Joseph P. Eimicke

Prevalence of depression and depression recognition in nursing homes

Background The aim of this study was to estimate the prevalence of depression among nursing home residents, and the extent of depression recognition among nursing home staff. Random samples totaling 319 nursing home residents, drawn from a simple random sample of six downstate New York nursing homes were evaluated psychiatrically for depression. Samples of nurse aides, nurses and social workers also assessed the same residents for the presence of depressive symptomatology. Method Psychiatrists assessed residents using the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) criteria. Depression measures used were the Cornell Scale for Depression in Dementia, the Feeling Tone Questionnaire, the Hamilton Depression Rating and the Structured Clinical Interview for DSM-III-R Personality Disorders Scale. Nursing and social services staff assessed residents using Depression Recognition Measures. Results Based on psychiatric evaluation, the prevalence estimate for probable and/or definite major depressive disorder among testable subjects was 14.4 % (95 % CI of 10.6 %–19.3 %); 15.4 % were not able to be assessed due to their refusal, impairment of consciousness, or severe physical illness. The estimate for minor depression was 16.8 % (95 % CI of 12.6 %–21.9 %). The prevalence of significant depressive symptomatology (including the category of possible depression) was 44.2 % (95 % CI of 38.2 %–50.3 %). The corresponding estimates of any depression were 19.7 % for social workers, 29 % for nurses and 32.1 % for nurse aides. Conclusions The prevalence of depressive disorders among nursing home residents is high; depression recognition is relatively low, with only 37 %–45 % of cases diagnosed by psychiatrists recognized as depressed by staff. A structured Depression Recognition Scale increased the rates of recognition (sensitivity of staff ratings) to 47 %–55 %, demonstrating the utility of the scale in increasing awareness of symptomatology.

A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study

CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care. OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older, ethnically diverse, medically underserved patients with diabetes. DESIGN, Setting, and Patients A randomized controlled trial was conducted, comparing telemedicine case management to usual care, with blinded outcome evaluation, in 1,665 Medicare recipients with diabetes, aged >/= 55 years, residing in federally designated medically underserved areas of New York State. Interventions Home telemedicine unit with nurse case management versus usual care. Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c (HgbA1c), low density lipoprotein (LDL) cholesterol, and blood pressure levels. RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints (HgbA1c, p = 0.001; LDL, p < 0.001; systolic and diastolic blood pressure, p = 0.024; p < 0.001). Estimated differences (95% CI) in year 5 were 0.29 (0.12, 0.46)% for HgbA1c, 3.84 (-0.08, 7.77) mg/dL for LDL cholesterol, and 4.32 (1.93, 6.72) mm Hg for systolic and 2.64 (1.53, 3.74) mm Hg for diastolic blood pressure. There were 176 deaths in the intervention group and 169 in the usual care group (hazard ratio 1.01 [0.82, 1.24]). CONCLUSIONS Telemedicine case management resulted in net improvements in HgbA1c, LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries. Mortality was not different between the groups, although power was limited. Trial Registration http://clinicaltrials.gov Identifier: NCT00271739.

Glycemic Control and Health Disparities in Older Ethnically Diverse Underserved Adults With Diabetes: Five-year results from the Informatics for Diabetes Education and Telemedicine (IDEATel) study

