporosis than those without disability (odds ratios [OR] 1.72, 95% confidence interval [CI] 1.70-1.73 in males; OR 1.28, 95% CI 1.27-1.28 in females); the multivariate-adjusted OR was especially prominent in disability related to respiratory disease (OR 2.07, 95% CI 1.93-2.21 in males; OR 1.74; 95% CI 1.60-1.90 in females), epilepsy (OR 2.16, 95% CI 1.78-2.61 in males; OR 1.71; 95% CI 1.53-1.91 in females), and physical disability types (OR 2.09, 95% CI 2.06-2.21 in males; OR 1.70; 95% CI 1.69-1.71 in females). In conclusion, the prevalence and risk of osteoporosis have increased in people with disabilities in Korea. In particular, the risk of osteoporosis increases significantly in people with respiratory diseases, epilepsy, and physical disability types. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Powered mobility interventions for very young children with mobility limitations to aid participation and positive development: the EMPoWER evidence synthesis

BACKGROUND

One-fifth of all disabled children have mobility limitations. Early provision of powered mobility for very young children (aged < 5 years) is hypothesised to trigger positive developmental changes. However, the optimum age at which to introduce powered mobility is unknown.

OBJECTIVE

The aim of this project was to synthesise existing evidence regarding the effectiveness and cost-effectiveness of powered mobility for very young children, compared with the more common practice of powered mobility provision from the age of 5 years.

REVIEW METHODS

The study was planned as a mixed-methods evidence synthesis and economic modelling study. First, evidence relating to the effectiveness, cost-effectiveness, acceptability, feasibility and anticipated outcomes of paediatric powered mobility interventions was reviewed. A convergent mixed-methods evidence synthesis was undertaken using framework synthesis, and a separate qualitative evidence synthesis was undertaken using thematic synthesis. The two syntheses were subsequently compared and contrasted to develop a logic model for evaluating the outcomes of powered mobility interventions for children. Because there were insufficient published data, it was not possible to develop a robust economic model. Instead, a budget impact analysis was conducted to estimate the cost of increased powered mobility provision for very young children, using cost data from publicly available sources.

DATA SOURCES

A range of bibliographic databases [Cumulative Index to Nursing and Allied Health Literature (CINHAL), MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Physiotherapy Evidence Database (PEDro), Occupational Therapy Systematic Evaluation of Evidence (OTseeker), Applied Social Sciences Index and Abstracts (ASSIA), PsycINFO, Science Citation Index (SCI; Clarivate Analytics, Philadelphia, PA, USA), Social Sciences Citation Index™ (SSCI; Clarivate Analytics), Conference Proceedings Citation Index - Science (CPCI-S; Clarivate Analytics), Conference Proceedings Citation Index - Social Science & Humanities (CPCI-SSH; Clarivate Analytics), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) Database and OpenGrey] was systematically searched and the included studies were quality appraised. Searches were carried out in June 2018 and updated in October 2019. The date ranges searched covered from 1946 to September 2019.

RESULTS

In total, 89 studies were included in the review. Only two randomised controlled trials were identified. The overall quality of the evidence was low. No conclusive evidence was found about the effectiveness or cost-effectiveness of powered mobility in children aged either < 5 or ≥ 5 years. However, strong support was found that powered mobility interventions have a positive impact on children's movement and mobility, and moderate support was found for the impact on children's participation, play and social interactions and on the safety outcome of accidents and pain. 'Fit' between the child, the equipment and the environment was found to be important, as were the outcomes related to a child's independence, freedom and self-expression. The evidence supported two distinct conceptualisations of the primary powered mobility outcome, movement and mobility: the former is 'movement for movement's sake' and the latter destination-focused mobility. Powered mobility should be focused on 'movement for movement's sake' in the first instance. From the budget impact analysis, it was estimated that, annually, the NHS spends £1.89M on the provision of powered mobility for very young children, which is < 2% of total wheelchair service expenditure.

LIMITATIONS

The original research question could not be answered because there was a lack of appropriately powered published research.

CONCLUSIONS

Early powered mobility is likely to have multiple benefits for very young children, despite the lack of robust evidence to demonstrate this. Age is not the key factor; instead, the focus should be on providing developmentally appropriate interventions and focusing on 'movement for movement's sake'.

FUTURE WORK

Future research should focus on developing, implementing, evaluating and comparing different approaches to early powered mobility.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018096449.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 50. See the NIHR Journals Library website for further project information.

Does urbanicity modify the relationship between a polygenic risk score for depression and mental health symptoms? Cross-sectional evidence from the observational HUNT Study in Norway

BACKGROUND

Research suggests that genetic predisposition for common mental disorders may be moderated by the environment. This study examines whether a polygenic risk score (PRS) for depression is moderated by the level of residential area urbanicity using five symptoms of poor mental health as outcomes.

