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Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993–2005 to clinical dementia assessments carried out in 2001–2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia. [ABSTRACT FROM AUTHOR]

Objectives. Obese Americans, who receive more care for chronic diseases, may receive fewer preventive services. We evaluated the association between body mass index (BMI) and receipt of screening mammography and Papanicolaou tests among middle-aged women and the association between BMI and receipt of influenza vaccination among the elderly. Methods. We analyzed 2 datasets: the Health and Retirement Study (4439 women aged 50-61 years) and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study (4045 women and 2154 men aged 70 years or more). Results. When BMI was greater than 18.5 kg/m², we found an inverse dose-response relationship between BMI and receipt of screening mammography and Pap tests among White, but not Black, middle-aged women. We found a similar association between BMI and influenza vaccination among the elderly. Conclusions. Higher BMI was associated with less frequent receipt of preventive services among middle-aged White women and elderly White women and men. The Healthy People 2010 clinical preventive service goals remain elusive, especially for overweight and obese White persons. [ABSTRACT FROM AUTHOR]

Although the bequest motive is one of the most important theoretical extensions of the life-cycle hypothesis, few empirical studies have measured determinants of unequal estate division. We estimated whether several proxies that are consistent with exchange and altruism lead to unequal estate division using data from a longitudinal survey of deceased elderly persons linked to probate court records. Equal division was the rule-between 70 and 83% of estates were divided equally, depending on the strictness of the definition of equal division. Several measures of exchange were not significant predictors of unequal division. Two factors that are consistent with both exchange and altruism-writing the last will and testament within five years of death and having more children-predict unequal estate division. The models control for selection, because many decedents do not file a record in probate court. [ABSTRACT FROM AUTHOR]

Background. Epidemiologic evidence suggests that African Americans have higher rates of Alzheimer's disease (AD) than do whites. Examining longitudinal trends in the number of persons who are identified as having AD in administrative databases may provide insights into this phenomenon. Methods. We analyzed 9-year longitudinal data (1991-1999) for 29,679 Medicare beneficiaries who were screened for the National Long-Term Care Survey. Cases of AD were identified using ICD-9-CM diagnosis codes from Medicare claims files. Results. Age-adjusted rates of Medicare beneficiaries identified as having AD rose from 1991-1999 for all groups studied, but particularly among African Americans. In 1991, African Americans made up 6.5% of the identified AD cases but comprised 11.0% of cases in 1999 (X² = 6.79, p = .005). The rate of increase in identification of AD was particularly large for women who were aged 85 years and older. Conclusions. Reasons for increased identification of AD in Medicare claims is likely multifactorial; sharp increases among African Americans may reflect improved access. [ABSTRACT FROM AUTHOR]

To determine whether residual difficulty in functioning in spite of equipment use is linked with increased use of personal assistance. Longitudinal. Two waves of the Asset and Health Dynamics Among the Oldest Old (AHEAD) database were used to test the effect of residual difficulty on hours of personal assistance and bed days at Wave 1 on hours of personal assistance, bed days, and nursing home placement at Waves 1 and 2. A nationally representative setting of community-dwelling persons aged 70 and older and their spouses, regardless of age at Wave 1 AHEAD. There was movement of some respondents into nursing homes by the Wave 2 interview. Respondents to the AHEAD survey, N=8,222 at Wave 1. The dependent variables were hours of personal assistance in the month before the AHEAD survey (Waves 1 and 2), number of days in month before the survey in which the person did not get out of bed (Waves 1 and 2), and residence in a nursing home at Wave 2. The key explanatory variable was a mutually exclusive (four category) variable that specified whether there was residual difficulty (yes/no) in indoor mobility in spite of using equipment to aid specifically with indoor mobility. The four-category variable was defined by the four categories created by a cross-tabulation of equipment use (yes/no) and difficulty with indoor mobility (yes/no). A similar four-category variable was also defined for transferring in the home. In cross section, equipment users with residual difficulty reported more hours of personal assistance in the case of indoor mobility impairment and were more likely to have some hours of personal assistance than those without residual difficulty with indoor mobility and transferring. Longitudinally, those with residual difficulty at Wave 1 were more likely to need some personal assistance hours at Wave 2 (odds ratio=1.67, 95% confidence interval= 1.23–2.26 for indoor mobility). For transferring, those with residual difficulty had 43 more hours of personal assistance per month ( P=.001) than those for whom equipment resolved their disability. Residual disability was linked to more bed days for users of indoor mobility and transferring equipment, but it was not predictive of nursing home placement by Wave 2. Equipment for indoor mobility or transfers apparently resolves difficulty for some users of the equipment but not for others. Residual task difficulty in spite of equipment for indoor mobility and transferring is linked with worse outcomes, including increased dependency on personal assistance and more days in bed. This shows that more attention is needed to determine whether equipment prescribed is appropriate for a patient's difficulty and that follow-up assessment is crucial after equipment is prescribed. [ABSTRACT FROM AUTHOR]

