Luohua Jiang

National Study of Chronic Disease Self-Management Age Comparison of Outcome Findings

Introduction. The adult population is increasingly experiencing one or more chronic illnesses and living with such conditions longer. The Chronic Disease Self-Management Program (CDSMP) helps participants cope with chronic disease-related symptomatology and improve their health-related quality of life. Nevertheless, the long-term effectiveness of this evidence-based program on older adults as compared to the middle-aged populations has not been examined in a large-scale, national rollout. Method. We identified baseline characteristics of CDSMP participants aged 65 years or older (n = 687, M = 74.8 years) in the National Study of CDSMP from 2010 to 2012. Comparisons were made to middle-aged participants aged 50 to 64 (n = 325, M = 58.3 years). Assessments were conducted at baseline and 12-month follow-up. Linear and generalized linear mixed models were performed to assess changes in primary and secondary outcomes, controlling the key sociodemographics and number of chronic conditions. Results. All primary outcomes (i.e., social/role activities limitation, depression, communication with doctors) significantly improved in both the older and middle-aged cohorts. Although improvements in illness symptomatology (e.g., fatigue, pain, shortness of breath, and sleep problems) were similar across both cohorts, only the middle-aged cohort benefitted significantly in terms of overall quality of life and unhealthy mental health days. Effect sizes were larger among the middle-aged population who were also more likely to enter the program in poorer health and be from minority backgrounds. Conclusions. The current study documented improved health outcomes but more so among the middle-aged population. Findings suggest the importance of examining how age and interacting life circumstances may affect chronic disease self-management.

Fall prevention in community settings: results from implementing stepping on in three States.

Stepping On is a community-based intervention that has been shown in a randomized controlled trial to reduce fall risk. The Wisconsin Institute for Healthy Aging adapted Stepping On for use in the United States and developed a training infrastructure to enable dissemination. The purpose of this study is to: (1) describe the personal characteristics of Stepping On participants; (2) quantify participants’ functional and self-reported health status at enrollment, and (3) measure changes in participants’ functional and self-reported health status after completing the program. Both survey and observed functional status [timed up and go (TUG) test] data were collected between September 2011 and December 2013 for 366 participants enrolled in 32 Stepping On programs delivered in Colorado, New York, and Oregon. Paired t-tests and general estimating equations models adjusted for socio-demographic factors were performed to assess changes over the program period. Among the 266 participants with pre–post survey data, the average participant age was 78.7 (SD ± 8.0) years. Most participants were female (83.4%), white (96.9%), and in good health (49.4%). The TUG test scores decreased significantly (p < 0.001) for all 254 participants with pre–post data. The change was most noticeable among high risk participants where TUG time decreased from 17.6 to 14.4 s. The adjusted odds ratio of feeling confident about keeping from falling was more than three times greater after completing Stepping On. Further, the adjusted odds ratios of reporting “no difficulty” for getting out of a straight back chair increased by 89%. Intended for older adults who have fallen in the past or are afraid of falling, Stepping On has the potential to reduce the frequency and burden of older adult falls.

Fall Prevention in Community Settings: Results from Implementing Tai Chi: Moving for Better Balance in Three States

Tai Chi: Moving for Better Balance (TCMBB) is an evidence-based fall prevention exercise program being disseminated in selected communities through state injury prevention programs. This study: (1) describes the personal characteristics of TCMBB participants; (2) quantifies participants’ functional and self-reported health status at enrollment; and (3) measures changes in participants’ functional and self-reported health status post-intervention. There were 421 participants enrolled in 36 TCMBB programs delivered in Colorado, New York, and Oregon. Of the 209 participants who completed both baseline enrollment and post-intervention surveys, the average age of participants was 75.3 (SD ± 8.2) years. Most participants were female (81.3%), non-Hispanic (96.1%), White (94.1%), and described themselves as in excellent or very good health (52.2%). Paired t-test and general estimating equation models assessed changes over the 3-month program period. Pre- and post-assessment self-reported surveys and objective functional data [Timed Up and Go (TUG) test] were collected. On average, TUG test scores decreased (p < 0.001) for all participants; however, the decrease was most noticeable among high-risk participants (mean decreased from 18.5 to 15.7 s). The adjusted odds ratio of reporting feeling confident that a participant could keep themselves from falling was five times greater after completing the program. TCMBB, which addresses gait and balance problems, can be an effective way to reduce falls among the older adult population. By helping older adults maintain their functional abilities, TCMBB can help community-dwelling older adults continue to live independently.

