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Objective: To determine whether higher activity of daily living (ADL) limitation stages are associated with increased risk of hospitalization, particularly for ambulatory care sensitive (ACS) conditions.Data Source: Secondary data analysis, including 8,815 beneficiaries from 2005 to 2006 Medicare Current Beneficiary Survey (MCBS).Study Design: ADL limitation stages (0-IV) were determined at the end of 2005. Hospitalization rates were calculated for 2006 and age adjusted using direct standardization. Multivariate negative binomial regression, adjusting for baseline demographic and health characteristics, with the outcome hospitalization count was performed to estimate the adjusted rate ratio of ACS and non-ACS hospitalizations for beneficiaries with ADL stages > 0 compared to beneficiaries without limitations.Data Collection: Baseline ADL stage and health conditions were assessed using 2005 MCBS data and count of hospitalization determined using 2006 MCBS data.Principal Findings: Referenced to stage 0, the adjusted rate ratios (95 percent confidence interval) for stage I to stage IV ranged from 1.9 (1.4-2.5) to 4.1 (2.2-7.8) for ACS hospitalizations compared with from 1.6 (1.3-1.9) to 1.8 (1.4-2.5) for non-ACS hospitalizations.Conclusions: Hospitalization rates for ACS conditions increased more dramatically with ADL limitation stage than did rates for non-ACS conditions. Adults with ADL limitations appear particularly vulnerable to potentially preventable hospitalizations for conditions typically manageable in ambulatory settings. [ABSTRACT FROM AUTHOR]

Background: Concerns about using Instrumental Activities of Daily Living (IADLs) in national surveys come up frequently in geriatric and rehabilitation medicine due to high rates of non-performance for reasons other than health. We aim to evaluate the effect of different strategies of classifying "does not do" responses to IADL questions when estimating prevalence of IADL limitations in a national survey.Methods: Cross-sectional analysis of a nationally representative sample of 13,879 non-institutionalized adult Medicare beneficiaries included in the 2010 Medicare Current Beneficiary Survey (MCBS). Sample persons or proxies were asked about difficulties performing six IADLs. Tested strategies to classify non-performance of IADL(s) for reasons other than health were to 1) derive through multiple imputation, 2) exclude (for incomplete data), 3) classify as "no difficulty," or 4) classify as "difficulty." IADL stage prevalence estimates were compared across these four strategies.Results: In the sample, 1853 sample persons (12.4 % weighted) did not do one or more IADLs for reasons other than physical problems or health. Yet, IADL stage prevalence estimates differed little across the four alternative strategies. Classification as "no difficulty" led to slightly lower, while classification as "difficulty" raised the estimated population prevalence of disability.Conclusions: These analyses encourage clinicians, researchers, and policy end-users of IADL survey data to be cognizant of possible small differences that can result from alternative ways of handling unrated IADL information. At the population-level, the resulting differences appear trivial when applying MCBS data, providing reassurance that IADL items can be used to estimate the prevalence of activity limitation despite high rates of non-performance. [ABSTRACT FROM AUTHOR]

Comprehensive rehabilitation services after acute stroke have been shown efficacious in European trials; however, their effectiveness in everyday practices in the United States is unknown. We compared outcomes of veteran patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services after acute stroke using propensity scores. Outcomes included change in patients’ physical and cognitive independence after rehabilitation, discharge to home as opposed to other settings, and 1-yr after hospital discharge survival. Of the 2,963 patients in the study, 683 (23.1%) received comprehensive rehabilitation while the remaining patients received consultative services. We found, after propensity adjustment, that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 (95% confidence interval [CI]: 9.1 to 16.5) more points of physical independence on a 78-point scale and gained 1.5 (95% CI: 0.8 to 2.2) more points of cognitive independence on a 30-point scale. The likelihoods of discharge to home from the hospital (odds ratio [OR] = 1.61, 95% CI: 1.07 to 2.44) and 1 yr posthospital discharge survival (OR = 1.79, 95% CI: 1.25 to 2.56) were significantly higher among those who received comprehensive rehabilitation. Among patients hospitalized for acute stroke, comprehensive rehabilitation services are associated with greater recovery of physical and cognitive independence, improved home discharge likelihood, and improved 1 yr survival. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to develop an index for establishing the probability of being discharged home after hospitalization for acute stroke using information about previous living circumstances, comorbidities, hospital course, and the physical grades and cognitive stages of independence achieved. Design: This is a longitudinal observational population-based study. All 6515 persons treated for acute stroke who received rehabilitation services in 110 Veterans Affairs facilities within a 2-yr period were included. Results: There were eight independent predictors of home discharge identified, and points were assigned through logistic regression: married (2 points); location before hospitalization (extended care = 0 points, other hospital = 9 points, home = 11 points); discharge physical grade (grade I, II, or III = 0 points; grade IV or V = 3 points; grade VI or VII = 5 points); discharge cognitive stage (stage I = 0 points; stage II, III, IV, or V = 3 points; stage VI or VII = 5 points); and absence of liver disease (2 points), mechanical ventilation (3 points), nonoral feeding (2 points), and intensive care unit admission (1 point). The points were added for all present factors to calculate scores. The probabilities of home discharge ranged from 65.03% in the least likely (≤21 points) to 98.24% in the most likely group (≥27 points). Conclusions: The treatment team might apply prognostic estimates from this index in discharge planning and functional goal setting after initial physical medicine and rehabilitation assessment. [ABSTRACT FROM AUTHOR]