Objectives. This study examined whether use of equipment (technological assistance) to cope with disability was associated with use of fewer hours of help from another person (personal assistance). Methods. In a cross-sectional study of 2368 community dwellers older than 65 years with 1 or more limitations in basic activities of daily living (ADLs) from the 1994 National Long Term Care Survey, the relation between technological assistance and personal assistance was examined. Results. Among people with ADL limitations, multivariate models showed a strong and consistent relation between technological assistance and personal assistance, whereby use of equipment was associated with fewer hours of help. Conclusions. Among people with disability, use of assistive technology was associated with use of fewer hours of personal assistance. (Am J Public Health. 2003;93:330-337) [ABSTRACT FROM AUTHOR]

We linked Medicare claims data to information on 417 patients with a clinical diagnosis of Alzheimer''s disease in the Consortium to Establish a Registry for Alzheimer''s Disease (CERAD) to determine what proportion of them were identified as having Alzheimer''s disease (AD) in Medicare claims records. Seventy-nine percent of these patients were identified as having AD using 5 years of claims data; 87% were identified as demented when a broader set of ICD-9-CM codes was used. An Anderson-Gill counting process approach was used to model the “hazard” of patients being identified as having AD in Medicare claims data. CERAD patients with mild dementia were less likely to be identified in the claims data as having AD. Once identified in Medicare claims as having AD, patients were more likely to be so identified again. When using only the physician supplier and institutional outpatient files, approximately 75% of CERAD patients were identified as having AD; hospital files used alone identified less than one-third (29%) of the CERAD patients as having AD. The data indicate that at least 3 consecutive years of physician supplier and physician outpatient claim files should be used to identify Medicare beneficiaries with AD using Medicare claims. [Copyright &y& Elsevier]

Objectives. This study determined the life extension obtained from stopping smoking at various ages. Methods. We estimated the relation between smoking and mortality among 877 243 respondents to the Cancer Prevention Study II. These estimates were applied to the 1990 US census population to examine the longevity benefits of smoking cessation. Results. Life expectancy among smokers who quit at age 35 exceeded that of continuing smokers by 6.9 to 8.5 years for men and 6.1 to 7.7 years for women. Smokers who quit at younger ages realized greater life extensions. However, even those who quit much later in life gained some benefits: among smokers who quit at age 65 years, men gained 1.4 to 2.0 years of life, and women gained 2.7 to 3.7 years. Conclusions. Stopping smoking as early as possible is important, but cessation at any age provides meaningful life extensions. (Am J Public Health. 2002;92:990-996) [ABSTRACT FROM AUTHOR]

Determines the relative impact of Alzheimer's disease and related dementias, disability (ADRD) and common comorbid health conditions on the cost of caring for community-dwelling elderly persons. Mediating role of ADRD on the effect of disability and common comorbidities on costs; Use of regression analysis to measure the adjusted impact of ADRD; Disability and comorbidity in risk adjustment procedure.