METHODS

The study sample consisted of 41 198 participants from the 2006-2008 wave of the Norwegian HUNT study. We created a weighted PRS for depression based on 99 variants identified in a recent genome -wide association study. Participants were classified into urban or rural place of residence based on wards that correspond to neighbourhoods. Mixed effects logistic regression models with participants nested in 477 neighbourhoods were specified.

RESULTS

A SD increase in PRS for depression was associated with a small but statistically significant increase in the odds of anxiety, comorbid anxiety and depression and mental distress. Associations for depression were weaker and not statistically significant. Compared with urban residents, rural resident had higher odds for reporting poor mental health. Genetic propensity for depression was higher for residents of urban than rural areas, suggesting gene-environment correlation. There was no sign of effect modification between genetic propensity and urbanicity for depression, anxiety, comorbid anxiety and depression, or mental distress.

CONCLUSION

The PRS predicted small but significant odds of anxiety, comorbid anxiety and depression and mental distress, but we found no support for a differential effect of genetic propensity in urban and rural neighbourhoods for any of the outcomes.

Association of Heel Bone Mineral Density With Incident Disability and Mortality in Community-Dwelling Older Adults

Age‐related bone loss is common in older adults. However, the association of low bone mass with incident disability and mortality is not well established. A sample of 738 participants in the Rush Memory and Aging Project (MAP) was evaluated at baseline for bone mineral density (BMD) using quantitative ultrasound at the calcaneus. An annual interview assessed basic activities of daily living (BADL), instrumental activities of daily living (IADL), mobility disability, and history of hip fracture. The associations between baseline BMD and risk of death; incident BADL, IADL, and mobility disability; and hip fracture were investigated using Cox hazard models, adjusting for age, sex, education, race, and body mass index (BMI). The robustness of our findings was evaluated by adjusting for confounding factors and health conditions including joint pain, musculoskeletal medications, smoking status, motor function, global cognition, falls, cardiovascular events, and diabetes. Participants were on average (mean ± SD) 80.9 ± 7.0 years old, 72% female, and 3.8% black, with a baseline BMI of 27.3 ± 5.4 kg/m², and a baseline of BMD of 0.44 ± 0.14 g/cm². In models adjusted for age, sex, education, race, and BMI, lower BMD was associated with a higher rate of death (hazard ratio [HR] 1.20; 95% confidence interval [CI], 1.08–1.33), incident BADL disability (HR 1.20; 95% CI, 1.05–1.37), and hip fracture (HR 2.57; 95% CI, 1.72–3.82), but not of IADL disability (HR 1.00; 95% CI, 0.85–1.17) or mobility disability (HR 1.13; 95% CI, 0.97–1.32). The association between BMD and mortality was not significant in fully adjusted models, but the BMD and BADL associations remained significant in models adjusting for both demographic variables and BMD‐modifying health conditions. BMD is associated with incident disability in older adults. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Association of illicit drug use in adolescence with socioeconomic and criminal justice outcomes in adulthood: prospective findings from a UK national birth cohort

BACKGROUND

Illicit drug use in adolescence has been linked to drug use and poor mental health in adult life, but few studies have examined the relation between adult economic and criminal justice outcomes.

METHODS

We analysed data from 14 082 participants (6999 women) in the 1970 British Birth Cohort Study. Illicit drug use over study members' lifetime and in the past year were self-reported at 16 years of age. Thirteen outcomes were self-reported at 30 years of age, including illicit drug use, smoking, problems with alcohol, mental and physical health, experience of socioeconomic disadvantage and experiences with the criminal justice system.

RESULTS

At 16 years of age, 20.3% of the participants had ever tried an illicit drug and 7.2% had used in the past year. After adjustment for childhood socioeconomic status and mental health problems, and following correction for multiple testing, there was a dose-response association between illicit drug use at 16 years with illicit drug use in adult life in the past year (OR; 95% CI - 1.83, 1.51 to 3.12), experiencing homelessness (1.74, 1.16 to 2.62), being arrested (1.57, 1.29 to 1.92) and cautioned (1.97, 1.50 to 2.57) by the police, and being found guilty at court (1.73, 1.34 to 2.23).

CONCLUSIONS

Adolescent drug use was associated with an array of social and criminal outcomes in later life.

Two speeds of increasing milk feeds for very preterm or very low-birthweight infants: the SIFT RCT

BACKGROUND

Observational data suggest that slowly advancing enteral feeds in preterm infants may reduce necrotising enterocolitis but increase late-onset sepsis. The Speed of Increasing milk Feeds Trial (SIFT) compared two rates of feed advancement.

