Jeanne D. Scinto

Long-Term Mortality in Cerebrovascular Disease

Background and Purpose— Stroke is the third leading cause of death in the United States, yet data are limited about the temporal pattern of mortality among patients with cerebrovascular disease. The objectives of this study were to identify predictors of 6-month mortality and to evaluate 5-year mortality in patients with cerebrovascular disease. Methods— Our population included fee-for-service Medicare beneficiaries aged ≥65 years who were discharged with an acute ischemic stroke, transient ischemic attack (TIA), or carotid stenosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 433 to 436) from Connecticut acute care hospitals in 1995. This cohort was followed through 2000 by means of part A Medicare claims and Social Security Administration mortality data. Results— Among 5123 patients, 4781 survived their hospitalization and were followed for an average of 3.4 years; 670 (14.0%) died within 6 months of discharge, and 2517 (52.6%) died within 5 years. Predictors of 6-month mortality included older age, male sex, increasing comorbidity, discharge not to home, and prior admission within a year of the index hospitalization. The annual mortality rates for year 1 after discharge differed depending on the discharge diagnosis of the index hospitalization: carotid stenosis, 10.6%; TIA, 14.8%; and acute ischemic stroke, 26.4%. The 5-year cumulative mortality rates were as follows: carotid stenosis, 38.3%; TIA, 49.6%; and acute ischemic stroke, 60.0%. Conclusions— Mortality after acute ischemic stroke, TIA, and carotid stenosis is substantial. Rates and patterns of mortality differ according to patients’ discharge diagnoses.

Burden of Illness Score for Elderly Persons: Risk adjustment incorporating the cumulative impact of diseases, physiologic abnormalities, and functional impairments

Background/Objectives. To develop and validate a new risk adjustment index–the Burden of Illness Score for Elderly Persons (BISEP)–which integrates multiple domains, including diseases, physiologic abnormalities, and functional impairments. Research Design Subjects. The index was developed in a prospective cohort of 525 patients aged ≥70 years from the medicine service of a university hospital. The index was validated in a cohort of 1246 patients aged ≥65 years from 27 hospitals. The outcome was 1-year mortality. Results. Five risk factors were selected from diagnosis, laboratory, and functional status axes: high-risk diagnoses, albumin ≤3.5 mg/dL, creatinine >1.5 mg/dL, dementia, and walking impairment. The BISEP score (range 0–7) created four groups of increasing risk: group I (score 0–1), group II (2), group III (3), and group IV (≥4). In the development cohort, where overall mortality was 154/525 (29%), 1-year mortality rates increased significantly across each risk group, from 8% to 24%, 51%, and 74%, in groups I to IV respectively (&khgr;2 trend, P = 0.001)—an overall 17-fold increased risk by hazard ratio. The c-statistic for the final model was 0.83. Corresponding rates in the validation cohort, where overall mortality was 488/1246 (39%), were 5%, 17%, 33%, and 61% in groups I to IV, respectively (&khgr;2 trend, P = 0.001)—an overall 18-fold increased risk by hazard ratio. The c-statistic for the final model was 0.77. In each cohort, sequential addition of variables from different sources (eg, administrative, laboratory, and chart) substantially improved model fit and predictive accuracy. BISEP had significantly superior mortality prediction compared with five widely used measures. Conclusions. BISEP provides a useful new risk adjustment system for hospitalized older persons. Although index performance using different data sources has been evaluated, the full BISEP model, incorporating disease, laboratory, and functional impairment information, demonstrates the best performance.

Mammography underutilization among older women in Connecticut

OBJECTIVES: The primary goals were to examine mammography use rates among older women in Connecticut and to determine if there was significant variation among different areas and racial groups in the state. The secondary goal was to examine what impact the initiation of Medicare reimbursement for mammography screening has had on mammography use.

Screening Mammography: Is It Suitably Targeted to Older Women Who are Most Likely to Benefit?

OBJECTIVES To determine whether screening mammography is suitably targeted to older women who are most likely to benefit. DESIGN Prospective cohort study. SETTING New Haven County, Connecticut. PARTICIPANTS Eight hundred forty-four community-dwelling older women were interviewed as part of the 1990 New Haven Established Populations for the Epidemiologic Study of the Elderly (EPESE) program. MEASUREMENTS Mammography use was ascertained from Medicare Part B claims data. A four-level prognostic mortality index was developed using items previously shown to be predictive of mortality. Mammography use and all-cause mortality were evaluated by prognostic stage over a 5-year period, January 1, 1991, to December 31, 1995. RESULTS Five-year mortality increased steadily with each prognostic stage (12% to 68%, P = .001), whereas the 5-year mammography use rate declined (48% to 7%, P = .001). Over half the women (53%) in the most favorable prognostic group did not receive a mammogram, whereas 13% in the two worst prognostic groups received at least one mammogram. CONCLUSION Screening mammography may be underutilized among older women who are the most likely to benefit and overutilized among those who are unlikely to benefit.

The Impact of a Physician Intervention Program on Older Women's Mammography Use

The Mammography Optimum Referral Effort (MORE) is a physician office-based intervention program initiated by the Connecticut PeerReview Organization (CPRO)to increase mammography use among older women in Connecticut. Three locales in the state were targetedfor the MORE intervention based on identified low mammography rates in women aged 65 years and older Thirty-seven physicians participated from March 1, 1996, to August 31, 1996. Annual mammography rates were derived by merging Medicare Part B mammography claims with a database from the Connecticut TumorRegistry. This strategy allowed us to exclude women with a prior history of breast cancer from the analysis, in order to estimate screening rates. The MORE intervention was associated with an absolute increase of 5.9%6, which represents a relative increase of 15.4%, in annual mammography use. Ourfindings suggest that a multifaceted physician intervention is capable of increasing mammography use among older women.