Determines the impact of trusts on elderly nursing home stay financed by the Medicaid in the United States. Characteristics of an elderly using a Medicaid-qualifying trust; Utilization of wave 1 of the Assets and Health Dynamics of the Oldest Old data base; Spend down as motif for trust use among the elderly; Implications on trust use policies.

Deals with a study which aimed to determine the number and geographical distribution of general practitioners in Great Britain National Health Service who qualified medically in South Asia and to project their numbers as they retire. Subjects and methods; Results; Conclusion.

Presents information on a comparative study which focuses on the health systems used in the United States (US) and the United Kingdom (UK), identifying the policies used by both countries to counteract geographical problem areas. Assessment of the approaches used by the UK and the US; Examination of the common focus of concern for health related problems in the two countries.

Focuses on the application of logistic regression analysis in determining women of childbearing age without medical insurance in North Carolina. Importance of the data to making decision on health insurance coverage policies; Significance for policy analysts and legislators; Usefulness of the method in making estimates under pressure.

Describes the Rural Obstetrical Care Incentive (ROCI) Program and how its implementation has maintained or increased access to obstetrical care in participating counties on the basis of site visits to local health departments in participating counties and data from the North Carolina Division of Maternal and Child Health. Program goals and aims; Program description; Program results; Discussion. By Donald H. Taylor Jr., Thomas C. Ricketts III, et al.

Describes the recruitment and retention of general practitioners in England and Wales. Examination of changes in their time commitment from October 1, 1990 to October 1, 1994.

Objectives. This study quantified changes in Medicare payments and outcomes for hip fracture and stroke from 1984 to 1994. Methods. We studied National Long Term Care Survey respondents who were hospitalized for hip fracture (n = 887) or stroke (n = 878) occurring between 1984 and 1994. Changes in Medicare payment and survival were primary outcomes. We also assessed changes in functional and cognitive status. Results. Medicare payments within 6 months increased following hip fracture (103%) or stroke (51%). Survival improved for stroke (P<.001) and to a lesser extent for hip fracture (P = .16). Condition-specific improvements were found in functional and cognitive status. Conclusions. During the period 1984 to 1994, Medicare payments for hip fracture and stroke rose and there were some improvements in survival and other outcomes. [ABSTRACT FROM AUTHOR]

Comments on debate in Canada about whether to allow for-profit hospitals. Increase in the number of for-profit hospitals in the U.S.; Concern about a study which found that for-profit hospitals had a higher mortality rate than non-profit private hospitals; Opinion that Canada should not adopt for-profit hospitals.

The article presents a study which examined the effectiveness of the Rural Obstetrical Care Incentive program initiated in North Carolina in 1989 to prevent the rising malpractice insurance costs and make obstetrical care more accessible to women. A questionnaire was mailed to all nurse-midwives participating in the program in August 1991. The participants played key parts in the obstetrical care delivery network in their respective counties. The nurse-midwives delivered more babies in 1990 than the family physician participants.

Objective: To study associations between number of children and obesity in middle-aged women and men. Methods: In the Health and Retirement Study, a national survey of households, we tested the association between increasing number of children and obesity (body mass index [BMI] ≥ 30) in 9046 middle-aged women and men (4523 couples). Results: Women (n = 4523) who were obese were more frequently nonwhite, reported lower household income, were more frequently employed outside the home, were less frequently covered by health insurance, and were more frequently less educated compared with nonobese women. Men (n = 4523) who were obese were younger, were more frequently African American, and were more frequently less educated and poorer compared with nonobese men. Among women, a 7% increase in risk of obesity was noted for each additional child, adjusting for age, race, household income, work status, physical activity, tobacco use, and alcohol use. Among men, a 4% increase in risk of obesity was noted for each additional child, adjusting for the same covariates. These sex differences were not significantly different. Conclusions: Previous research has demonstrated an association between number of children and obesity among women. These results suggest a similar association among men. Public health interventions focused on obesity prevention should target both parents, especially those parents with several children. [ABSTRACT FROM AUTHOR]

Examines the frequency of self-reported receipt of screening mammography and Pap smear in older women. Influence of education and income on medical screening behavior; Factors affecting patient's values and preferences for making informed screening decisions; Strengths and limitations of elderly females.

