Brenda R. Wamsley

Patient Satisfaction, Empowerment, and Health and Disability Status Effects of a Disease Management–Health Promotion Nurse Intervention Among Medicare Beneficiaries With Disabilities

PURPOSE To report the impact on patient and informal caregiver satisfaction, patient empowerment, and health and disability status of a primary care-affiliated disease self-management-health promotion nurse intervention for Medicare beneficiaries with disabilities and recent significant health services use. DESIGN AND METHODS The Medicare Primary and Consumer-Directed Care Demonstration was a 24-month randomized controlled trial that included a nurse intervention. The present study (N = 766) compares the nurse (n = 382) and control (n = 384) groups. Generalized linear models for repeated measures, linear regression, and ordered logit regression were used. RESULTS The patients whose activities of daily living (ADL) were reported by the same respondent at baseline and 22 months following baseline had significantly fewer dependencies at 22 months than did the control group (p = .038). This constituted the vast majority of respondents. In addition, patient satisfaction significantly improved for 6 of 7 domains, whereas caregiver satisfaction improved for 2 of 8 domains. However, the intervention had no effect on empowerment, self-rated health, the SF-36 physical and mental health summary scores, and the number of dependencies in instrumental ADL. IMPLICATION If confirmed in other studies, this intervention holds the potential to reduce the rate of functional decline and improve satisfaction for Medicare beneficiaries with ADL dependence.

Depression and Suicidal Behaviors in Medicare Primary Care Patients Under Age 65

OBJECTIVE: To examine suicidal behavior and depression prevalence among a group of Medicare patients under age 65 with functional impairment and recent significant health care services use.DESIGN: An observational study of baseline characteristics of participants in a randomized controlled trial.SETTING: A Medicare demonstration (N=1,605) that enrolled primary care patients in 8 counties in New York, 6 counties in West Virginia, and 5 counties in Ohio.PATIENTS/PARTICIPANTS: All demonstration participants under age 65 (n=164). Participants were required to have impairment in at least 2 activities of daily living or 3 instrumental activities of daily living, and to have had recent significant health care use.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: The Paykel questionnaire for suicidal ideation and attempts, the Mini-international Neuropsychiatric Interview Major Depressive Episode module, and the 15-item Geriatric Depression Scale were administered at baseline; 14.8% of the patients indicated suicidal ideation during the past year, 4.9% reported a suicide attempt during that time, 25.9% indicated at least 1 lifetime suicide attempt, 34.6% had a major depressive episode in the last month, and 58.3% had clinically significant depressive symptoms during the previous week.CONCLUSIONS: These levels of suicidal ideation and behaviors and of deprssion are far higher than those found in studies of nonelderly American adults, and may indicate the need for routine screening in this population.

Measurement bias of the SF-36 Health Survey in older adults with chronic conditions

PurposeThe objectives of this study were to investigate the psychometric properties of the SF-36 in a sample of older adults with chronic conditions and to test whether measurement bias exists based on the levels of comorbidity.MethodsParticipants included were 979 cognitively intact older adults with comorbidities who were interviewed at their homes. We examined the psychometric properties of the SF-36 and conducted confirmatory factor analysis (CFA) to investigate the assumption of measurement invariance by the levels of comorbidity.ResultsOverall data quality was high and scaling assumptions were generally met with few exceptions. Floor and ceiling effects were present for the role-physical and role-emotional subscales. Using CFA, we found that a three-factor measurement model fits the data well. We identified two violations of measurement invariance. Results showed that participants with high comorbidity level place more emphasis on social functioning (SF) and bodily pain (BP) in relation to physical health-related quality of life (HRQoL) than those with low comorbidity level.ConclusionsMeasurement bias was present for the SF and BP components of the SF-36 physical HRQoL measure. Researchers should be cautious when considering the use of SF-36 in clinical studies among older adults with comorbidities.

Impact of body mass index on the effectiveness of a disease management-health promotion intervention on disability status.