OBJECTIVE

To determine if faster (30 ml/kg/day) or slower (18 ml/kg/day) daily feed increments improve survival without moderate or severe disability and other morbidities in very preterm or very low-birthweight infants.

DESIGN

This was a multicentre, two-arm, parallel-group, randomised controlled trial. Randomisation was via a web-hosted minimisation algorithm. It was not possible to safely and completely blind caregivers and parents.

SETTING

The setting was 55 UK neonatal units, from May 2013 to June 2015.

PARTICIPANTS

The participants were infants born at < 32 weeks' gestation or a weight of < 1500 g, who were receiving < 30 ml/kg/day of milk at trial enrolment.

INTERVENTIONS

When clinicians were ready to start advancing feed volumes, the infant was randomised to receive daily feed increments of either 30 ml/kg/day or 18 ml/kg/day. In total, 1400 infants were allocated to fast feeds and 1404 infants were allocated to slow feeds.

MAIN OUTCOME MEASURES

The primary outcome was survival without moderate or severe neurodevelopmental disability at 24 months of age, corrected for gestational age. The secondary outcomes were mortality; moderate or severe neurodevelopmental disability at 24 months corrected for gestational age; death before discharge home; microbiologically confirmed or clinically suspected late-onset sepsis; necrotising enterocolitis (Bell's stage 2 or 3); time taken to reach full milk feeds (tolerating 150 ml/kg/day for 3 consecutive days); growth from birth to discharge; duration of parenteral feeding; time in intensive care; duration of hospital stay; diagnosis of cerebral palsy by a doctor or other health professional; and individual components of the definition of moderate or severe neurodevelopmental disability.

RESULTS

The results showed that survival without moderate or severe neurodevelopmental disability at 24 months occurred in 802 out of 1224 (65.5%) infants allocated to faster increments and 848 out of 1246 (68.1%) infants allocated to slower increments (adjusted risk ratio 0.96, 95% confidence interval 0.92 to 1.01). There was no significant difference between groups in the risk of the individual components of the primary outcome or in the important hospital outcomes: late-onset sepsis (adjusted risk ratio 0.96, 95% confidence interval 0.86 to 1.07) or necrotising enterocolitis (adjusted risk ratio 0.88, 95% confidence interval 0.68 to 1.16). Cost-consequence analysis showed that the faster feed increment rate was less costly but also less effective than the slower rate in terms of achieving the primary outcome, so was therefore found to not be cost-effective. Four unexpected serious adverse events were reported, two in each group. None was assessed as being causally related to the intervention.

LIMITATIONS

The study could not be blinded, so care may have been affected by knowledge of allocation. Although well powered for comparisons of all infants, subgroup comparisons were underpowered.

CONCLUSIONS

No clear advantage was identified for the important outcomes in very preterm or very low-birthweight infants when milk feeds were advanced in daily volume increments of 30 ml/kg/day or 18 ml/kg/day. In terms of future work, the interaction of different milk types with increments merits further examination, as may different increments in infants at the extremes of gestation or birthweight.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76463425.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 18. See the NIHR Journals Library website for further project information.

Fit-for-work or fit-for-unemployment? Does the reassessment of disability benefit claimants using a tougher work capability assessment help people into work?

BACKGROUND

Many governments have introduced tougher eligibility assessments for out-of-work disability benefits, to reduce rising benefit caseloads. The UK government initiated a programme in 2010 to reassess all existing disability benefit claimants using a new functional checklist. We investigated whether this policy led to more people out-of-work with long-standing health problems entering employment.

METHOD

We use longitudinal data from the Labour Force Survey linked to data indicating the proportion of the population experiencing a reassessment in each of 149 upper tier local authorities in England between 2010 and 2013. Regression models were used to investigate whether the proportion of the population undergoing reassessment in each area was independently associated with the chances that people out-of-work with a long-standing health problem entered employment and transitions between inactivity and unemployment. We analysed whether any effects differed between people whose main health problem was mental rather than physical.

RESULTS

There was no significant association between the reassessment process and the chances that people out-of-work with a long-standing illness entered employment. The process was significantly associated with an increase in the chances that people with mental illnesses moved from inactivity into unemployment (HR=1.22, 95% CI 1.03 to 1.45).

CONCLUSIONS

The reassessment policy appears to have shifted people with mental health problems from inactivity into unemployment, but there was no evidence that it had increased their chances of employment. There is an urgent need for services that can support the increasing number of people with mental health problems on unemployment benefits.

Assessing morbidity compression in two cohorts from the Health and Retirement Study

BACKGROUND

Increases in life expectancy are hypothesised to be associated with shorter proportional time spent with morbidity (compression of morbidity). We assessed whether this has occurred among older adults in the USA during the 1990s and 2000s.

