Courtney Harold Van Houtven

Home Blood Pressure Management and Improved Blood Pressure Control Results From a Randomized Controlled Trial

BACKGROUND To determine which of 3 interventions was most effective in improving blood pressure (BP) control, we performed a 4-arm randomized trial with 18-month follow-up at the primary care clinics at a Veterans Affairs Medical Center. METHODS Eligible patients were randomized to either usual care or 1 of 3 telephone-based intervention groups: (1) nurse-administered behavioral management, (2) nurse- and physician-administered medication management, or (3) a combination of both. Of the 1551 eligible patients, 593 individuals were randomized; 48% were African American. The intervention telephone calls were triggered based on home BP values transmitted via telemonitoring devices. Behavioral management involved promotion of health behaviors. Medication management involved adjustment of medications by a study physician and nurse based on hypertension treatment guidelines. RESULTS The primary outcome was change in BP control measured at 6-month intervals over 18 months. Both the behavioral management and medication management alone showed significant improvements at 12 months-12.8% (95% confidence interval [CI], 1.6%-24.1%) and 12.5% (95% CI, 1.3%-23.6%), respectively-but not at 18 months. In subgroup analyses, among those with poor baseline BP control, systolic BP decreased in the combined intervention group by 14.8 mm Hg (95% CI, -21.8 to -7.8 mm Hg) at 12 months and 8.0 mm Hg (95% CI, -15.5 to -0.5 mm Hg) at 18 months, relative to usual care. CONCLUSIONS Overall intervention effects were moderate, but among individuals with poor BP control at baseline, the effects were larger. This study indicates the importance of identifying individuals most likely to benefit from potentially resource intensive programs. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00237692.

The effect of informal care on work and wages.

Cross-sectional evidence in the United States finds that informal caregivers have less attachment to the labor force. The causal mechanism is unclear: do children who work less become informal caregivers, or are children who become caregivers working less? Using longitudinal data from the Health and Retirement Study, we identify the relationship between informal care and work in the United States, both on the intensive and extensive margins, and examine wage effects. We control for time-invariant individual heterogeneity; rule out or control for endogeneity; examine effects for men and women separately; and analyze heterogeneous effects by task and intensity. We find modest decreases-2.4 percentage points-in the likelihood of working for male caregivers providing personal care. Female chore caregivers, meanwhile, are more likely to be retired. For female care providers who remain working, we find evidence that they decrease work by 3-10hours per week and face a 3 percent lower wage than non-caregivers. We find little effect of caregiving on working mens hours or wages. These estimates suggest that the opportunity costs to informal care providers are important to consider when making policy recommendations about the design and funding of public long-term care programs.

Economic Burden for Informal Caregivers of Lung and Colorectal Cancer Patients

BACKGROUND Informal care provides many benefits to cancer patients, but can be costly to caregivers. This study quantified the economic burden for informal caregivers of lung cancer (LC) and colorectal cancer (CRC) patients, examining differences by cancer type, phase of disease, stage at diagnosis, patient age, and relationship. METHODS A cross-sectional survey of caregivers of LC and CRC patients participating in the Share Thoughts on Care survey was conducted. Economic burden was calculated using the opportunity cost of caregiver time, the value of work hours lost, and out-of-pocket expenditures. Factors associated with economic burden to caregivers were modeled using fixed-effects generalized least squares estimation. RESULTS Informal caregivers (1,629) completed mailed surveys. Of these, 663, 822, and 144 were surveyed during the patients initial phase (first year after diagnosis, not within 6 months of death), continuing phase (after 1 year, not within 6 months of death), and terminal phase (within 6 months of death) of disease, respectively. The accumulated economic burdens for caregivers were

Inter-vivos Transfers and Exchange

7,028,

Impact of Caring for Grandchildren on the Health of Grandparents in Taiwan

19,701, and

An organizing framework for informal caregiver interventions: detailing caregiving activities and caregiver and care recipient outcomes to optimize evaluation efforts

14,234 for those evaluated during the patients initial phase, continuing phase, and terminal phase of disease, respectively. Economic burden was higher for caregivers of LC patients than CRC patients (p = .044) and for caregivers of patients diagnosed at stage 4 versus stage 1 (p = .001). Spouses faced higher economic burden than other relatives (p = .000) or friends (p = .000). CONCLUSIONS Economic burden for informal caregivers of LC and CRC patients is substantial and should be included in estimates of the societal cost of cancer care.

