Kenneth S. Boockvar

Recent trends in chronic disease, impairment and disability among older adults in the United States

BackgroundTo examine concurrent prevalence trends of chronic disease, impairment and disability among older adults.MethodsWe analyzed the 1998, 2004 and 2008 waves of the Health and Retirement Study, a nationally representative survey of older adults in the United States, and included 31,568 community dwelling adults aged 65 and over. Measurements include: prevalence of chronic diseases including hypertension, heart disease, stroke, diabetes, cancer, chronic lung disease and arthritis; prevalence of impairments, including impairments of cognition, vision, hearing, mobility, and urinary incontinence; prevalence of disability, including activities of daily living (ADLs) and instrumental activities of daily living (IADLs).ResultsThe proportion of older adults reporting no chronic disease decreased from 13.1% (95% Confidence Interval [CI], 12.4%-13.8%) in 1998 to 7.8% (95% CI, 7.2%-8.4%) in 2008, whereas the proportion reporting 1 or more chronic diseases increased from 86.9% (95% CI, 86.2%-89.6%) in 1998 to 92.2% (95% CI, 91.6%-92.8%) in 2008. In addition, the proportion reporting 4 or more diseases increased from 11.7% (95% CI, 11.0%-12.4%) in 1998 to 17.4% (95% CI, 16.6%-18.2%) in 2008. The proportion of older adults reporting no impairments was 47.3% (95% CI, 46.3%-48.4%) in 1998 and 44.4% (95% CI, 43.3%-45.5%) in 2008, whereas the proportion of respondents reporting 3 or more was 7.2% (95% CI, 6.7%-7.7%) in 1998 and 7.3% (95% CI, 6.8%-7.9%) in 2008. The proportion of older adults reporting any ADL or IADL disability was 26.3% (95% CI, 25.4%-27.2%) in 1998 and 25.4% (95% CI, 24.5%-26.3%) in 2008.ConclusionsMultiple chronic disease is increasingly prevalent among older U.S. adults, whereas the prevalence of impairment and disability, while substantial, remain stable.

The effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture.

Objectives: To describe the epidemiology of perioperative anemia in patients with hip fracture and assess the relationship between the hemoglobin measurements and clinical outcomes. Design: Prospective observational cohort study. Setting: Four university and community teaching hospitals. Patients: A consecutive cohort of 550 patients who underwent surgery for hip fracture and survived to discharge from August 1997 and August 1998 were evaluated and followed prospectively. Main Outcome Measures: Deaths, readmissions and Functional Independence Motor mobility scores within 60 days of discharge. Results: Anemia (defined as hemoglobin <12.0 g/dL) was present in 40.4% of patients on admission, 45.6% at the presurgery nadir, 93.0% at the postsurgery nadir, and 84.6% near discharge. The mean drop in hemoglobin after surgery was 2.8 ± 1.6 g/dL. In multivariate analyses, higher hemoglobin levels on admission were associated with shorter lengths of hospital stay and lower odds of death and readmission even after controlling for a broad range of prefracture patient characteristics, clinical status on discharge, and use of blood transfusion. Admission and preoperative anemia was not associated with risk-adjusted Functional Independence Motor mobility scores. In multivariable analyses, higher postoperative hemoglobin was associated with shorter length of stay and lower readmission rates, but did not effect rates of death or Functional Independence Motor mobility scores. Conclusions: Substantial declines in hemoglobin were common in patients with hip fracture. Higher preoperative hemoglobin was associated with shorter length of stay and lower odds of death and readmission within 60 days of discharge. Postoperative hemoglobin was also related to length of stay and readmission rates.

Hospital Readmissions After Hospital Discharge for Hip Fracture: Surgical and Nonsurgical Causes and Effect on Outcomes

OBJECTIVES:  To examine the causes of hospital readmission after hip fracture and the relationships between hospital readmission and 6‐month physical function and mortality.

Outcomes of Infection in Nursing Home Residents with and without Early Hospital Transfer

Objectives: To compare outcomes of infection in nursing home residents with and without early hospital transfer.

Effects of blood transfusion on clinical and functional outcomes in patients with hip fracture.

BACKGROUND:  Anemia and transfusion are common among elderly patients requiring surgery. The effects of transfusion on morbidity and mortality are controversial. The influence of transfusion on risk‐adjusted mortality, readmissions, and functional mobility was examined.

Prescribing discrepancies likely to cause adverse drug events after patient transfer

Background: Medication-prescribing discrepancies are used as a quality measure for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by prescribing discrepancies and the discrimination of an index of high-risk transition drug prescribing. Methods: We examined medical records of patients transferred between seven nursing homes and three hospitals between 1999 and 2005 in New York and Connecticut for transfer-associated prescribing discrepancies. ADEs caused by discrepancies were determined by two clinician raters. We calculated the fraction of medication discrepancies that caused ADEs in each of 22 drug classes by calculating positive predictive values (PPVs). We calculated the discrimination of a count of high-risk drug discrepancies, selected from published lists of high-risk medications and using observed PPVs. Results: 208 patients were hospitalised 304 times. Overall, 65 of 1350 prescribing discrepancies caused ADEs, for a PPV of 0.048 (95% CI 0.037 to 0.061). PPVs by drug class ranged from 0 to 0.28. Drug classes with the highest PPVs were opioid analgesics, metronidazole, and non-opioid analgesics. Patients with 0, 1–2 and ⩾3 high-risk discrepancies had a 13%, 23% and 47% chance of experiencing a discrepancy-related ADE, respectively. Conclusions: Discrepancies in certain drug classes more often caused ADEs than other types of discrepancies in hospitalised nursing-home patients. Information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients and inform the development of decision-support tools at the time of patient transfer.

