Jennifer Voth

Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions

BackgroundFalls and chronic disease are both important health issues in older adults. The objectives of this study were to quantify the prevalence of falls and multi-morbidity (≥2 chronic conditions) in Canadian older adults; examine associations between falls and number of chronic conditions; and explore whether certain patterns of chronic disease were associated with a greater risk of falling.MethodsData were derived from the Canadian Community Health Survey- Healthy Aging. Primary outcomes from 16,357 community-dwelling adults aged 65 years and over were self-reported falls in the previous 12 months and presence of 13 chronic conditions. Prevalence estimates were calculated with normalized sampling weights, and hierarchical cluster analysis was used to identify clusters based on chronic condition patterns, and tested for association to falls with logistic regression.ResultsOverall prevalence of falling and multi-morbidity were 19.8% and 62.0% respectively. Fall risk was significantly greater in individuals with one, two, four, five and six or more chronic conditions relative to those with none (all p < 0.05). A seven-cluster model was selected, including groups with low prevalence of chronic disease, or high prevalence of hypertension and arthritis, visual impairment, hypertension, chronic obstructive pulmonary disease (COPD), diabetes, or heart disease and hypertension. Only the hypertension cluster (Odds Ratio [OR] = 1.2) and COPD cluster (OR = 1.6) were significantly associated with increased falls relative to the low prevalence group.ConclusionsBoth the number and pattern of chronic conditions were related to falls. COPD emerged as a significant predictor of falls despite affecting a smaller proportion of respondents. Continued study is warranted to verify this association and determine how to incorporate consideration of chronic disease and multi-morbidity into fall risk assessments.

Increasing access to chronic disease self-management programs in rural and remote communities using telehealth.

OBJECTIVE This study examined whether a telehealth chronic disease self-management program (CDSMP) would lead to improvements in self-efficacy, health behaviors, and health status for chronically ill adults living in Northern Ontario, Canada. Two telehealth models were used: (1) single site, groups formed by participants at one telehealth site; and (2) multi-site, participants linked from multiple sites to form one telehealth group, as a strategy to increase access to the intervention for individuals living in rural and remote communities. SUBJECTS AND METHODS Two hundred thirteen participants diagnosed with heart disease, stroke, lung disease, or arthritis attended the CDSMP at a preexisting Ontario Telemedicine Network studio from September 2007 to June 2008. The program includes six weekly, peer-facilitated sessions designed to help participants develop important self-management skills to improve their health and quality of life. Baseline and 4-month follow-up surveys were administered to assess self-efficacy beliefs, health behaviors, and health status information. Results were compared between single- and multi-site delivery models. RESULTS Statistically significant improvements from baseline to 4-month follow-up were found for self-efficacy (6.6±1.8 to 7.0±1.8; p<0.001), exercise behavior, cognitive symptom management, communication with physicians, role function, psychological well-being, energy, health distress, and self-rated health. There were no statistically significant differences in outcomes between single- and multi-site groups. CONCLUSIONS Improvements in self-efficacy, health status, and health behaviors were equally effective in single- and multi-site groups. Access to self-management programs could be greatly increased with telehealth using single- and multi-site groups in rural and remote communities.

Impact of psychological characteristics in self-management in individuals with traumatic spinal cord injury

Study design:Cross-sectional survey.Objective:To examine the association between psychological characteristics in self-management and probable depression status in individuals with a traumatic spinal cord injury (SCI).Setting:Community-dwelling individuals with traumatic SCI living across Canada.Methods:Individuals with SCI were recruited by email via the Rick Hansen Institute as well as an outpatient hospital spinal clinic. Data were collected by self-report using an online survey. Standardized questionnaires were embedded within a larger survey and included the Hospital Anxiety and Depression Scale (HADS), the short version of the Patient Activation Measure (PAM), the Moorong Self-Efficacy Scale (MSES) and the Pearlin-Schooler Mastery Scale (PMS).Results:Individuals with probable depression (n=25) had lower self-efficacy (67.9 vs 94.2, P<0.0001), mastery (18.9 vs 22.9, P<0.0001) and patient activation (60.4 vs 71.6, P<0.0001) as well as higher anxiety (9.0 vs 5.5, P<0.0001), compared with their non-depressed counterparts (n=75). A logistic regression determined that lower self-efficacy and mastery scores as well as less time since injury were associated with depression status (P=0.002; P=0.02 and P=0.02, respectively). Individuals with higher anxiety scores were almost 1.5 times more likely to be depressed, while older age was positively associated with depression status (P=0.016 and P=0.024, respectively).Conclusion:Interventions for depression in SCI, including a self-management program, should target factors such as self-efficacy and mastery, which could improve secondary medical complications and overall quality of life.

