Rodney M. Coe

Health services utilization among the noninstitutionalized elderly.

Data from a two-stage random sample of401 noninstitutionalized elderly individuals residing in 18 census tracts in the south-central part of Metropolitan St. Louis are used to assess the effects of the predisposing, enabling, and need characteristics on ten measures of health services utilization. Hierarchical multiple regression analyses indicate that: (I) Most of the explained variance in health services utilization may be attributed to the need characteristics, suggesting an apparently equitable system; (2) When a comprehensive version of Andersens behavioral model is fielded, from 12 to 35 percent of the variance in health services utilization can be explained; and (3) Nutritional risk is the most important predictor of the total number of physician visits, visits to physicians in the emergency room, and the occurrence of hospital episodes. The implications of these analyses for modeling the health services utilization of elderly as well as for public policy concerning their health care, are discussed.

Veterans' and nonveterans' use of health services. A comparative analysis.

This study compares the use of health services by veterans with that by nonveterans; compares the use of health services by veterans from different service cohorts with each other; and examines the correlates of veterans use of the VA health care delivery system. After adjusting for differences in the predisposing, enabling, and need characteristics, there were virtually no meaningful differences in the use of health services between veterans and nonveterans. This suggests that health care planning within the VA can proceed similarly to health care planning for the civilian population, albeit taking into consideration the significant difference in the sex distribution between the two populations. Virtually no meaningful or consistent veteran cohort effects on the use of health services were found. This suggests that health care planning within the VA may proceed without regard to changes in the nature of the veteran cohort structure. Finally, although there was a strong and obvious effect of service-connected disabilities (high-priority eligibility due to health status) on the use of the VA health care delivery system for veterans, there was no effect of being 65 years of age and older (high-priority eligibility due to age) on the use of the VA. Aside from service-connected disabilities, limited access to other health care delivery systems was the major factor behind the demand for VA care.

Progress in the Development of a Nutritional Risk Index

The development of a 16-item nutritional risk index (NRI) is chronicled from its inception through its application in three studies designed to assess its reliability and validity. Study I involved a survey of 401 community-dwelling elderly in St. Louis, Missouri who were interviewed at baseline, 4-5 mo later, and 1 yr later. Study II involved a cross-sectional survey of 377 male outpatients attending two clinics at the St. Louis Veterans Administration Medical Center. Study III involved a cross-sectional survey of 424 community-dwelling elderly in Houston, Texas. Internal consistency reliability coefficients ranged between 0.47 and 0.60, and test-retest reliability coefficients ranged between 0.65 and 0.71. Validity was established by using the NRI to predict the use of health services, as well as by correlating it with a variety of anthropometric, laboratory, and clinical markers of nutritional status. The utility of the NRI for future applications is discussed.

A cohort analysis of the use of health services by elderly Americans.

This paper presents a cohort analysis of the use of health services by elderly Americans. Standard cohort tables are constructed using data on approximately 50,000 individuals from the 1972, 1976, and 1980 Health Interview Surveys. Six 4-year age cohorts are tracked: the youngest, 56-59 years old in 1972; the oldest, 84-87 years old in 1980. Significant age and period effects on physician and hospital contact have been detected; for example the aging effect reflects an increase in the percentage of individuals who either saw a physician on an outpatient basis or were hospitalized in the previous year. Analysis of the volume of physician visits reveals an inverse J-curve relationship with age, with the pivotal point occurring at or about age 80. Consideration of nine alternative explanations of the J-curve phenomenon shows that three are plausible on either conceptual or empirical grounds. Two of these explanations suggest the substitution of either (1) hospital-based services for ambulatory-based services or (2) social supports (especially in the form of older children as care givers) for physicians services; the third explanation focuses on the involuntary severance of patient-practitioner relationships, resulting from the retirement or death of longstanding family physicians. Finally, competing policy implications of these explanations are discussed.

Nutritional Risk in Inner‐City‐Dwelling Older Black Americans

OBJECTIVE: To define the degree of nutritional risk in older inner‐city black Americans and to identify important underlying factors associated with high nutritional risk.