METHODS

We used data from the Health and Retirement Study to estimate a morbidity score based on eight chronic conditions and compare it (1) prospectively between two age-matched cohorts in 1992 and 2004 over a 6-year follow-up, and (2) retrospectively in the three waves prior to death among respondents who die in (1998-2004) and (2004-2010).

RESULTS

Prospective assessment shows significantly higher prevalence in 6 of eight chronic conditions in the 2000s, with 37% higher diabetes prevalence. A retrospective evaluation shows significantly higher prevalence in 7 of eight chronic conditions in the three waves prior to death for (2004-2010) versus (1998-2004), with 41% higher prevalence of arthritis. Importantly, the farther away from time of death, the higher the average number of chronic conditions in (2004-2010).

CONCLUSIONS

Using the largest longitudinal ageing study in the USA, we found no clear evidence of compression of morbidity as measured by self-reported chronic disease. Older adults in the USA may be experiencing greater disease burden in recent times.

Socioeconomic differences in the benefits of structured physical activity compared with health education on the prevention of major mobility disability in older adults: the LIFE study

BACKGROUND

Evidence is lacking on whether health-benefiting community-based interventions differ in their effectiveness according to socioeconomic characteristics. We evaluated whether the benefit of a structured physical activity intervention on reducing mobility disability in older adults differs by education or income.

METHODS

The Lifestyle Interventions and Independence for Elders (LIFE) study was a multicentre, randomised trial that compared a structured physical activity programme with a health education programme on the incidence of mobility disability among at-risk community-living older adults (aged 70-89 years; average follow-up of 2.6 years). Education (≤ high school (0-12 years), college (13-17 years) or postgraduate) and annual household income were self-reported (<$24 999, $25 000 to $49 999 and ≥$50 000). The risk of disability (objectively defined as loss of ability to walk 400 m) was compared between the 2 treatment groups using Cox regression, separately by socioeconomic group. Socioeconomic group×intervention interaction terms were tested.

RESULTS

The effect of reducing the incidence of mobility disability was larger for those with postgraduate education (0.72, 0.51 to 1.03; N=411) compared with lower education (high school or less (0.93, 0.70 to 1.24; N=536). However, the education group×intervention interaction term was not statistically significant (p=0.54). Findings were in the same direction yet less pronounced when household income was used as the socioeconomic indicator.

CONCLUSIONS

In the largest and longest running trial of physical activity amongst at-risk older adults, intervention effect sizes were largest among those with higher education or income, yet tests of statistical interactions were non-significant, likely due to inadequate power.

TRIAL REGISTRATION NUMBER

NCT01072500.

Inequality in disability-free life expectancies among older men and women in six countries with developing economies

Background

It is unclear whether the increase in life expectancy (LE) globally is coupled with a postponement of morbidity and disability. Evidence on trends and determinants of disability-free life expectancies (DFLEs) are available in high-income countries but less in low and middle-income countries (LMICs). This study examines the levels of and inequalities in LE, disability and DFLE between men and women across different age groups aged 50 years and over in six countries with developing economies.

Methods

This study utilised the cross-sectional data (n=32 724) from the WHO Study on global AGEing and adult health (SAGE) in China, Ghana, India, Mexico, the Russian Federation and South Africa in 2007–2010. Disability was measured with the activity of daily living (ADL) instrument. The DFLE was estimated using the Sullivan method based on the standard period life table and ADL-disability proportions.

Results

The disability prevalence ranged from 13% in China to 54% in India. The prevalence of disability was highest and occurred at younger age in both sexes in India. Women were more disadvantaged with higher prevalence of disability across all age groups, and the situation was worst among older women in Mexico and the Russian Federation. Though women had higher LE, their proportion of remaining LE free from disability was lower than men.

Conclusions

There are inequalities in the levels of disability and DFLE among men and women in different age groups among people aged over 50 years in these six countries. Countermeasures to decrease intercountry and gender gaps in DFLE, including improvements in health promotion and healthcare distribution, with a gender equity focus, are needed.

Disability in Fibromyalgia Associates with Symptom Severity and Occupation Characteristics

OBJECTIVE

It is intuitive that disability caused by illness should be reflected in illness severity. Because disability rates for fibromyalgia (FM) are high in the developed world, we have examined disease and work characteristics for patients with FM who were working, unemployed, or receiving disability payments for disability as a result of FM.

METHODS

Of the 248 participants in a tertiary care cohort study of patients with FM, 90 were employed, 81 were not employed and not receiving disability payments, and 77 were not working and currently receiving disability payments awarded for disability caused by FM. Demographic, occupation, and disease characteristics were compared among the groups.