Purpose. To examine the impact of body mass index (BMI) on the effectiveness of a disease management—health promotion intervention among community-dwelling Medicare beneficiaries with disabilities. Design. Secondary data analyses of a randomized controlled trial. Settings. Nineteen counties in upstate New York and on the West Virginia—Ohio border. Subjects. Four hundred fifty-two Medicare beneficiaries who participated in the Medicare Primary and Consumer-Directed Care Demonstration between August 1998 and June 2002 and completed the 22-month follow-up. Intervention. Multicomponent disease management—health promotion intervention involving patient education, individualized health promotion coaching, medication management, and physician care management. Measures. Body mass index and dependence in Activies of Daily Living (ADLs). Analysis. Multivariate linear regression. Results. The intervention resulted in significantly less worsening in ADLs dependence among normal-weight participants (coefficient, − .42; p = .04). However, the intervention did not have a significant effect for underweight participants (F test p = .33 vs. underweight participants in the control group) or overweight or obese participants (F test p = .78 vs. overweight or obese participants in the control group). Conclusions. A positive effect of the intervention on disability was found among normal-weight participants but not among underweight or overweight or obese participants. Future health promotion interventions should take into consideration the influence of BMI categories on treatment effects.

Body Mass Index and the Impact of a Health Promotion Intervention on Health Services Use and Expenditures

Objective: To examine the effect of body mass index (BMI) on the impact of a health promotion intervention on health services use and expenditures among Medicare beneficiaries with disabilities. Method: We analyzed data from 452 Medicare beneficiaries who participated in a Medicare demonstration. The intervention included the following components: patient education, health promotion coaching, medication management, and physician care management. We performed the analysis by using generalized linear models (GLM) to examine the impact of BMI and the intervention on total health care expenditures. Results: The intervention was cost neutral over the 2-year study period. Participants in the intervention group used less home health aide services (p = .03) and had fewer nursing home days (p = .05). The intervention appeared to have smaller effects on expenditures as BMI level increased. Discussion: The findings suggest that a health promotion intervention may achieve better beneficiary outcomes without an increase in resource use in this Medicare population.

Impact of a Disease Management-Health Promotion Nurse Intervention on Personal Assistance Use and Expenditures

The purpose of this study is to evaluate the effect of a primary care affiliated disease management-health promotion nurse intervention on paid personal assistance (PA) use and expenditures among Medicare beneficiaries with disabilities. We analyzed data on 570 community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Primary and Consumer-Directed Care Demonstration, a randomized controlled trial. We estimated a two-part model to test the effect of the nurse intervention on PA use and expenditures during the 2 years after study entry. Adjusting for covariates, average annual PA expenditures were

Do Disabled Elderly Medicare Beneficiaries with Major Depression Make Less Use of a Consumer-Directed Home Care Voucher Benefit?

1,464 (29%) lower per person in the intervention group as compared to the control group. The findings of this study will help policy makers and practitioners understand the potential benefit of primary care affiliated nurse home visiting interventions on PA expenditures.

Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences

Older adults with major depression may underutilize consumer-directed long-term care. Systematic underutilization would create disparities in outcomes, undermining program effectiveness. The Medicare Primary and Consumer-Directed Care Demonstration included a consumer-directed indemnity benefit that paid for goods and services not financed by traditional Medicare. Overall and for most categories of goods and services there was little difference in use and expenditures between those with and without major depression. However, among those using the benefit to hire in-home workers, arguably the most important consumer-directed purchase, average spending for workers was about 30% lower for depressed persons. While our findings are generally reassuring for public policy, future research is needed to verify that major depression is associated with less spending on in-home workers.

Effect of a Consumer-Directed Voucher and a Disease-Management–Health-Promotion Nurse Intervention on Home Care Use

PURPOSE To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. METHODS The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19 counties in New York State, West Virginia, and Ohio. A total of 839 participants were randomly assigned to receive a voucher benefit (up to

Effect of a Voucher Benefit on the Demand for Paid Personal Assistance

250 per month with a 20% copayment) that could be used toward PAS provided by either independent or agency workers. A bivariate probit model was used to estimate the probabilities of choosing either type of PAS provider while controlling for potential confounders. FINDINGS The voucher was associated with a 32.4% (P < .01) increase in the probability of choosing agency providers and a 12.5% (P= .03) increase in the likelihood of choosing independent workers. When the analysis was stratified by rural/urban status, rural voucher recipients had 36.8% higher probability of using independent workers compared to rural controls. Urban voucher recipients had 37.1% higher probability of using agency providers compared to urban controls. CONCLUSIONS This study provided evidence that rural and urban Medicare beneficiaries with disabilities may have very different responses to a consumer-choice PAS voucher program. Offering a consumer-choice voucher option to rural populations holds the potential to significantly improve their access to PAS.