Dean Reker

Co-morbidity adjustment for functional outcomes in community-dwelling older adults

Objective: To characterize relationships between self-reported co-morbidity and functional outcomes in community-dwelling older adults, and to assess whether the impact of co-morbidity persists even after adjustment for baseline functional status. Design: Prospective observational study. We examined associations between self-reported co-morbidity at baseline and functional outcomes at one year, with and without adjustment for baseline functional status. Setting: Outpatient clinics at a managed care and a Veterans Affairs site. Subjects: Four hundred and ”fty-seven community-dwelling older adults representing a broad spectrum of overall health status. Main outcome measures: (a) New basic ADL (activities of daily living) problem during follow-up; (b) 10-point decline in the physical function index of the MOS-36 (MOS-PFI). Results: Co-morbidity was associated with adverse functional outcomes in bivariable analyses. After adjustment for age and baseline functional status, an accumulated co-morbidity score provided additional explanatory power for predicting new ADL problems; odds ratios were 2.30 (1.09, 5.09) and 2.96 (1.48, 6.25) for 2 and 33 affected co-morbidity domains, respectively. The impact of baseline status was also important; odds ratios for new ADL problems were 4.77 (2.68, 8.81) when at least one instrumental activity of daily living (IADL) problem was present at baseline, and 15.6 (8.05, 31.3) when at least one basic ADL problem was present at baseline. Conclusions: Accumulated self-reported co-morbidity has signi”cant negative effects on function at one year; these effects are attenuated but not eliminated by adjustment for baseline status. Co-morbidity adjustment is probably an important design element in clinical research focused on functional outcomes in older adults.

Performance of a mail-administered version of a stroke-speci” c outcome measure, the Stroke Impact Scale

Objective: To evaluate the feasibility and concurrent validity of a new, mail-administered, stroke-speci”c outcome measure, the Stroke Impact Scale (SIS). Design: Observational cohort study. Setting and patients: Stroke patients who had lived independently in the community prior to their stroke and who were candidates for post-stroke rehabilitation were recruited from nine, high-volume, Department of Veteran Affairs Medical Centers. Methods: Two hundred and six patients were mailed the SIS after a sixmonth post-stroke telephone interview. Telephone assessments included the Functional Independence Measure, the Lawton IADL and the SF-36. Results: The response rate for the mailed SIS was 63%, with 45% of the responses from proxies. The average rate of missing item level scores per patient was 1.3 (range 0–20) resulting in an average rate of 0.13 missing domain scores per patient (range 0–3). Nonresponders to the mailed SIS had more severe strokes with lower functional status at the time of the survey than responders. Proxies were more likely to complete the survey if the subjects were older, married, cognitively impaired and more functionally limited. The SIS did not exhibit a high rate of ‘oor and ceiling effects, particularly in physical function domains, as did the FIM and the SF-36. Conclusions: The mailed SIS is a feasible means of assessing post-stroke function. Missing items and missing domain scores were extremely low, however, there is a trade-off between the low-cost mail SIS survey on the one hand and the resulting nonresponse bias on the other.

Racial differences in use of colonoscopy, sigmoidoscopy, and barium enema in Medicare beneficiaries.

Colorectal cancer is often diagnosed at a later stage in blacks. We wanted to know if racial differences existed in the use of tests for detection of colorectal cancer. A 5% random sample was obtained of all Medicare beneficiaries with Part B coverage, aged 65 years and older and classified as white or black race. The numbers of colonoscopies, flexible sigmoidoscopies, and barium enemas were determined from the Physician/Supplier file. Blacks were 18% less likely to receive colonoscopy and 39% less likely to receive flexible sigmoidoscopy after controlling for age, sex, income, and access to care in a multivariable logistic regression model. Barium enema was not significantly different between the races. Black men had 25% lower use of colonoscopy and 50% decreased use of flexible sigmoidoscopy. Blacks receive less colonoscopy and flexible sigmoidoscopy than whites. Black men are particularly vulnerable to the under-use of these tests.

Characteristics of Community Nursing Homes Serving Per Diem Veterans, 1999 to 2002

This study compared the characteristics of community nursing homes where veterans received their care with those of facilities that did not treat veterans from 1999 to 2002 using the Centers for Medicare and Medicaid Services (CMS) Online Survey Certification and Reporting system data merged with the CMS Minimum Data Set. A structure, process, and outcome model was used to examine whether the presence of per diem veterans had any impact on multidimensional quality measures. Facilities with any veterans were less likely to meet recommended nurse staffing standards; more likely to have patients with tube feeding, new catheterizations, and mobility restraints; and more likely to have actual harm citations and new pressure sores, plus quality-of-care, quality-of-life, and total deficiencies, than facilities without veterans. The implications of this study are that the U.S. Department of Veterans Affairs may need to examine its contracting policies with community facilities to understand both quality and selection effects that may be occurring.

Dose escalation of proton pump inhibitor (PPI) therapy during endoscopic ablation of Barrett's esophagus (BE)

Dose escalation of proton pump inhibitor (PPI) therapy during endoscopic ablation of Barretts esophagus (BE)