Kerri M. Clough-Gorr

Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials

Objective To assess the effects of inpatient rehabilitation specifically designed for geriatric patients compared with usual care on functional status, admissions to nursing homes, and mortality. Design Systematic review and meta-analysis. Data sources Medline, Embase, Cochrane database, and reference lists from published literature. Review methods Only randomised controlled trials were included. Trials had to report on inpatient rehabilitation and report at least one of functional improvement, admission to nursing homes, or mortality. Trials of consultation or outpatient services, trials including patients aged <55, trials of non-multidisciplinary rehabilitation, and trials without a control group receiving usual care were excluded. Data were double extracted. Odds ratios and relative risks with 95% confidence intervals were calculated. Results 17 trials with 4780 people comparing the effects of general or orthopaedic geriatric rehabilitation programmes with usual care were included. Meta-analyses of effects indicated an overall benefit in outcomes at discharge (odds ratio 1.75 (95% confidence interval 1.31 to 2.35) for function, relative risk 0.64 (0.51 to 0.81) for nursing home admission, relative risk 0.72 (0.55 to 0.95) for mortality) and at end of follow-up (1.36 (1.07 to 1.71), 0.84 (0.72 to 0.99), 0.87 (0.77 to 0.97), respectively). Limited data were available on impact on health care or cost. Compared with those in control groups, weighted mean length of hospital stay after randomisation was longer in patients allocated to general geriatric rehabilitation (24.5 v 15.1 days) and shorter in patients allocated to orthopaedic rehabilitation (24.6 v 28.9 days). Conclusion Inpatient rehabilitation specifically designed for geriatric patients has the potential to improve outcomes related to function, admission to nursing homes, and mortality. Insufficient data are available for defining characteristics and cost effectiveness of successful programmes.

'It's just like you talk to a friend' relational agents for older adults

Relational agents-computational artifacts designed to build and maintain long-term social-emotional relationships with users-may provide an effective interface modality for older adults. This is especially true when the agents use simulated face-to-face conversation as the primary communication medium, and for applications in which repeated interactions over long time periods are required, such as in health behavior change. In this article, we discuss the design of a relational agent for older adults that plays the role of an exercise advisor, and report on the results of a longitudinal study involving 21 adults aged 62-84, half of whom interacted with the agent daily for 2 months in their homes and half who served as a standard-of-care control. Results indicate the agent was accepted and liked, and was significantly more efficacious at increasing physical activity (daily steps walked) than the control.

The eight-item modified Medical Outcomes Study Social Support Survey: psychometric evaluation showed excellent performance

OBJECTIVE Evaluation and validation of the psychometric properties of the eight-item modified Medical Outcomes Study Social Support Survey (mMOS-SS). STUDY DESIGN AND SETTING Secondary analyses of data from three populations: Boston breast cancer study (N=660), Los Angeles breast cancer study (N=864), and Medical Outcomes Study (N=1,717). The psychometric evaluation of the eight-item mMOS-SS compared performance across populations and with the original 19-item Medical Outcomes Study Social Support Survey (MOS-SS). Internal reliability, factor structure, construct validity, and discriminant validity were evaluated using Cronbachs alpha, principal factor analysis (PFA), and confirmatory factor analysis (CFA), Spearman and Pearson correlation, t-test and Wilcoxon rank sum tests. RESULTS mMOS-SS internal reliability was excellent in all three populations. PFA factor loadings were similar across populations; one factor >0.6, well-discriminated two factor (instrumental/emotional social support four items each) >0.5. CFA with a priori two-factor structure yielded consistently adequate model fit (root mean squared errors of approximation 0.054-0.074). mMOS-SS construct and discriminant validity were similar across populations and comparable to MOS-SS. Psychometric properties held when restricted to women aged ≥ 65 years. CONCLUSION The psychometric properties of the eight-item mMOS-SS were excellent and similar to those of the original 19-item instrument. Results support the use of briefer mMOS-SS instrument; better suited to multidimensional geriatric assessments and specifically in older women with breast cancer.

Acceptance and usability of a relational agent interface by urban older adults

This study examines the acceptance and usability of an animated conversational agent designed to establish long-term relationships with older, mostly minority adult users living in urban neighborhoods. The agent plays the role of an exercise advisor who interacts with subjects daily for two months on a touch-screen computer installed in their homes for the study. Survey results indicate the eight subjects who completed the pilot study (aged 62-82) found the agent very easy to interact with, even though most of them had little or no previous experience using computers. Most subjects also indicated strong liking for and trust in the agent, felt that their relationship with the agent was more similar to a close friend than a stranger, and expressed a strong desire to continue working with the agent at the end of the study. These results were also confirmed through qualitative analysis of post-experiment debrief transcripts.