OBJECTIVE The Informatics for Diabetes Education and Telemedicine (IDEATel) project randomized ethnically diverse underserved older adults with diabetes to a telemedicine intervention or usual care. Intervention participants had lower A1C levels over 5 years. New analyses were performed to help better understand this difference. RESEARCH DESIGN AND METHODS IDEATel randomized Medicare beneficiaries with diabetes (n = 1,665) to receive home video visits with a diabetes educator and upload glucose levels every 4–6 weeks or usual care (2000–2007). Annual measurements included BMI, A1C (primary outcome), and completion of questionnaires. Mixed-model analyses were performed using random effects to adjust for clustering within primary care physicians. RESULTS At baseline, A1C levels (mean ± SD) were 7.02 ± 1.25% in non-Hispanic whites (n = 821), 7.58 ± 1.78% in non-Hispanic blacks (n = 248), and 7.79 ± 1.68% in Hispanics (n = 585). Over time, lower A1C levels were associated with more glucose uploads (P = 0.02) and female sex (P = 0.002). Blacks, Hispanics, and insulin-users had higher A1C levels than non-Hispanic whites (P < 0.0001). BMI was not associated with A1C levels. Blacks and Hispanics had significantly fewer uploads than non-Hispanic whites over time. Hispanics had the highest baseline A1C levels and showed the greatest improvement in the intervention, but, unlike non-Hispanic whites, Hispanics did not achieve A1C levels <7.0% at 5 years. CONCLUSIONS Racial/ethnic disparities were observed in this cohort of underserved older adults with diabetes. The IDEATel telemedicine intervention was associated with improvement in glycemic control, particularly in Hispanics, who had the highest baseline A1C levels, suggesting that telemedicine has the potential to help reduce disparities in diabetes management.

Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes The randomized IDEATel trial

Diabetes case management (DCM) may improve medical outcomes (1,2). Case managers coordinate care and often provide a mix of interventions, e.g., telephone outreach, education, reminders. However, the efficacy of DCM is unclear. Three systematic reviews lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid, weight, or blood pressure benefits (3–5). DCM studies typically target biomedical outcomes and ignore potential psychosocial effects. Yet, psychosocial variables (e.g., depression, anxiety, social support) relate to hyperglycemia, complications, adherence, and quality of life (6–11). Thus, a positive impact of DCM on these factors is important. Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction (cluster visit) (12) and quality of life (dietitian-led DCM group) (13). Because barriers (e.g., distance, weather) limit DCM access, telemedicine can be used. A review of telemedicine versus face-to-face trials concluded that, while feasible and acceptable, there is little evidence that telemedicine has clinical benefits (14). Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients (15). The intervention resulted in significant improvements in glycemic control, blood pressure, and total and LDL cholesterol (16). The purpose of the Informatics for Diabetes Education and Telemedicine (IDEATel) project, funded by the Centers for Medicare and Medicaid Services, is to evaluate the feasibility and effectiveness of telemedicine with a diverse, medically underserved, elderly diabetic sample. The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes. A detailed description of the IDEATel study design has been previously reported (15,16). Medicare recipients were recruited if they were aged ≥55 years, diagnosed with diabetes, and without moderate/severe impairments or comorbidities. Research nurses blinded to the groups …

Ambulatory Pulse Pressure and Progression of Urinary Albumin Excretion in Older Patients With Type 2 Diabetes Mellitus

We studied whether ambulatory blood pressure monitoring added to office blood pressure in predicting progression of urine albumin excretion over 2 years of follow-up in a multiethnic cohort of older people with type-2 diabetes mellitus. Participants in the Informatics for Diabetes Education and Telemedicine study underwent a baseline evaluation that included office and 24-hour ambulatory blood pressure measurement and a spot urine measurement of albumin-to-creatinine ratio (ACR). Measurements of albumin-to-creatinine ratio were repeated 1 and 2 years later. In bivariate analyses, ambulatory 24-hour pulse pressure was the blood pressure variable most strongly associated with follow-up ACR. Repeated-measures mixed linear models (n=1040) were built adjusting for baseline ACR ratio, clustered randomization, time to follow-up, and multiple covariates. When both were entered into the model, ambulatory 24-hour pulse pressure and office pulse pressure were independently associated with follow-up ACR (β [SE]=0.010 [0.002], P<0.001, and 0.004 [0.001], P=0.002, respectively). Cox proportional hazards models examined associations with progression of albuminuria in 954 participants without macroalbuminuria at baseline, adjusting for all of the covariates independently associated with follow-up ACR in mixed linear models. Ambulatory 24-hour pulse pressure, but not office pulse pressure, was independently associated with progression of albuminuria (P=0.015 and 0.052, respectively). The adjusted hazards ratio (95% CI) per each 10-mm Hg increment in ambulatory pulse pressure was 1.23 (1.04 to 1.42). In conclusion, ambulatory pulse pressure may provide additional information to predict progression of albuminuria in elderly diabetic subjects above and beyond office blood pressure.

Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project

Objectives. Adherence to diabetes self care is poor for Hispanic American and African-American patients. This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients. We also examined whether adherence mediated the effect of the intervention on glycemic control (A1c). Design. The Informatics for Diabetes Education and Telemedicine project randomized medically underserved Medicare patients (n=1665) to telemedicine case management (televideo educator visits, individualized goal-setting/problem solving) or usual care. Hispanic and African-American educators delivered the intervention in Spanish if needed. Main outcome measures. Annual assessment included A1c and self-reported adherence (Summary of Diabetes Self-Care Activities scale). A simple model (only time and group terms) and a model with covariates (e.g., age) were examined for baseline and 5 years of follow-up. SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c, by performing tests of the mediating path coefficients. Results. Over time, self-reported adherence improved for the treatment group compared to usual care (p<0.001). There was no significant interaction with racial/ethnic group membership, i.e., all groups improved. However, minority subjects were consistently less adherent than whites. Also, greater comorbidity and diabetes symptoms predicted poorer adherence, greater duration of diabetes and more years of education predicted better adherence. Adherence was a significant mediator of A1c (p<0.001). Conclusions. A unique, tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care. However, African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention. The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity.

Lessened decline in physical activity and impairment of older adults with diabetes with telemedicine and pedometer use: results from the IDEATel study

OBJECTIVE to examine the effects of the Informatics for Diabetes Education and Telemedicine (IDEATel) telemedicine intervention and pedometer use on physical activity (PA) and impairment in older adults with diabetes. DESIGN randomised clinical trial. Subjects ethnically diverse medically underserved Medicare beneficiaries with diabetes (n= 1,650). METHODS participants received home videovisits with a diabetes educator every 4-6 weeks or usual care. All received a pedometer. Annual measurements included hemoglobin A1c, Comprehensive Assessment and Referral Evaluation Activities of Daily Living, Diabetes Self-Care Activities, Charlson Comorbidity Index, Luben Social Support and pedometer use. Mixed model analyses were performed using random effects to adjust for clustering within primary care physicians. RESULTS in the telemedicine group compared with the usual care group, the rate of decline in PA (P= 0.0128) and physical impairment (PI) (P= 0.0370) was significantly less over time. Significant mean endpoint differences were observed for PA (P= 0.003). Pedometer use was significantly associated with PA (P= 0.0006) and PI (P< 0.0001). Baseline characteristics associated with greater PA included having fewer comorbid conditions (P= 0.0054), less depression (P< 0.0001), more social networking (P< 0.0001), lower BMI (P< 0.0001), male gender (P< 0.0001) and lower hemoglobin A1c level (P= 0.0045). Similar predictors were observed for PI, except duration of diabetes also predicted increased impairment (P< 0.0001). Significant indirect effects were observed through use of the pedometer on reduced decline in PA (P= 0.0024, 0.0013) and PI (P= 0.0024, P< 0.0001). CONCLUSIONS this telemedicine intervention reduced rates of decline in PA and impairment in older adults with diabetes. Pedometers may be a helpful inexpensive adjunct to diabetes initiatives delivered remotely with emerging technologies. ClinicalTrials.gov identifier NCT 00271739.

Medicare payments, healthcare service use, and telemedicine implementation costs in a randomized trial comparing telemedicine case management with usual care in medically underserved participants with diabetes mellitus (IDEATel).

Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention. Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State. Measurements We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000- February 27, 2006). Results Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups,

A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: results from a cluster randomized trial.

9040 (

Psychosocial outcomes of telemedicine case management for elderly patients with diabetes: IDEATel, a randomized trial

386) and