A Note on Sample Size and Solution Propriety for Confirmatory Factor Analytic Models

Determining an appropriate sample size for use in latent variable modeling techniques has presented ongoing challenges to researchers. In particular, small sample sizes are known to present concerns over sampling error for the variances and covariances on which model estimation is based, as well as for fit indexes and convergence failures. The literature on the topic has focused on conducting power analyses as well as identifying rules of thumb for deciding an appropriate sample size. Often the advice involves an assumption that sample size requirement is moderated by aspects of the model in question. In this study, an effort was undertaken to extend the findings of Gagné and Hancock (2006) on measurement model quality and solution propriety to a broader set of confirmatory factor analysis models. As well, we examined whether Herzog, Boomsma, and Reineckes (2007) findings for the Swain correction to the χ2 statistic for large models would generalize to models in our study. Our findings suggest that Gagné and Hancocks approach extends to large models with surprisingly little increase in sample size requirements and that the Swain correction to χ2 performs fairly well. We argue that likely rejection or model fit should be taken into account when determining sample size requirements and therefore, provide an updated table of minimum sample size that incorporates Gagné and Hancocks method and model fit.

Rehospitalization After Traumatic Brain Injury: A Population-Based Study

OBJECTIVE To examine, from a Canadian population-based perspective, the incidence and etiology of long-term hospital utilization among persons living with traumatic brain injury (TBI) by age and sex. DESIGN Retrospective cohort study. SETTING Acute care hospitals. PARTICIPANTS Index cases of TBI (N=29,269) were identified from the Discharge Abstract Database for fiscal years 2002/2003 through 2009/2010 and were followed-up until 36 months after injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Rehospitalization was defined as admission to an acute care facility that occurred up to 36 months after index injury. Diagnoses associated with subsequent rehospitalization were examined by age and sex. RESULTS Of the patients with TBI, 35.5% (n=10,390) were subsequently hospitalized during the 3-year follow-up period. Multivariable logistic regression (controlling for index admission hospital) identified men, older age, mechanism of injury being a fall, greater injury severity, rural residence, greater comorbidity, and psychiatric comorbidity to be significant predictors of rehospitalization in a 3-year period postinjury. The most common causes for rehospitalization differed by age and sex. CONCLUSIONS Rehospitalization after TBI is common. Factors associated with rehospitalization can inform long-term postdischarge planning. Findings also support examining causes for rehospitalization by age and sex.

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study

Abstract Objective To compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI). Design A retrospective cohort design was employed, using data retrieved from administrative databases. Setting Rehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011. Participants Patients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation. Outcome measures Demographic, impairment, functional outcome (as defined by the Functional Independence Measure (FIM)), discharge, healthcare utilization, survival, and tumor characteristics. Results There was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%). Conclusion Despite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.

Spanning Boundaries into Remote Communities: An Exploration of Experiences with Telehealth Chronic Disease Self-Management Programs in Rural Northern Ontario, Canada

BACKGROUND In rural and remote settings, providing education programs for chronic conditions can be challenging because of the limited access and availability of healthcare services. The purpose of this study was to explore the experiences of participants in a chronic disease self-management program via telehealth (tele-CDSMP) and to identify facilitators and barriers to inform future tele-CDSMP delivery models. MATERIALS AND METHODS Nineteen tele-CDSMP courses were delivered to 13 Northern Ontario (Canada) communities. Two types of group were delivered: (1) single telehealth site (one community formed a self-management group linked to program leaders via telehealth) and (2) multiple telehealth sites (several remote communities were linked to each other and program leaders via telehealth). Following the completion of the courses, participants were invited to partake in a focus group. RESULTS Overall, 44 people participated in the focus groups. Four main themes were identified by tele-CDSMP participants related to the overall experience of the program: (1) bridging the access gap, (2) importance of group dynamics, (3) importance of strong leaders, and (4) preference for extended session time. Key barriers were related to transportation, lack of session time, and access to Internet-based resources. The main facilitators were having strong program leaders, encouraging the development of group identity, and providing enough time to be comfortable with technology. CONCLUSIONS Our findings suggest overall the tele-CDSMP was a positive experience for participants and that tele-CDSMPs are an effective option to increasing access to more geographically isolated communities.

Level of disability, multi-morbidity and breast cancer screening: Does severity matter?