Informal Care and Caregiver's Health

Most parents divide their bequests equally among their children, whereas inter-vivos transfers are usually unequal. We propose that exchange is better for inducing inter-vivos transfers than bequests. Inter-vivos transfers can be adjusted quickly to the amount of care, are less costly than writing a will, and can be kept secret from other family members and the public. The results from national longitudinal data show that, as expected, if a parent gives any inter-vivos transfers, she is more likely to give to children who provide informal care. Informal care has no effect on the equality of intended bequests.

Caregiver psychological distress as a barrier to influenza vaccination among community-dwelling elderly with dementia.

OBJECTIVES To understand how caring for grandchildren affects the physical and mental health of grandparents in Taiwan. METHOD Grandparents aged 50 and older from 4 waves of the Taiwan Longitudinal Study on Aging (1993-2003, n = 3,711) were divided into 7 categories based on living arrangement and caregiving history. Generalized estimation equations controlling for sociodemographic characteristics and disease status were used to estimate the relationship between caregiving and 4 outcomes: self-rated physical health, mobility limitation, life satisfaction, and depressive symptoms. RESULTS Compared with noncaregivers, long-term multigenerational caregivers were more likely to report better self-rated health, higher life satisfaction, and fewer depressive symptoms. We found some evidence of reduced mobility limitations for both skipped-generation and nonresidential caregivers relative to noncaregivers. The associations in self-rated health and depressive symptoms were more pronounced in long-term caregivers than among those who recently started caregiving. DISCUSSION Improvements in self-rated health and mobility associated with caregiving support our hypothesis that caring for grandchildren can be beneficial for grandparents in Taiwan, especially for long-term multigenerational caregivers. Comparing Taiwanese grandparents across different types of caregiving shows that the associations of grandparent caregiving with health vary by living arrangement and duration. However, these findings may not be causal because caregiving and health outcomes were observed simultaneously in our data.

Rural-urban differences in preventable hospitalizations among community-dwelling veterans with dementia

BackgroundCaregiver interventions may help improve the quality of informal care. Yet the lack of a systematic framework specifying the targets and outcomes of caregiver interventions hampers our ability to understand what has been studied, to evaluate existing programs, and to inform the design of future programs. Our goal was to develop an organizing framework detailing the components of the caregiving activities and the caregiver and care recipient outcomes that should be affected by an intervention. In so doing, we characterize what has been measured in the published literature to date and what should be measured in future studies to enable comparisons across interventions and across time.MethodsOur data set comprises 121 reports of caregiver interventions conducted in the United States and published between 2000 and 2009. We extracted information on variables that have been examined as primary and secondary outcomes. These variables were grouped into categories, which then informed the organizing framework. We calculated the frequency with which the interventions examined each framework component to identify areas about which we have the most knowledge and under-studied areas that deserve attention in future research.ResultsThe framework stipulates that caregiver interventions seek to change caregiving activities, which in turn affect caregiver and care recipient outcomes. The most frequently assessed variables have been caregiver psychological outcomes (especially depression and burden) and care recipient physical and health care use outcomes.ConclusionsBased on the organizing framework, we make three key recommendations to guide interventions and inform research and policy. First, all intervention studies should assess quality and/or quantity of caregiving activities to help understand to what extent and how well the intervention worked. Second, intervention studies should assess a broad range of caregiver and care recipient outcomes, including considering whether expanding to economic status and health care use of the caregiver can be accommodated, to ease subsequent economic evaluations of caregiving. Third, intervention studies should measure a common set of outcomes to facilitate cross-time and cross-study comparisons of effectiveness.

Characterizing hospice discharge patterns in a nationally representative sample of the elderly, 1993-2000.

This study aims to measure the causal effect of informal caregiving on the health and health care use of women who are caregivers, using instrumental variables. We use data from South Korea, where daughters and daughters-in-law are the prevalent source of caregivers for frail elderly parents and parents-in-law. A key insight of our instrumental variable approach is that having a parent-in-law with functional limitations increases the probability of providing informal care to that parent-in-law, but a parent-in-laws functional limitation does not directly affect the daughter-in-laws health. We compare results for the daughter-in-law and daughter samples to check the assumption of the excludability of the instruments for the daughter sample. Our results show that providing informal care has significant adverse effects along multiple dimensions of health for daughter-in-law and daughter caregivers in South Korea.