Nonprofit organizations may predominate when output quality is difficult to monitor. Hospital care has this characteristic. This study compared program cost and quality of care for Medicare patients hospitalized following onset of four common conditions by hospital ownership. Payments on behalf of Medicare patients admitted to for-profit hospitals during the first 6 months following a health shock were higher than for those admitted to other hospitals. With quality measured in terms of survival, changes in functional and cognitive status, and living arrangements, we found no differences in outcomes by hospital ownership. [ABSTRACT FROM AUTHOR]

Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death--a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program. [ABSTRACT FROM AUTHOR]

Background: Concerns about unsustainable costs in the US Medicare program loom as the number of retirees increase and experiences serious and costly illnesses like cancer. Engagement of stakeholders, particularly cancer patients and their families, in prioritizing insured services offers a valuable strategy for informing Medicare coverage policy. We designed and evaluated a decision exercise that allowed cancer patients and family members to choose Medicare benefits for advanced cancer patients. Methods: The decision tool, Choosing Health plans All Together (CHAT) was modified to select services for advanced cancer patients. Patients with a cancer history (N = 246) and their family members (N = 194) from North Carolina participated in 70 CHAT sessions. Variables including participants’ socio-demographic characteristics, health status, assessments of the exercise and results of group benefit selections were collected. Routine descriptive statistics summarized participant characteristics and Fisher’s exact test compared group differences. Qualitative analysis of group discussions were used to ascertain reasons for or against selecting benefits. Results: Patients and family members (N = 440) participated in 70 CHAT exercises. Many groups opted for such services as palliative care, nursing facilities, and services not currently covered by the Medicare program. In choosing among four levels of cancer treatment coverage, no groups chose basic coverage, 27 groups (39%) selected intermediate coverage, 39 groups (56%) selected high coverage, and 4 groups (6%) chose the most comprehensive cancer coverage. Reasons for or against benefit selection included fairness, necessity, need for prioritizing, personal experience, attention to family needs, holistic health outlook, preference for comfort, freedom of choice, and beliefs about the proper role of government. Participants found the exercise very easy (59%) or fairly easy (39%) to understand and very informative (66%) or fairly informative (31%). The majority agreed that the CHAT exercise led to fair decisions about priorities for coverage by which they could abide. Conclusions: It is possible to involve cancer patients and families in explicit discussions of their priorities for affordable advanced cancer care through the use of decision tools designed for this purpose. A key question is whether such a conversation is possible on a broader, national level. [ABSTRACT FROM AUTHOR]

Purpose: The relationship between prescription medication adherence and financial burden is understudied, particularly in patients seeking financial assistance. Methods: We conducted a cross-sectional survey to examine the association between patient-reported prescription medication nonadherence and financial distress. Eligible patients were adults receiving treatment for solid malignancies enrolled between June 2010 and May 2011 from the Health- Well Foundation, a national copay assistance program. Nonadherence was defined as taking less medication than prescribed because of cost, not filling or partially filling a prescription because of cost, or taking medications prescribed for others. Logistic regression assessed associations between medication nonadherence and patient-reported, subjective financial distress. Results: Among 164 participants, 45% reported cost-related medication nonadherence. Four percent took medications prescribed for another person, 22% took less medication than prescribed, 25% filled a partial prescription, and 27% did not fill a prescription, all as a result of cost. Nonadherent participants were more likely than adherent participants to reduce spending on basics like food and clothing to pay for medication (P < .01), and borrow and/or use credit to pay for medications (P = .01). In adjusted analyses, financial distress did not change odds of nonadherence (odds ratio [OR] = 1.60; 95% CI, 0.71 to 3.60). Having a prescription drug plan (OR = 0.27; 95% CI, 0.09 to 0.83) and older age (OR 0.48; 95% CI, 0.27 to 0.85) decreased odds of nonadherence. Being unemployed increased odds of nonadherence (OR = 6.28; 95% CI, 1.60 to 24.64). Conclusions: Cost-related medication nonadherence was prevalent among cancer patients who sought financial assistance. Further investigation is needed to understand predictors of prescription medication adherence, a key component of quality care. [ABSTRACT FROM AUTHOR]