Objectives To examine the independent association between five stages of activities of daily living ( ADLs) and mortality after accounting for known diagnostic and sociodemographic risk factors. Design For five stages of ADLs (0 to IV), determined according to the severity and pattern of ADL limitations, unadjusted life expectancies and adjusted associations with mortality were estimated using a Cox proportional hazards regression model. Setting Community. Participants Nine thousand four hundred forty-seven participants aged 70 and older from the second Longitudinal Study of Aging. Measurements One-, 5-, and 10-year survival and time to death. Results Median life expectancy was 10.6 years for participants with no ADL limitations and 6.5, 5.1, 3.8, and 1.6 years for those at ADL stages I, II, III, and IV, respectively. The sociodemographic- and diagnostic-adjusted hazard of death at 1 year was five times as great at stage IV as at stage 0 (hazard ratio = 5.6, 95% confidence interval = 3.8-8.3). The associations between ADL stage and mortality declined over time but remained statistically significant at 5 and 10 years. Conclusion ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs. [ABSTRACT FROM AUTHOR]

The article reports on the study that examines the linkages between impairment and activity limitation among groups of elderly community-living persons. The study reveals that musculoskeletal impairments accounted for more than one-third of all perceived causes. It suggests that impairments associated with brain or behavioral disturbance were perceived as most disabling.

To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older. Cross-sectional. Community. Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II). Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV). ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI)=2.4-4.4) to 41.9 (95% CI=19.6-89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR=17.8, 95% CI=13.0-24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race. ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features. [ABSTRACT FROM AUTHOR]

Background: To address the impact of using multiple sources of data in the United States Medicare Current Beneficiary Survey (MCBS) compared to using only one source of data to identify those with neuropsychiatric diagnoses.Methods: Our data source was the 2010 MCBS with associated Medicare claims files (N = 14, 672 beneficiaries). The MCBS uses a stratified multistage probability sample design to select a nationally representative sample of Medicare beneficiaries. We excluded those participants in Medicare Health Maintenance Organizations (n = 3894) and performed a cross-sectional analysis. We classified neuropsychiatric conditions according to four broad categories: intellectual/developmental disorders, neurological conditions affecting the central nervous system (Neuro-CNS), dementia, and psychiatric conditions. To account for different baseline prevalence differences of the categories we calculated the relative increase in prevalence that occurred from adding information from claims in addition to the absolute increase to allow comparison among categories.Results: The estimated proportion of the sample with neuropsychiatric disorders increased to 50.0 (both sources) compared to 38.9 (health survey only) and 33.2 (claims only) with an overlap between sources of only 44.1 %. Augmenting health survey data with claims led to an increase in estimated percentage of intellectual/developmental disorders, psychiatric disorders, Neuro-CNS disorders and dementia of 1.3, 5.9, 11.5 and 3.8 respectively. In the community sample, the largest relative increases were seen for dementia (147.6 %) and Neuro-CNS disorders (87.4 %). With the exception of dementia, larger relative increases were seen in the facility sample with the greatest being for intellectual/developmental disorders (121.5 %) and Neuro-CNS disorders (93.8 %).Conclusions: The magnitude of potentially underestimated sample proportions using health survey only data varied strikingly according to the category of diagnosis and setting. Augmentation of survey data with claims appears essential particularly when attempting to estimate proportion of the sample affected by conditions that cause cognitive impairment which may affect ability to self-report. Augmenting proxy survey data with claims data also appears to be essential when ascertaining proportion of the facility-dwelling sample affected by neuropsychiatric disorders. [ABSTRACT FROM AUTHOR]