National dissemination of chronic disease self-management education programs: an incremental examination of delivery characteristics.

With a near 20-year developmental history as an evidence-based program, the suite of Chronic Disease Self-Management Education (CDSME) programs were selected in 2010 for grand-scale dissemination in a federally supported initiative to improve the health of older Americans. The primary charge of this national effort was to establish a sustainable program delivery system for empowering American adults with one or more chronic conditions to better manage their health. The current study focused on a series of dissemination and implementation science research questions to: (1) examine the geographic distribution of participation in this initiative across the Unites States; (2) describe workshop characteristics engaged to reach program participants in various settings; and (3) describe personal characteristics of the first 100,000 participants. Each subsequent entering cohort was descriptively examined to indicate whether there was constancy or change in delivery sites and populations reached over time. Findings show a strengthening of the workshop delivery infrastructure in that it took 9.4 months to reach the first 25,000 participants in 853 counties compared to 5.4 months to reach the last 25,000 participants in 1,109 counties. The workshop delivery characteristics and participant characteristics remained relatively consistent across increments of 25,000 participants reached, although general trends were observed for some variables. For example, after reaching the first 25,000 participants, subsequent groups of 25,000 participants were reached more quickly. Additionally, workshops were increasingly delivered in ZIP Codes with higher percentages of families residing below the federal poverty line. As more participants were reached, more participants with chronic conditions were enrolled. This national translational study illustrates the rapid expansion of CDSME programs throughout the United States and capability to reach diverse populations in a variety of settings.

Gait Speed among Older Participants Enrolled in an Evidence-Based Fall Risk Reduction Program: A Subgroup Analysis.

Background Functional decline is a primary risk factor for institutionalization and mortality among older adults. Although community-based fall risk reduction programs have been widely disseminated, little is known about their impact on gait speed, a key indicator of functional performance. Changes in functional performance between baseline and post-intervention were examined by means of timed up and go (TUG), a standardized functional assessment test administered to participants enrolled in A Matter of Balance/Volunteer Lay Leader (AMOB/VLL) model, an evidence-based fall risk reduction program. Methods This study included 71 participants enrolled in an AMOB/VLL program in the Brazos Valley and South Plain regions of Texas. Paired t-tests were employed to assess program effects on gait speed at baseline and post-intervention for all participants and by subgroups of age, sex, living status, delivery sites, and self-rated health. The Bonferroni correction was applied to adjust inflated Type I error rate associated with performing multiple t-tests, for which p-values <0.0042 (i.e., 0.5/12 comparisons) were deemed statistically significant. Results Overall, gait speed of enrolled participants improved from baseline to post-intervention (t = 3.22, p = 0.002). Significant changes in TUG scores were observed among participants who lived with others (t = 4.45, p < 0.001), rated their health as excellent, very good, or good (t = 3.05, p = 0.003), and attended program workshops at senior centers (t = 3.52, p = 0.003). Conclusion Findings suggest community-based fall risk reduction programs can improve gait speed for older adults. More translational research is needed to understand factors related to the effectiveness of fall risk reduction programs in various populations and settings.

Factors Associated with Hispanic Adults Attending Spanish-Language Disease Self-Management Program Workshops and Workshop Completion

Many factors influence ways in which middle-aged and older Hispanic adults prefer to receive health-related information. While Spanish-language disease management programs are increasingly offered in community and healthcare settings, less is known about their utilization among the Hispanic population. This study aimed to identify participant and workshop factors associated with middle-aged and older Hispanic adults attending Spanish-language disease self-management program workshops and receiving the recommended intervention dose (i.e., successful workshop completion is defined as attending four or more of the six workshop sessions). Data were analyzed from 12,208 Hispanic adults collected during a national dissemination of the Stanford suite of Chronic Disease Self-Management Education (CDSME) programs spanning 45 states, the District of Columbia, and Puerto Rico. Two logistic regression analyses were performed. Over 65% of participants attended Spanish-language workshops, and 78.3% of participants successfully completed workshops. Relative to participants in English-language workshops, participants who attended Spanish-language CDSME workshops were more likely to successfully complete workshops, as were those aged 80 years and older, females, and those who lived alone. Participants who were aged 50–79 years and female were significantly more likely to attend Spanish-language workshops than their counterparts under age 50. Conversely, those with more chronic conditions were less likely to attend Spanish-language workshops. Those who attended workshops with more participants and where the Hispanic population was less affluent were more likely to attend Spanish-language workshops. This study provides insight into Spanish-language CDSME program recruitment and utilization with implications for program adoption in underserved Hispanic community settings.