Achieving consensus on withdrawing or withholding care for critically ill patients

Objective:To examine the decision-making process to withhold of stop life support.Design:Survey.Setting:Medical intensive care unit of a tertiary care center.Participants:Physicians and families of 15 critically ill patients; in seven cases patients also participated.Measurements:Meetings between physicians and family members concerning a decision to withhold or stop treatment of a critically ill family member were tape-recorded. Transcriptions of the meetings were analyzed for 1) process: how the physician introducedthe need for a decision, framedthe likely outcomes of options, and closedon a decision; 2) what decision was made; and 3) the outcome; died, discharged home, or discharged to another institution.Results:The concept of “patient’s wishes” was a central orientation point for the negotiation of consensus regarding withholding or withdrawing therapy even when the patient was not a participant. Physicians tended to provide a direct and unambiguous introduction, give equal weights to options during decision framing, but narrow the options during decision closure to correspond to their judgments. Not every decision was consistent with the physician’s judgment.Conclusions:Decision making to withhold or withdraw life-support therapy from critically ill persons involves complex, difficult processes. Successful management of the tension among life extension, quality of life, patient autonomy, and social justice requires better understanding of these processes.

Correlates of a measure of coping in older veterans: A preliminary report

Sense of Coherence (SOC) is a specific measure of perception of coping ability which is examined here in relation to demographic characteristics and measures of physical and mental health status of older veterans (N=240). Results suggest that the SOC is strongly correlated with measures of subjective health status. It does not uniquely contribute to that dimension but does exhibit appropriate psychometric properties to encourage its use in further research.

Inner-city older blacks have high levels of functional disability.

OBJECTIVES: To describe the frequency and severity of functional problems in two groups of noninstitutionalized inner‐city blacks aged 70 years and older contrasted with results from appropriate groups of white and black older adults and with the goals of the Healthy People 2000 program.

Improving Quality of Geriatric Health Care in Four Delivery Sites: Suggestions from Practitioners and Experts

t is well documented that physicians and other health care I practitioners often miss important problems in older patient~.’-~ This has occurred in the outpatient setting,’ hospita1,2-6 emergency department,’ and nursing A number of studies in the United States as well as in other countries have demonstrated that one-quarter to two-thirds of seniors who undergo carotid endarterectomies, upper gastrointestinal endoscopies, coronary angiographies, coronary artery bypass surgery, and cholecystectomies have the procedure performed for inappropriate or questionable At the same time, elderly patients suffer a high rate of iatrogenic complications, more than a third of which are potentially preventable.12 If these problems were managed better, elderly patients would receive better care and would probably experience improved health care outcome^.^^^^^ A simple change in method of physician payment or limitation of resources through global budgeting is unlikely to improve this situation; rather, approaches that affect clinical care more directly will be required.” One such approach is quality improvement (QI). Newer QI techniques, with exciting potential for improving the quality and efficiency of services, have recently been introduced to health are.^***^ M uch congruence exists between the philosophy and methodology of these new techniques and those of geriatric medicine. Thus, these modern QI approaches offer an important opportunity for improving geriatric care.16 We conducted surveys of and group discussions with experts in the care of older persons and in modem QI techniques to develop an agenda for QI in geriatric care and to identify a model method for designing specific QI programs. Results regarding the QI agenda for geriatric care will be presented here.

Clinical validation of a nutritional risk index

This research assessed the clinical validity of a nutritional risk index (NRI). Subjects were 377 male veterans, aged 55+, attending general medicine and geriatric outpatient clinics. Data were collected by personal interviews, anthropometric measurements, laboratory assay of nutritional parameters, three-day food records, and medical record reviews. Although the results showed that the NRI correlated significantly with only two nutritional measures (body mass index, total energy intake), critical values or threshold levels of NRI were identified that significantly discriminated low risk from high risk patients on four nutritional parameters (body mass index, total energy intake, laboratory risk, and medications risk). It was concluded that the NRI is a valid measure of health status and contains a nutritional dimension.