Brian J. Dudgeon

Falls in the Medicare Population: Incidence, Associated Factors, and Impact on Health Care

Background and Purpose: Falls are a major health problem in the elderly community; however, questions regarding incidence, risk factors, and provider response to falls exist. The purpose of this study was to examine the incidence of falls, associated factors, health care costs, and provider response to falls among Medicare beneficiaries. Participants: The participants were 12,669 respondents to the Medicare Current Beneficiaries Survey (MCBS). Methods: Categories of number of falls (none, one, recurrent) and injury type (medically injurious versus not medically injurious) were created from the falls supplement to the MCBS. Means and proportions for the entire Medicare population were estimated using sampling weights. The association between sociodemographic variables and fall status was modeled using ordinal or binary logistic regression. Aggregate health costs by fall category were estimated from claims data. Results: Population estimates of falls reported in 2002 ranged from 3.7 million (single fall) to 3.1 million (recurrent falls), with an estimated 2.2 million people having a medically injurious fall. Recurrent falls were more likely with increased age, being female, being nonwhite, reporting fair or poor health, and increased number of limitations in personal activities of daily living and instrumental activities of daily living and comorbidities. Although estimates of the actual costs of falls could not be determined, “fallers” consistently had larger utilization costs than “nonfallers” for the year 2002. Fewer than half (48%) of the beneficiaries reported talking to a health care provider following a fall, and 60% of those beneficiaries reported receiving fall prevention information. Discussion and Conclusions: Falls are common and may be associated with significant health care costs. Most importantly, health care providers may be missing many opportunities to provide fall prevention information to older people.

Getting the work done: a qualitative study of individuals with multiple sclerosis

The Problem : Work can be defined as an activity performed to accomplish something in the presence of obstacles that may make accomplishing the goal difficult. For individuals with MS, work is not only limited by physical impairments but also by factors such as fatigue and cognitive changes Purpose : The aim of this study is to examine the experiences of individuals with mild to moderate MS as they carry out everyday work activities both inside and outside the home. Method : Eleven women and three men were recruited from the community to participate in a series of semi-structured interviews. Using qualitative research methodology that examined the experiences of the participants, two major themes and seven subthemes emerged. Results : The first theme, Defining the work, included Priorities : seeing whats important; Plans : learning about resources and requirements; and Perspectives : fixing it yourself. The second theme, Changing how things get done, includes Precipitating factors; Awareness; Constructing the strategies; and Evaluating the strategies. Conclusions : Individuals with MS develop strategies and utilize resources in order to get the work done. Comparisons are made between existing intervention theories or programmes and the experiences described by participants in this study.

Assistive Technology Use Among Adolescents and Young Adults With Spina Bifida

OBJECTIVES We sought to determine the use of assistive technology among a population of individuals with spina bifida. METHODS We performed a descriptive analysis of individuals aged 13 to 27 years diagnosed with myelomeningocele (n=348) using data obtained from an existing database at Childrens Hospital and Regional Medical Center, Seattle, Washington. We summarized disease characteristics, utilization of assistive technology, community and self-care independence, and other variables. RESULTS Eighty-four percent of the respondents lived with at least 1 of their natural parents. Fifty-seven percent used wheelchairs, 35% used braces, and 23% used walking aids. Independent self-care was a common skill, but 72% reported limited participation in structured activities. Half were aged 18 years or older; of those, only 50% had completed high school and 71% were unemployed. Those aged younger than 18 years were all still in school (100%). CONCLUSIONS Adolescents and young adults with spina bifida rely on assistive technology and specialized care routines to maintain their health. Assistive technology use for mobility is common; little is known about secondary complications associated with use of these technologies or the use of assistive technology to address learning disabilities and other societal barriers. Underutilization of assistive technology could delay successful transitions to independent living and community participation.

Cerebral Palsy and Chronic Pain: A Descriptive Study of Children and Adolescents

The experiences of chronic pain among children and adolescents with cerebral palsy (CP) were examined in this survey-based study. Perspectives of both the individual and the parent were solicited in a preliminary sample of 20 youths with CP, ages 6-to-17 years from a metropolitan area. Selected participants completed in-person, structured interviews that focused on quality of life with attention to pain experiences. Quantitative data were analyzed descriptively. Seventy percent of participants (n = 14) experienced recurrent chronic pain of moderate intensity on a daily or weekly basis. Greater than half of those participants (n = 9) reported that pain presented a problem for them and especially interfered with self-care and with sleep. Pain appears to be a problem for many youths with CP, and may create additional interference with routine activities of daily living and participation. Further exploration regarding pain experiences and the nature of pain interference is warranted in order to address development and maintenance of routine activities and participation by children and adolescents with CP.

Pain assessment using the NIH Toolbox

Objective: Pain is an important component of health and function, and chronic pain can be a problem in its own right. The purpose of this report is to review the considerations surrounding pain measurement in the NIH Toolbox, as well as to describe the measurement tools that were adopted for inclusion in the NIH Toolbox assessment battery. Methods: Instruments to measure pain in the NIH Toolbox were selected on the basis of scholarly input from a diverse group of experts, as well as review of existing instruments, which include verbal rating scales, numerical rating scales, and graphical scales. Results: Brief self-report measures of pain intensity and pain interference were selected for inclusion in the core NIH Toolbox for use with adults. A 0 to 10 numerical rating scale was recommended for measuring pain intensity, and a 6-item Patient Reported Outcome Measurement Information System (PROMIS) short form for measuring pain interference. The 8-item PROMIS Pediatric Pain Interference measure was recommended as a supplemental measure. No specific measure was recommended for measuring pain intensity in children. Conclusions: Core and supplemental measures were recommended for the NIH Toolbox. Additional measures were reviewed for investigators who seek tools for measuring pain intensity in pediatric samples.