Purpose: With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice. Methods: This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011. Results: The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58%were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms. Conclusions: Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community- based palliative care. [ABSTRACT FROM AUTHOR]

Purpose: With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice. Methods: This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011. Results: The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58%were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms. Conclusions: Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community- based palliative care. [ABSTRACT FROM AUTHOR]

This study investigated the impact of own and spouse's urinary incontinence on depressive symptoms. Attention was paid to the possibility that gender and caregiving might be important factors in understanding significant effects. We used negative binomial regression to analyze survey data for 9974 middle-aged and older respondents to the Health and Retirement Study in the USA. Results supported the hypothesis that the respondents' own urinary incontinence was associated with depressive symptoms (unadj. IRR = 1.73, 95% CIs = 1.53, 1.95 for men; unadj. IRR = 1.50, 95% CIs = 1.38, 1.63 for women). Controlling sociodemographic and health variables reduced this relationship, but it remained statistically significant for both men and women. Having an incontinent wife put men at greater risk for depressive symptoms (unadj. IRR = 1.13, 95% CIs = 1.02, 1.25), although this relation became nonsignificant with the addition of control variables. No relation between women's depressive symptoms and husbands' (in)continence status was found. Caregiving was not a significant variable in the adjusted analyses, but spouses' depressive symptoms emerged as a significant predictor of the respondents' own depressive symptoms. Health care providers must be sensitive to the emotional impact of urinary incontinence. Our findings also suggest the importance of considering the patient's mental health within a wider context, particularly including the physical and mental health of the patient's spouse. [ABSTRACT FROM AUTHOR]

Presents a study which determined whether the *epsilon4 allele of apolipoprotein E is predictive of mortality in a community-based sample. Allelic forms of the apolipoprotein E; Presence of the *epsilon4 allele; Characteristics of the sample and relationship of the characteristics to death.

Background: Concerns about unsustainable costs in the US Medicare program loom as the number of retirees increase and experiences serious and costly illnesses like cancer. Engagement of stakeholders, particularly cancer patients and their families, in prioritizing insured services offers a valuable strategy for informing Medicare coverage policy. We designed and evaluated a decision exercise that allowed cancer patients and family members to choose Medicare benefits for advanced cancer patients.Methods: The decision tool, Choosing Health plans All Together (CHAT) was modified to select services for advanced cancer patients. Patients with a cancer history (N = 246) and their family members (N = 194) from North Carolina participated in 70 CHAT sessions. Variables including participants' socio-demographic characteristics, health status, assessments of the exercise and results of group benefit selections were collected. Routine descriptive statistics summarized participant characteristics and Fisher's exact test compared group differences. Qualitative analysis of group discussions were used to ascertain reasons for or against selecting benefits.Results: Patients and family members (N = 440) participated in 70 CHAT exercises. Many groups opted for such services as palliative care, nursing facilities, and services not currently covered by the Medicare program. In choosing among four levels of cancer treatment coverage, no groups chose basic coverage, 27 groups (39%) selected intermediate coverage, 39 groups (56%) selected high coverage, and 4 groups (6%) chose the most comprehensive cancer coverage. Reasons for or against benefit selection included fairness, necessity, need for prioritizing, personal experience, attention to family needs, holistic health outlook, preference for comfort, freedom of choice, and beliefs about the proper role of government. Participants found the exercise very easy (59%) or fairly easy (39%) to understand and very informative (66%) or fairly informative (31%). The majority agreed that the CHAT exercise led to fair decisions about priorities for coverage by which they could abide.Conclusions: It is possible to involve cancer patients and families in explicit discussions of their priorities for affordable advanced cancer care through the use of decision tools designed for this purpose. A key question is whether such a conversation is possible on a broader, national level. [ABSTRACT FROM AUTHOR]