Purpose of the study: To assess the recruitment, adherence, and retention of urban elderly, predominantly African Americans to a falls reduction exercise program. Design and methods: The randomized controlled trial was designed as an intervention development pilot study. The goal was to develop a culturally sensitive intervention for elderly persons who suffered a fall and visited an emergency department (ED). Participants were taught exercises during 4 on-site group classes and encouraged to continue exercising at home for 12 weeks and attend additional on-site monthly classes. The protocol included a specifically designed intervention for increasing retention through trained community interventionists drawn from the participants’ neighborhoods. Results: The screening of 1,521 ED records after falling yielded the recruitment of 204 patients aged 65 years and older. Half were randomized into the falls prevention program. Of the 102 people in the intervention group, 92 completed the final 6-month assessment, 68 attended all on-site sessions, but only 1 reported exercising at home all 12 weeks. Those who lived alone were more likely (p = .03) and those with symptoms of depression were less likely (p = .05) to attend all on-site exercise classes. The final recruitment rate was estimated as 31.8%. The final retention rates were 90.2% and 87.3% for the intervention and control groups, respectively. Implications: Recruitment of frail elderly African American patients is resource intensive. Adherence to the on-site exercise classes was better than to the home-based component of the program. These findings have implications for the design of future community-based exercise programs and trials. [ABSTRACT FROM PUBLISHER]

Objective: We sought to develop a risk scoring system for predicting functional deterioration, institutionalization, and mortality. Identifying predictors of poor health outcomes informs clinical decision-making, service provision, and policy development to address the needs of persons at greatest risk for poor health outcomes. Design: This is a cohort study with 21,257 community-dwelling Medicare beneficiaries 65 yrs and older who participated in the 2001-2008 Medicare Current Beneficiary Survey. Derivation of the model was conducted in 60% of the sample and validated in the remaining 40%. Multinomial logistic regression model generated β coefficients, which were used to create a risk scoring system. Our outcome was instrumental activity of daily living stage transitions (stable/improved function and functional deterioration), institutionalization, or mortality for 2 yrs of follow-up. Results: A total of 18 factors were identified for functional deterioration (P < 0.05). In the derivation cohort, the likelihood of functional deterioration ranged from 6.27% to 33.51%, risk of institutionalization from 0.07% to 12.13%, and risk of mortality from 2.13% to 31.83%, in comparison with stable/improved function. Conclusions: A risk scoring system predicting Medicare beneficiaries' risk of functional deterioration, institutionalization, and mortality based on demographic and clinical indicators may feasibly be developed with implications for healthcare delivery. [ABSTRACT FROM AUTHOR]

This study's objective was to determine how treatment-, environmental-, and facility-level characteristics contribute to postdischarge mortality prediction. The study included 4,153 Veterans who underwent lower-limb amputation in Department of Veterans Affairs facilities during fiscal years 2003 and 2004. Veterans were followed 1 yr postamputation. A Cox regression identified characteristics associated with mortality risk after hospital discharge following amputation. Older age, higher amputation level, and more comorbidities increased mortality likelihood. Patients who had inpatient procedures for pulmonary and renal problems had higher hazards of postdischarge death than those who did not (hazard ratio [HR] = 2.10, 95% confidence interval [CI] = 1.16-3.77, and HR = 2.22, 95% CI = 1.80-2.74, respectively). Patients who had central nervous system procedures had higher hazards of death early postdischarge (HR = 2.23, 95% CI = 1.60-3.11) at 0 d, but this association became insignificant by 180 d. Patients in a surgical intensive care unit (ICU), medical ICU, or medical bed section at the time of discharge were more likely to die than patients on a surgical bed section. Patients hospitalized in the Midwest were less likely to die early after discharge than patients in the Mountain Pacific region, but this regional effect became insignificant by 90 d. Adding treatment-, environmental-, and facility-level characteristics contributed additional information to a mortality risk model. [ABSTRACT FROM AUTHOR]

The article presents a study of patient- and facility-level characteristics that cause late specialized rehabilitation among veterans who already received postoperative services. Data were obtained for 2453 patients who went through lower limb amputation in Veterans Affairs Medical Centers. A Cox proportional hazards model was used. The study concludes that the factors linked with late specialized rehabilitation driven primarily by facility-level features and care process variables.