RESULTS

The prevalence of disability caused by FM was 30.8%. There were no demographic differences among the working, unemployed, or disabled patients. With the exception of measures for anxiety and depression, all measurements for disease severity differed significantly among the groups, with greater severity reported for the disabled group, which used more medications and participated less in physical activity. Disabled patients were more likely previously employed in manual professions or the service industry, whereas employed patients were more commonly working in non-manual jobs that included clerical, managerial, or professional occupations (p = 0.005).

CONCLUSION

The one-third rate of disability for this Canadian cohort of patients with FM is in line with other reports from the western world. Associations of disability compensation were observed for subjective report of symptom severity, increased use of medications, and previous employment in more physically demanding jobs.

Volunteering is associated with increased survival in able-bodied participants of the English Longitudinal Study of Ageing

BACKGROUND

Volunteering has been linked to reduced mortality in older adults, but the mechanisms explaining this effect remain unclear. This study investigated whether volunteering is associated with increased survival in participants of the English Longitudinal Study of Ageing and whether differences in survival are modified by functional disabilities.

METHODS

A multivariate Cox Proportional Hazards model was used to estimate the association of volunteering with survival over a period of 10.9 years in 10 324 participants, while controlling for selected confounders. To investigate effect modification by disability, the analyses were repeated in participants with and without self-reported functional disabilities.

RESULTS

Volunteering was associated with a reduced probability of death from all causes in univariate analyses (HR=0.65, CI 0.58 to 0.73, p<0.0001), but adjustment for covariates rendered this association non-significant (HR=0.90, CI 0.79 to 1.01, p=0.07). Able-bodied volunteers had significantly increased survival compared with able-bodied non-volunteers (HR=0.81, 95% CI 0.69 to 0.95, p=0.009). There was no significant survival advantage among disabled volunteers, compared with disabled non-volunteers (HR=1.06, CI 0.88 to 1.29, p=0.53).

CONCLUSIONS

Volunteering is associated with reduced mortality in older adults in England, but this effect appears to be limited to volunteers who report no disabilities.

'First, do no harm': are disability assessments associated with adverse trends in mental health? A longitudinal ecological study

Background

In England between 2010 and 2013, just over one million recipients of the main out-of-work disability benefit had their eligibility reassessed using a new functional checklist—the Work Capability Assessment. Doctors and disability rights organisations have raised concerns that this has had an adverse effect on the mental health of claimants, but there are no population level studies exploring the health effects of this or similar policies.

Method

We used multivariable regression to investigate whether variation in the trend in reassessments in each of 149 local authorities in England was associated with differences in local trends in suicides, self-reported mental health problems and antidepressant prescribing rates, while adjusting for baseline conditions and trends in other factors known to influence mental ill-health.

Results

Each additional 10 000 people reassessed in each area was associated with an additional 6 suicides (95% CI 2 to 9), 2700 cases of reported mental health problems (95% CI 548 to 4840), and the prescribing of an additional 7020 antidepressant items (95% CI 3930 to 10100). The reassessment process was associated with the greatest increases in these adverse mental health outcomes in the most deprived areas of the country, widening health inequalities.

Conclusions

The programme of reassessing people on disability benefits using the Work Capability Assessment was independently associated with an increase in suicides, self-reported mental health problems and antidepressant prescribing. This policy may have had serious adverse consequences for mental health in England, which could outweigh any benefits that arise from moving people off disability benefits.

Labour and delivery interventions in women with intellectual and developmental disabilities: a population-based cohort study

BACKGROUND

Our objectives were to: (1) examine the occurrence of labour induction, caesarean section, and operative vaginal delivery in women with intellectual and developmental disabilities compared to those without and (2) determine whether pre-pregnancy health conditions and pregnancy complications explain any elevated occurrence of these interventions.

METHODS

We conducted a population-based study using linked Ontario (Canada) administrative data. We identified deliveries to women with (N=3932) and without (N=382,774) intellectual and developmental disabilities (2002-2011). Modified Poisson regression was used to estimate adjusted relative risks (aRR) and 95% CIs for interventions, controlling for sociodemographic characteristics. We used generalised estimating equations to determine whether pre-pregnancy health conditions and pregnancy complications explained any statistically significantly elevated aRRs.

RESULTS

After controlling for socio-demographic characteristics, women with intellectual and developmental disabilities were more likely to have labour inductions (aRR, 1.13; 95% CI 1.06 to 1.20) and caesarean sections (aRR, 1.09; 95% CI 1.03 to 1.16) but not operative vaginal deliveries, compared to the referent group. Pre-pregnancy health conditions explained 12.9% of their elevated aRR for labour induction. Pre-pregnancy health conditions and maternal complications explained 27.8% and 13.3%, respectively, of their elevated aRR for caesarean section.