BACKGROUND Women with disability may be less likely screened for breast cancer. Research is limited on the extent to which level of disability and multi-morbidity influence screening. METHODS Using a retrospective population-based cohort study design, we linked administrative and self-reported survey data to identify screening in Ontario. The cohort was identified using two waves of the Canadian Community Health Survey (2005 and 2007/08). Fee codes were used to identify mammography imaging. Rates were examined over a two-year period and compared across level of disability and multi-morbidity. RESULTS Among 10,363 women identified for study inclusion, 4660 reported some level of disability. Women with moderate disability had higher screening rates (71.4%) than women with no disability (62.0%) and women with severe disability (67.9%). We observed an inverse V-shaped relationship between level of disability and screening across all levels of multi-morbidity. In multivariate regression, women with moderate disability had higher odds of being screened compared to women with no disability (OR 1.2 [1.09-1.38]). Women with severe disability had lower odds of being screened compared to women with moderate disability (OR 0.72 [0.63-0.82]) and no disability (OR 0.88 [0.78-0.99]). Women with one chronic condition had higher odds of screening compared to women with no chronic conditions (OR 1.31 [1.17-1.46]). CONCLUSIONS Our findings suggest that severe levels of disability and morbidity are associated with low likelihoods of breast cancer screening.

Characteristics of Non-traumatic Spinal Cord Dysfunction in Canada Using Administrative Health Data

Background: There is a paucity of studies using administrative health data to examine the epidemiology, health care utilization, and outcomes for non-traumatic spinal cord dysfunction (NTSCD). Objective: The purpose of this study is to characterize discrete NTSCD cohorts using decision algorithms with Canadian health administrative databases. Method: Data were provided by the Canadian Institute for Health Information that included all acute care hospital, day surgery, ambulatory, and inpatient rehabilitation records of patients with neurological impairment between April 1, 2004 and March 31, 2011. Diagnostic codes for neurological impairment and NTSCD etiology were used to identify cases and classify 3 NTSCD groups (most likely, probable, and possible). Logistic regression identified factors related to inpatient rehabilitation admission within 7 days of discharge among the preferred group. Results: The most likely NTSCD group (n = 6,362) was significantly older and had a greater proportion of women and individuals with cauda equina lesions compared to the other 2 NTSCD groups (probable [n = 2,777] and possible [n = 11,179]; ps < .001). Factors associated with the likelihood of an inpatient rehabilitation admission included being older (odds ratio [OR], 1.01; 95% CI, 1.00-1.01), being female (OR, 1.18; 95% CI, 1.06-1.32), having paraplegia diagnosis compared to cauda equina (OR, 1.24; 95% CI, 1.09-1.41), residing in an urban area compared to a rural area (OR, 1.34; 95% CI, 1.13-1.58), having degenerative etiology compared to other (OR, 1.59; 95% CI, 1.41-1.80), and having an MRI on record compared to not (OR = 1.57; 95% CI, 1.39-1.76). Conclusion: Administrative data allow for ongoing surveillance of a population in a relatively cost-effective manner. Advancing our knowledge of NTSCD epidemiology, health outcomes, and system performance can inform policy and system planning.

“In this together”: Social identification predicts health outcomes (via self-efficacy) in a chronic disease self-management program

RATIONALE Self-management programs are an established approach to helping people cope with the challenges of chronic disease, but the psychological mechanisms underlying their effectiveness are not fully understood. A key assumption of self-management interventions is that enhancing peoples self-efficacy (e.g., via the development of relevant skills and behaviours) encourages adaptive health-related behaviors and improved health outcomes. However, the group-based nature of the programs allows for the possibility that identification with other program members is itself a social psychological platform for positive changes in illness-related confidence (i.e., group-derived efficacy) and physical and mental health. METHOD The researchers evaluated this hypothesis in a telehealth version of a chronic disease self-management program delivered in 13 rural and remote communities in northern Ontario, Canada (September 2007 to June 2008). Participants were 213 individuals with a self-reported physician diagnosis of chronic lung disease, heart disease, stroke, or arthritis. Measures of social identification, group-derived efficacy, and individual efficacy were administered seven weeks after baseline, and mental and physical health outcomes (health distress, psychological well-being, depression, vitality, pain, role limits, and disability) were assessed at four months. RESULTS Structural equation modeling indicated that social identification was a positive predictor of group-derived efficacy and (in turn) individual self-efficacy (controlling for baseline), which was significantly associated with better physical and mental health outcomes. CONCLUSION The results are consistent with growing evidence of the value of a social identity-based approach in various health and clinical settings. The success of chronic disease self-management programs could be enhanced by attending to and augmenting group identification during and after the program.