Impact of unlinked deaths and coding changes on mortality trends in the Swiss National Cohort

BackgroundResults of epidemiological studies linking census with mortality records may be affected by unlinked deaths and changes in cause of death classification. We examined these issues in the Swiss National Cohort (SNC).MethodsThe SNC is a longitudinal study of the entire Swiss population, based on the 1990 (6.8 million persons) and 2000 (7.3 million persons) censuses. Among 1,053,393 deaths recorded 1991–2007 5.4% could not be linked using stringent probabilistic linkage. We included the unlinked deaths using pragmatic linkages and compared mortality rates for selected causes with official mortality rates. We also examined the impact of the 1995 change in cause of death coding from version 8 (with some additional rules) to version 10 of the International Classification of Diseases (ICD), using Poisson regression models with restricted cubic splines. Finally, we compared results from Cox models including and excluding unlinked deaths of the association of education, marital status, and nationality with selected causes of death.ResultsSNC mortality rates underestimated all cause mortality by 9.6% (range 2.4% - 17.9%) in the 85+ population. Underestimation was less pronounced in years nearer the censuses and in the 75–84 age group. After including 99.7% of unlinked deaths, annual all cause SNC mortality rates were reflecting official rates (relative difference between −1.4% and +1.8%). In the 85+ population the rates for prostate and breast cancer dropped, by 16% and 21% respectively, between 1994 and 1995 coincident with the change in cause of death coding policy. For suicide in males almost no change was observed. Hazard ratios were only negligibly affected by including the unlinked deaths. A sudden decrease in breast (21% less, 95% confidence interval: 12% - 28%) and prostate (16% less, 95% confidence interval: 7% - 23%) cancer mortality rates in the 85+ population coincided with the 1995 change in cause of death coding policy.ConclusionsUnlinked deaths bias analyses of absolute mortality rates downwards but have little effect on relative mortality. To describe time trends of cause-specific mortality in the SNC, accounting for the unlinked deaths and for the possible effect of change in death certificate coding was necessary.

Automated inter-rater reliability assessment and electronic data collection in a multi-center breast cancer study

BackgroundThe choice between paper data collection methods and electronic data collection (EDC) methods has become a key question for clinical researchers. There remains a need to examine potential benefits, efficiencies, and innovations associated with an EDC system in a multi-center medical record review study.MethodsA computer-based automated menu-driven system with 658 data fields was developed for a cohort study of women aged 65 years or older, diagnosed with invasive histologically confirmed primary breast cancer (N = 1859), at 6 Cancer Research Network sites. Medical record review with direct data entry into the EDC system was implemented. An inter-rater and intra-rater reliability (IRR) system was developed using a modified version of the EDC.ResultsAutomation of EDC accelerated the flow of study information and resulted in an efficient data collection process. Data collection time was reduced by approximately four months compared to the project schedule and funded time available for manuscript preparation increased by 12 months. In addition, an innovative modified version of the EDC permitted an automated evaluation of inter-rater and intra-rater reliability across six data collection sites.ConclusionAutomated EDC is a powerful tool for research efficiency and innovation, especially when multiple data collection sites are involved.

Examining five- and ten-year survival in older women with breast cancer using cancer-specific geriatric assessment

PURPOSE To examine five- and ten-year survival based on cancer-specific geriatric assessment (C-SGA) in older women with early stage breast cancer. METHODS We evaluated 660 women ≥65-years old diagnosed with stage I-IIIA primary breast cancer and attending physician permission to contact in four geographic regions in the United States of America (USA). Data were collected over ten-years of follow-up from consenting womens medical records, telephone interviews, National Death Index and Social Security Death Index. C-SGA was described by four domains using six measures: socio-demographic (financial resources); clinical (comorbidity, obesity); function (physical function limitations); and psychosocial (general mental health, social support). Survival from all-cause and breast-cancer-specific mortality and receipt of guideline-recommended therapy was assessed for different groups of subjects with C-SGA domain deficits (cut-off ≥3 deficits). RESULTS The proportion of women with ≥3 C-SGA deficits surviving ten-years was consistently statistically significantly lower (all-cause 26% versus 46% and breast-cancer-specific 76% versus 89%, p≤0.04). The proportion significantly decreased as number of C-SGA deficits increased (linear trend p<0.0001). Receipt of guideline-recommended therapy decreased with age but not consistently by number of C-SGA deficits. The all-cause and breast-cancer-specific death rate at five- and ten-years was consistently approximately two times higher in women with ≥3 C-SGA deficits even when fully adjusted for confounding factors (HR(5-yrAllCauseFullyAdjusted)=1.87 [1.36-2.57], HR(10-yrAllCauseFullyAdjusted)=1.74 [1.35-2.15], HR(5-yrBreastCancerFullyAdjusted)=1.95 [1.18-3.20], HR(10-yrBreastCancerFullyAdjusted)=1.99 [1.21-3.28]). CONCLUSION Regardless of age and stage of disease, C-SGA predicts five- and ten-year all-cause and breast-cancer-specific survival in older women. Hence, C-SGA may provide an effective strategy to guide treatment decision-making and to identify risk factors for intervention.