CONCLUSIONS

Women with intellectual and developmental disabilities are slightly more likely to have labour inductions and caesarean sections than women without intellectual and developmental disabilities. The elevated occurrence of these interventions is not fully explained by their pre-pregnancy health conditions or pregnancy complications. Non-medical issues should be evaluated for their influence on the timing of labour and delivery in this population.

Effect of a community intervention programme promoting social interactions on functional disability prevention for older adults: propensity score matching and instrumental variable analyses, JAGES Taketoyo study

BACKGROUND

The efficacy of promoting social interactions to improve the health of older adults is not fully established due to residual confounding and selection bias.

METHODS

The government of Taketoyo town, Aichi Prefecture, Japan, developed a resident-centred community intervention programme called 'community salons', providing opportunities for social interactions among local older residents. To evaluate the impact of the programme, we conducted questionnaire surveys for all older residents of Taketoyo. We carried out a baseline survey in July 2006 (prior to the introduction of the programme) and assessed the onset of functional disability during March 2012. We analysed the data of 2421 older people. In addition to the standard Cox proportional hazard regression, we conducted Cox regression with propensity score matching (PSM) and an instrumental variable (IV) analysis, using the number of community salons within a radius of 350 m from the participant's home as an instrument.

RESULTS

In the 5 years after the first salon was launched, the salon participants showed a 6.3% lower incidence of functional disability compared with non-participants. Even adjusting for sex, age, equivalent income, educational attainment, higher level activities of daily living and depression, the Cox adjusted HR for becoming disabled was 0.49 (95% CI 0.33 to 0.72). Similar results were observed using PSM (HR 0.52, 95% CI 0.33 to 0.83) and IV-Cox analysis (HR 0.50, 95% CI 0.34 to 0.74).

CONCLUSIONS

A community health promotion programme focused on increasing social interactions among older adults may be effective in preventing the onset of disability.

Work Disability in Early Systemic Sclerosis: A Longitudinal Population-based Cohort Study

OBJECTIVE

To study work disability (WD) with reference to levels of sick leave and disability pension in early systemic sclerosis (SSc).

METHODS

Patients with SSc living in the southern part of Sweden with onset of their first non-Raynaud symptom between 2003 and 2009 and with a followup of 36 months were included in a longitudinal study. Thirty-two patients (26 women, 24 with limited SSc) with a median age of 47.5 years (interquartile range 43-53) were identified. WD was calculated in 30-day intervals from 12 months prior to disease onset until 36 months after, presented as the prevalence of WD per year (0-3) and as the period prevalence of mean net days per month (± SD). Comparisons were made between patients with different disease severity and sociodemographic characteristics, and between patients and a reference group (RG) from the general population.

RESULTS

Seventy-eight percent had no WD 1 year prior to disease onset, which decreased to 47% after 3 years. The relative risk for WD in patients with SSc compared with RG was 0.95 (95% CI 0.39-2.33) at diagnosis, and increased to 2.41 (1.28-4.55) after 3 years. There were no significant correlations between WD and disease severity, but between WD and years at workplace (rs = -0.72; p = 0.002), education (rs = -0.51; p = 0.004), and sickness absence the month before disease onset (rs = 0.58; p = 0.001), respectively.

CONCLUSION

Considerable increase in WD was noted 3 years after disease onset. Limited education, fewer years at workplace, and sickness absence before disease onset may be risk factors for sustained WD.

Mothering alone: cross-national comparisons of later-life disability and health among women who were single mothers

BACKGROUND

Single motherhood is associated with poorer health, but whether this association varies between countries is not known. We examine associations between single motherhood and poor later-life health in the USA, England and 13 European countries.

METHODS

Data came from 25 125 women aged 50+ who participated in the US Health and Retirement Study, the English Longitudinal Study of Ageing and Survey of Health, Ageing and Retirement in Europe. We tested whether single motherhood at ages 16-49 was associated with increased risk of limitations with activities of daily living (ADL), instrumental ADL and fair/poor self-rated health in later life.

RESULTS

33% of American mothers had experienced single motherhood before age 50, versus 22% in England, 38% in Scandinavia, 22% in Western Europe and 10% in Southern Europe. Single mothers had higher risk of poorer health and disability in later life than married mothers, but associations varied between countries. For example, risk ratios for ADL limitations were 1.51 (95% CI 1.29 to 1.98) in England, 1.50 (1.10 to 2.05) in Scandinavia and 1.27 (1.17 to 1.40) in the USA, versus 1.09 (0.80 to 1.47) in Western Europe, 1.13 (0.80 to 1.60) in Southern Europe and 0.93 (0.66 to 1.31) in Eastern Europe. Women who were single mothers before age 20, for 8+ years, or resulting from divorce or non-marital childbearing, were at particular risk.