Developing a scale of communicative participation: A cognitive interviewing study

Purpose. To revise and improve the instructions, candidate items and response format for a tool to measure communicative participation. Method. Cognitive interviewing techniques, designed to study the process that respondents use to answer survey questions, were used to test a bank of candidate items for a measure of communicative participation. Twelve participants with spasmodic dysphonia (SD), a neurologic condition characterized by voice and speech changes, were asked to complete a sample questionnaire and then were interviewed regarding the clarity of instructions, candidate items and response format. Analysis of the interviews was conducted using qualitative techniques and resulted in a series of modifications to the measurement tool. Results. Problems identified related to candidate items included inadequate context, double-barreled or ambiguous items, redundancy, unclear or generally confusing items, infrequent situations, and cultural sensitivity. Participants preferred response options that asked them to rate interference rather than other dimensions such as satisfaction. Conclusions. Subtle differences in items and response options make key differences in how participants interpret and make decisions about their responses. Rich contextual information is needed in order to respond to items that sample communicative participation. Participants preferred response options that capture the barriers that they experience when participating in everyday communication situations.

Experiences of Living With Non-Cancer-Related Lymphedema: Implications for Clinical Practice

Lymphedema is a chronic medical condition caused by lymphatic insufficiency that can lead to extreme swelling and susceptibility to infection. Physical and psychosocial effects of the condition can have a significant impact on an individuals life and level of participation. Research about experiences of individuals living with lymphedema has focused primarily on women with breast cancer, yet individuals with non-cancer-related lymphedema are a distinct group. In this study, the authors used qualitative description to explore the experience of 7 individuals living with advanced and complicated cases of lymphedema who had been treated in an inpatient setting. Findings reveal the extensive impact lymphedema has on those who live with it. Participants spoke of difficulty finding a correct diagnosis and effective treatment, the importance of their inpatient experiences, and the challenges of daily self-management. The authors make recommendations to increase lymphedema awareness, promote inpatient treatment programs, and create effective self-management techniques.

A Longitudinal Evaluation of Persons With Disabilities: Does a Longitudinal Definition Help Define Who Receives Necessary Care?

OBJECTIVE To assess, using a longitudinal definition, the impact of disability on a broad range of objective health care quality indicators. DESIGN Longitudinal cohort study following up with patients over several years. The first 2 interviews, 1 year apart, were used to determine each patients disability status in activities of daily living (ADLs). Assessment of the health care indicators commenced after the second interview and continued throughout the survey period (an additional 1-3y). SETTING National survey. PARTICIPANTS Participants (N=29,074) of the Medicare Current Beneficiary Survey (1992-2001) with no, increasing, decreasing, and stable ADL disability. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The incidence of 5 avoidable outcomes, receipt of 3 preventive care measures, and adherence to 32 diagnostically based indicators assessing the quality of treatment for acute myocardial infarction [AMI], angina, breast cancer, cerebrovascular accident, transient ischemic attack, cholelithiasis, chronic obstructive pulmonary disease [COPD], congestive heart failure, depression, gastrointestinal bleeding, diabetes, and hypertension. RESULTS For most indicators, less than 75% of eligible patients received necessary care, regardless of disability status. For 5 indicators, less than 50% of patients received appropriate treatment. In a logistic regression analysis that controlled for patient age, sex, race, and income, disability status was a significant factor in 7 quality measures (AMI, breast cancer, COPD, diabetes, angina, pneumonia, annual visits). CONCLUSIONS Using a longitudinal definition of disability and objective health quality indicators, we found that disability status can be an important factor in determining receipt of quality health care in a broad range of diagnostic categories. However, the impact of disability status varies depending on the indicator measured. In this cohort of patients, the changing nature of a persons disability seems to have less impact than whether they ever have had any functional deficits.

Educational performance and vocational participation after spinal cord injury in childhood

OBJECTIVE To examine educational achievement and vocational success of children with SCI. DESIGN Surveys administered to students and teachers, and content analysis of school records. SETTING Regional pediatric rehabilitation program. PARTICIPANTS Participants were selected from 144 children with SCI treated from 1979 through 1992; 98 met inclusion criteria of onset of SCI before the age of 18 years, older than 3 years, residual paresis, and no cognitive impairment; 29% were lost to follow-up, and 53 of the 70 contacted were enrolled. MAIN OUTCOME MEASURES School completion rates, absenteeism, grades, ratings of participation; education and living situations after high school; history of paid employment. RESULTS The 53 responders were: 33 boys, 20 girls; 25 with paraplegia (47%), 28 with tetraplegia (53%); mean length of disability = 9.4 years; 12 primary students (23%), 19 secondary students (36%), and 22 postsecondary participants (41%). Students and teachers rated student participation and performance as average or above compared to peers; 84% of secondary students planned to attend college after graduation. Only 33% of high school students over age 15 had been employed. Ninety-one percent of postsecondary subjects had graduated from high school. Seven (32%) had graduated from college or a vocational program, 11 (50%) were enrolled in college full- or part-time, and 4 others (18%) were neither in school nor employed. Current employment rates were 71% of college graduates, 36% of those in college, and 0% of those who had never enrolled. Level of SCI was not related to employment. CONCLUSIONS Students with SCI demonstrate adequate participation and performance in educational settings, but may benefit from more vocational counseling and opportunities for paid employment.

Minority Disparities in Disability Between Medicare Beneficiaries

OBJECTIVES: To examine racial and ethnic disparities in mobility limitation, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) in older adults enrolled in Medicare.