Association of chronic diseases and impairments with disability in older adults: a decade of change?

Background:Little is known about how the relationship between chronic disease, impairment, and disability has changed over time among older adults. Objective:To examine how the associations of chronic disease and impairment with specific disability have changed over time. Research Design:Repeated cross-sectional analysis, followed by examining the collated sample using time interaction variables, of 3 recent waves of the Health and Retirement Study. Subjects:The subjects included 10,390, 10,621 and 10,557 community-dwelling adults aged 65 years and above in 1998, 2004, and 2008. Measurements:Survey-based history of chronic diseases including hypertension, heart disease, heart failure, stroke, diabetes, cancer, chronic lung disease, and arthritis; impairments, including cognition, vision, and hearing; and disability, including mobility, complex activities of daily living (ADL), and self-care ADL. Results:Over time, the relationship of chronic diseases and impairments with disability was largely unchanged; however, the association between hypertension and complex ADL disability weakened from 1998 to 2004 and 2008 [odds ratio (OR)=1.24; 99% confidence interval (CI), 1.06–1.46; OR=1.07; 99% CI, 0.90–1.27; OR=1.00; 99% CI, 0.83–1.19, respectively], as it did for hypertension and self-care disability (OR=1.32; 99% CI, 1.13–1.54; OR=0.97; 99% CI, 0.82–1.14; OR=0.99; 99% CI, 0.83–1.17). The association between diabetes and self-care disability strengthened from 1998 to 2004 and 2008 (OR=1.21; 99% CI, 1.01–1.46; OR=1.37; 99% CI, 1.15–1.64; OR=1.52; 99% CI, 1.29–1.79), as it also did for lung disease and self-care disability (OR=1.64; 99% CI, 1.33–2.03; OR=1.63; 99% CI, 1.32–2.01; OR=2.11; 99% CI, 1.73–2.57). Conclusions:Although relationships between diseases, impairments, and disability were largely unchanged, disability became less associated with hypertension and more with diabetes and lung disease.

Effect of Admission Medication Reconciliation on Adverse Drug Events From Admission Medication Changes

M edication reconciliation, a process by which a health care provider obtains and documents a thorough medication history with specific attention to comparing current and previous medication use, has been a focus of major patient safety initiatives. Evaluations of medication reconciliation programs have reported factors associated with successful implementation and its effect on prescribing outcomes such as medication errors and potential adverse drug events but not its effect on actual adverse drug events (ADEs). The objective of this study was to estimate the effectiveness of inpatient medication reconciliation at the time of hospital admission on ADEs caused by admission prescribing changes.

Pharmacist- versus physician-initiated admission medication reconciliation: impact on adverse drug events.

BACKGROUND Medication reconciliation (MR) has proven to be a problematic task for many hospitals to accomplish. It is important to know the clinical impact of physician- versus pharmacist-initiated MR in the resource-limited hospital environment. METHODS This quasi-experimental study took place from December 2005 to February 2006 at an urban US Veterans Affairs hospital. MR was implemented on 2 similar general medical units: one received physician-initiated MR and the other received pharmacist-initiated MR. Adverse drug events (ADEs) and a 72-hour medication-prescribing risk score were ascertained by research pharmacists for all admitted patients by structured record review. Multivariable models were tested for intervention effect, accounting for quasi-experimental design and clustered observations, and were adjusted for patient and encounter covariates. RESULTS Pharmacists completed the MR process in 102 admissions and physicians completed the process in 116 admissions. In completing the MR process, pharmacists documented statistically more admission medication changes than physicians (3.6 vs 0.8; P < 0.001). The adjusted odds of an ADE caused by an admission prescribing change with pharmacist-initiated MR compared with a physician-initiated MR were 1.04 with a 95% CI of 0.53 to 2.0. The adjusted odds of an ADE caused by an admission prescribing change that was a prescribing error with pharmacist-initiated MR compared with a physician-initiated MR were 0.38 with a confidence interval of 0.14 to 1.05. No difference was observed in 72-hour prescribing risk score (coefficient = 0.10; 95% CI, -0.54 to 0.75). CONCLUSION MR performed by pharmacists versus physicians was more comprehensive and was followed by lower odds of ADEs from admission prescribing errors but with similar odds of all types of ADEs. Further research is warranted to examine how MR tasks may be optimally divided among clinicians and the mechanisms by which MR affects the likelihood of subsequent ADEs.

Predictive value of nonspecific symptoms for acute illness in nursing home residents.

OBJECTIVES: To examine the predictive value of nonspecific symptoms for acute illness in nursing home residents.