CONCLUSIONS

Single motherhood during early-adulthood or mid-adulthood is associated with poorer health in later life. Risks were greatest in England, the USA and Scandinavia. Selection and causation mechanisms might both explain between-country variation.

Predicting the risk of physical disability in old age using modifiable mid-life risk factors

BACKGROUND

We aimed to investigate the relationship between potentially modifiable risk factors in middle age and disability after 13 years using the Framingham Offspring Study (FOS). We further aimed to develop a disability risk algorithm to estimate the risk of future disability for those aged 45-65 years.

METHODS

FOS is a longitudinal study. We used examination 5 (1991-1995; 'baseline') and examination 8 (2005-2008; 'follow-up'). We included participants aged between 45-65 years at 'baseline' with complete predictor and outcome measures (n=2031; mean age 53.9 years). Predictors considered were body mass index, smoking, hypertension, diabetes and dyslipidaemia. We used multinomial logistic regression to identify predictors of disability or death.We assessed external validity using Australian data.

RESULTS

By examination 8, 156 participants had disability and 198 had died. Disability was associated with smoking (OR (95% CI) 1.81 (1.18 to 2.78)); obesity (2.95 (1.83 to 4.77)); diabetes 1.96 (1.11 to 3.45) and being female (OR 1.67 (1.13 to 2.45). The model performed moderately well in predicting disability and death in an Australian population. Based on our algorithm, a 45-year-old man/woman with the combined risk factors of obesity, diabetes and smoking has similar likelihood of surviving free of disability to a 65-year-old man/woman without any of the same risk factors.

CONCLUSIONS AND RELEVANCE

The derived risk algorithm allows, for the first time, quantification of the substantial combined impact on future disability of key modifiable risk factors in mid-life. Here we demonstrated the combined impact of obesity, diabetes and smoking to be similar to 20 years of aging.

The effectiveness of community-based rehabilitation programmes: an impact evaluation of a quasi-randomised trial

BACKGROUND

Community-based rehabilitation (CBR) programmes have been described as highly effective means of promoting the rights and opportunities of persons with disabilities (PwD). Although CBR is often the main way in which PwD in low-income and middle-income countries access rehabilitation services, there is little literature providing rigorous evaluation of their impact on people's well-being.

METHODS

Data were collected in the Mandya and Ramanagar districts (Karnataka state, India), between December 2009 and May 2010. In total 2540 PwD were interviewed using stratified random sampling: 1919 CBR beneficiaries (who joined the programme between 1997 and 2009) and 621 persons who were living in villages not covered by the programme. We controlled for the systematic differences between people joining and not joining the programme using the propensity score matching method controlling for covariates at individual and village level. We evaluated the impact of the programme on the subgroups of PwD who are disadvantaged on the dimensions of interest: access to pensions, use of aid appliances, access to paid jobs and improvement in personal-practical autonomy after 4 and 7 years of joining the CBR.

RESULTS

We observed a positive and significant impact of the programme on access to services, rights and opportunities of PwD. The results indicate that compared with the control group access to pensions and allowances, aid appliances, access to paid jobs and personal-practical autonomy increased by 29.7%, 9.4%, 12.3% and 36.2%, respectively, after 7 years.

CONCLUSIONS

The CBR programme analysed has a positive impact on access to services and the well-being of PwD who are particularly deprived on outcomes of interest.

Employment status and mental health among persons with and without a disability: evidence from an Australian cohort study

BACKGROUND

Unemployment and economic inactivity are associated with worse mental health in the general population, but there is limited understanding of whether these relationships are different for those persons with mental or physical disabilities. The aim of this study was to assess whether there were differences in mental health by labour force status among persons with and without disabilities.

METHOD

Over eight annual waves of the Household, Income and Labour Dynamics in Australia (HILDA) survey, a total of 2379 people with disabilities and 11 417 people without disabilities were identified. Mental health using the Mental Component Summary (MCS) from the Short Form 36 was modelled as a function of labour force status using fixed-effects regression models to control for time invariant confounding. Differences between those with and without disabilities were assessed by including an interaction term in regression models.

RESULTS

After finding evidence of effect modification, regression models were stratified by disability status. After adjustment, unemployment and economic inactivity were associated with a -1.85 (95% CI -2.96 to -0.73, p=0.001) and -2.66 (95% CI -3.46 to -1.86, p<0.001) reduction in scores of the MCS among those with a disability. For those without a disability, there were smaller declines associated with unemployment (-0.57, 95% CI -1.02 to -0.12, p=0.013) and economic inactivity (-0.34, 95% CI -0.64 to 0.05, p=0.022).

CONCLUSIONS

These results suggest a greater reduction in mental health for those persons with disabilities who were unemployed or economically inactive than those who were employed. This highlights the value of employment for people with disabilities.