Longitudinal Patterns of Stages of Change for Exercise and Lifestyle Intervention Outcomes: An Application of Latent Class Analysis with Distal Outcomes.

Stages of change measure an individual’s readiness to alter a health behavior. This study examined the latent longitudinal patterns of stages of change (SoC) for regular exercise over time among individuals participating in a lifestyle intervention project. It also investigated the association between the longitudinal patterns of SoC and intervention outcomes using a new statistical method to assess the relationship between latent class membership and distal outcomes. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program, a lifestyle intervention program to prevent diabetes among American Indians and Alaska Natives. Latent class analysis (LCA) was conducted to identify the longitudinal patterns of SoC for regular exercise reported at three time points. LCA with distal outcomes was performed to investigate the associations between latent class membership and behavioral changes after the intervention. The parameters and standard errors of the LCA with distal outcomes models were estimated using an improved three-step approach. Three latent classes were identified: Pre-action, Transition, and Maintenance classes. The Transition class, where stage progression occurred, had the greatest improvements in physical activity and weight outcomes at both time points post-baseline among female participants. It also had the largest improvements in weight outcomes among male participants. Furthermore, the Pre-action class had more attenuation in the improvements they had achieved initially than the other two classes. These findings suggest the potential importance of motivating participants to modify their readiness for behavioral change in future lifestyle interventions.

Translation of Fit & Strong! for Middle-Aged and Older Adults: Examining Implementation and Effectiveness of a Lay-Led Model in Central Texas

The Fit & Strong! program is an evidence-based, multi-component program promoting physical activity among older adults, particularly those suffering from lower-extremity osteoarthritis. The primary purpose of the study is to examine if the Fit & Strong! program translated into a lay-leader model can produce comparable outcomes to the original program taught by physical therapists and/or certified exercise instructors. A single-group, pre–post study design was employed, and data were collected at the baseline (n = 136 participants) and the intervention conclusion (n = 71) with both baseline and post-intervention data. The measurements included socio-demographic information, health- and behavior-related information, and health-related quality of life. Various statistical tests were used for the program impact analysis and examination of the association between participant characteristics and program completion. As in the original study, there were statistically significant (p < 0.05) improvements in self-efficacy for exercise, aerobic capacity, joint stiffness, level of energy, and amount and intensity of physical activities. The odds of completing the program were significantly lower for the participants from rural areas and those having multiple chronic conditions. Successful adaptation of the Fit & Strong! program to a lay-leader model can increase the likelihood of program dissemination by broadening the selection pool of instructors and, hence, reducing the potential issue of resource limitation. However, high program attrition rates (54.1%) emphasize the importance of adopting evidence-based strategies for improving the retention of the participants from rural areas and those with multiple chronic conditions.

Potentially Preventable Hospitalizations and the Burden of Healthcare-Associated Infections.

Background: An estimated 4% of hospital admissions acquired healthcare-associated infections (HAIs) and accounted for

Health indicators associated with falls among middle-aged and older women enrolled in an evidence-based program

9.8 (USD) billion in direct cost during 2011. In 2010, nearly 140 000 of the 3.5 million potentially preventable hospitalizations (PPHs) may have acquired an HAI. There is a knowledge gap regarding the co-occurrence of these events. Aims: To estimate the period occurrences and likelihood of acquiring an HAI for the PPH population. Methods: Retrospective, cross-sectional study using logistic regression analysis of 2011 Texas Inpatient Discharge Public Use Data File including 2.6 million admissions from 576 acute care hospitals. Agency for Healthcare Research and Quality Prevention Quality Indicator software identified PPH, and existing administrative data identification methodologies were refined for Clostridium difficile infection, central line–associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia. Odds of acquiring HAIs when admitted with PPH were adjusted for demographic, health status, hospital, and community characteristics. Findings: We identified 272 923 PPH, 14 219 HAI, and 986 admissions with PPH and HAI. Odds of acquiring an HAI for diabetic patients admitted for lower extremity amputation demonstrated significantly increased odds ratio of 2.9 (95% confidence interval: 2.16-3.91) for Clostridium difficile infection. Other PPH patients had lower odds of acquiring HAI compared to non-PPH patients, and results were frequently significant. Conclusions: Clinical implications include increased risk of HAI among diabetic patients admitted for lower extremity amputation. Methodological implications include identification of rare events for inpatient subpopulations and the need for improved codification of HAIs to improve cost and policy analyses regarding allocation of resources toward clinical improvements.