Longitudinal Patterns in Survival, Comorbidity, Healthcare Utilization and Quality of Care among Older Women Following Breast Cancer Diagnosis

OBJECTIVESTo compare longitudinal patterns of health care utilization and quality of care for other health conditions between breast cancer-surviving older women and a matched cohort without breast cancer.DESIGNProspective five-year longitudinal comparison of cases and matched controls.SUBJECTSNewly identified breast cancer patients recruited during 1997–1999 from four geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island; N = 422) were matched by age, race, baseline comorbidity and zip code location with up to four non-breast-cancer controls (N = 1,656).OUTCOMESSurvival; numbers of hospitalized days and physician visits; total inpatient and outpatient Medicare payments; guideline monitoring for patients with cardiovascular disease and diabetes, and bone density testing and colorectal cancer screening.RESULTSFive-year survival was similar for cases and controls (80% and 82%, respectively; p = 0.18). In the first follow-up year, comorbidity burden and health care utilization were higher for cases (p < 0.01), with most differences diminishing over time. However, the number of physician visits was higher for cases (p < 0.01) in every year, driven partly by more cancer and surgical specialist visits. Cases and controls adhered similarly to recommended bone density testing, and monitoring of cardiovascular disease and diabetes; adherence to recommended colorectal cancer screening was better among cases.CONCLUSIONBreast cancer survivors’ health care utilization and disease burden return to pre-diagnosis levels after one year, yet their greater use of outpatient care persists at least five years. Quality of care for other chronic health problems is similar for cases and controls.

Older Breast Cancer Survivors: Factors Associated with Self-reported Symptoms of Persistent Lymphedema Over 7 years of Follow-up

Abstract:  Lymphedema of the arm is a common complication of breast cancer with symptoms that can persist over long periods of time. For older women (over 50% of breast cancer cases) it means living with the potential for long‐term complications of persistent lymphedema in conjunction with the common diseases and disabilities of aging over survivorship. We identified women ≥65 years diagnosed with primary stage I–IIIA breast cancer. Data were collected over 7 years of follow‐up from consenting patients’ medical records and telephone interviews. Data collected included self‐reported symptoms of persistent lymphedema, breast cancer characteristics, and selected sociodemographic and health‐related characteristics. The overall prevalence of symptoms of persistent lymphedema was 36% over 7 years of follow‐up. Having stage II or III (OR = 1.77, 95% CI: 1.07–2.93) breast cancer and having a BMI >30 (OR = 3.04, 95% CI: 1.69–5.45) were statistically significantly predictive of symptoms of persistent lymphedema. Women ≥80 years were less likely to report symptoms of persistent lymphedema when compared to younger women (OR = 0.44, 95% CI: 0.18–0.95). Women with symptoms of persistent lymphedema consistently reported worse general mental health and physical function. Symptoms of persistent lymphedema were common in this population of older breast cancer survivors and had a noticeable effect on both physical function and general mental health. Our findings provide evidence of the impact of symptoms of persistent lymphedema on the quality of survivorship of older women. Clinical and research efforts focused on risk factors for symptoms of persistent lymphedema in older breast cancer survivors may lead to preventative and therapeutic measures that help maintain their health and well‐being over increasing periods of survivorship.

Reduced rates of cancer-related worries and mortality associated with guideline surveillance after breast cancer therapy.

AbstractObjective. Guidelines have been developed for appropriate post-therapy surveillance for breast cancer recurrence. Two objectives of post-therapy surveillance are to support and counsel patients and to detect potentially curable local recurrences and new cancers in the opposite breast. The objective of this investigation was to assess the impact of guideline surveillance (history, physical examination, and annual mammography) on cancer-related worries and all-cause mortality. Study design and setting. We collected data on a cohort of 303 Massachusetts women with stages I or II breast cancer diagnosed between 1992 and 1994. Cases were women with increasing cancer-related worries or decedents. We used risk-set sampling to match five controls to each case on follow-up time. Cases and members of their matched risk set were characterized with respect to receipt of guideline surveillance and covariates preceding the date of their outcomes. Results. The adjusted odds ratio associating guideline surveillance in the preceding year with an increase in cancer-related worries equaled 0.37 (95% CI=0.14–0.99). The adjusted odds ratio associating continuous guideline surveillance with all-cause mortality equaled 0.66 (95% CI=0.51-0.86). Conclusion. The results are consistent with the stated objectives of surveillance follow-up of breast cancer patients after the completion of their primary therapy.