Work productivity loss and fatigue in psoriatic arthritis

OBJECTIVE

To explore the relationship between fatigue and work productivity loss (WPL) in people with psoriatic arthritis (PsA).

METHODS

Data were collected from participants in the Utah Psoriasis Initiative Arthritis registry between January 2010 and May 2013. WPL was measured with the 8-item Work Limitations Questionnaire. Fatigue was assessed with question 1 from the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI#1), "How would you describe the overall level of fatigue/tiredness you have experienced?" and with question 1 from the Psoriatic Arthritis Quality of Life Questionnaire (PsAQOL#1) "I feel tired whatever I do." Psoriatic activity was evaluated with tender joint count (TJC), swollen joint count (SJC), dactylitis count, enthesitis count, inflammatory back pain (IBP), physician global assessment, body surface area, and psoriasis pain and itch.

RESULTS

Among 107 participants, work productivity was reduced by 6.7%, compared to benchmark employees without limitations. Fatigue was reported by 54 patients (50.5%) on PsAQOL#1, and 64 (60.0%) were classified as high fatigue by BASDAI#1. TJC, SJC, enthesitis count, IBP, and depressed mood were highest or most frequent in participants reporting fatigue. After adjustments for psoriatic activity and depressed mood, WPL was associated with fatigue, as measured by PsAQOL#1 (p = 0.01) and BASDAI#1 (p = 0.002).

CONCLUSION

WPL was associated with fatigue, and the association was not entirely explained by the evaluated musculoskeletal, cutaneous, or psychiatric manifestations of PsA.

Ischemic digital ulcers affect hand disability and pain in systemic sclerosis

OBJECTIVE

Ischemic digital ulcers (DU) are frequent and severe complications of systemic sclerosis (SSc). The purpose of our study was to assess the effect of DU on hand disability and pain in patients with SSc.

METHODS

The Evaluation of the Impact of Recurrent Ischemic DU on Hand Disability in Patients with SSc (ECLIPSE) is a prospective, multicenter, noninterventional study with a 2-year followup. Patients with SSc who experienced at least 1 DU in the previous year and received bosentan therapy were included between October 2009 and March 2011. This cohort is described at the time of inclusion.

RESULTS

There were 190 patients (132 females) from 53 centers. Mean age ± SD was 43 ± 15 years at SSc diagnosis and 53 ± 15 years at inclusion. In 105 patients (56.2%), DU were the first non-Raynaud symptoms of SSc. The mean time interval between the occurrence of Raynaud phenomenon and the first DU episode was 6.6 ± 9.1 years. The mean numbers of active DU and fingers affected per patient for both hands were 2.3 ± 1.8 and 2.2 ± 1.6, respectively. Presence of active DU at inclusion was significantly associated with pain and impaired hand function: Visual Analog Scale for pain (0 to 10) was 6.2 ± 2.6 versus 2.5 ± 2.4 (p < 0.0001) and Cochin Hand Function Scale for hand disability (0 to 90) was 38 ± 20 versus 25 ± 19 (p < 0.0001), respectively.

CONCLUSION

DU represent a major sign of SSc, often affecting multiple fingers and both hands. They are significantly associated with pain and hand disability.

Item response theory, computerized adaptive testing, and PROMIS: assessment of physical function

OBJECTIVE

Patient-reported outcome (PRO) questionnaires record health information directly from research participants because observers may not accurately represent the patient perspective. Patient-reported Outcomes Measurement Information System (PROMIS) is a US National Institutes of Health cooperative group charged with bringing PRO to a new level of precision and standardization across diseases by item development and use of item response theory (IRT).

METHODS

With IRT methods, improved items are calibrated on an underlying concept to form an item bank for a "domain" such as physical function (PF). The most informative items can be combined to construct efficient "instruments" such as 10-item or 20-item PF static forms. Each item is calibrated on the basis of the probability that a given person will respond at a given level, and the ability of the item to discriminate people from one another. Tailored forms may cover any desired level of the domain being measured. Computerized adaptive testing (CAT) selects the best items to sharpen the estimate of a person's functional ability, based on prior responses to earlier questions. PROMIS item banks have been improved with experience from several thousand items, and are calibrated on over 21,000 respondents.

RESULTS

In areas tested to date, PROMIS PF instruments are superior or equal to Health Assessment Questionnaire and Medical Outcome Study Short Form-36 Survey legacy instruments in clarity, translatability, patient importance, reliability, and sensitivity to change.

CONCLUSION

Precise measures, such as PROMIS, efficiently incorporate patient self-report of health into research, potentially reducing research cost by lowering sample size requirements. The advent of routine IRT applications has the potential to transform PRO measurement.