Thelma J. Mielenz

Driving Cessation and Health Outcomes in Older Adults

To determine what effect driving cessation may have on subsequent health and well‐being in older adults.

Multiple chronic conditions and limitations in activities of daily living in a community-based sample of older adults in New York City, 2009.

Introduction Nationally, 60% to 75% of older adults have multiple (2 or more) chronic conditions (MCCs), and the burden is even higher among low-income, racial/ethnic minority populations. MCCs limit activities of daily living (ADLs), yet this association is not well characterized outside of clinical populations. We examined the association of MCCs with ADLs in a racially/ethnically diverse population of low-income older adults living in New York City public housing. Methods A representative sample of 1,036 New York City Housing Authority residents aged 65 or older completed a telephone survey in June 2009. We examined the association of up to 5 chronic conditions with basic ADL (BADL) limitations, adjusting for potential confounders by using logistic regression. Results Of respondents, 28.7% had at least 1 BADL limitation; 92.9% had at least 1 chronic condition, and 79.0% had MCCs. We observed a graded association between at least 1 BADL limitation and number of chronic conditions (using 0 or 1 condition as the reference group): adjusted odds ratio (AOR) for 3 conditions was 2.2 (95% confidence interval [CI], 1.3–3.9); AOR for 4 conditions, 4.3 (95% CI, 2.5–7.6); and AOR for 5 conditions, 9.2 (95% CI, 4.3–19.5). Conclusion Prevalence of BADL limitations is high among low-income older adults and increases with number of chronic conditions. Initiating prevention of additional conditions and treating disease constellations earlier to decrease BADL limitations may improve aging outcomes in this population.

Association of Self-Efficacy and Outcome Expectations with Physical Activity in Adults with Arthritis

Background and Purpose. The purpose of this study is to determine whether higher baseline levels of (a) self-efficacy for physical activity, (b) self-efficacy for arthritis self-management, and (c) outcome expectations for exercise are associated with higher physical activity levels following an exercise intervention for adults with arthritis. Methods. A secondary analysis of the intervention cohort (n = 130) within a randomized controlled trial of the People with Arthritis Can Exercise program was performed. Multiple linear regression evaluated the relationship between physical activity at a time point three months after the completion of an exercise intervention and three main explanatory variables. Results. After controlling for baseline physical activity, neither self-efficacy for arthritis self-management nor outcome expectations for exercise related to three-month physical activity levels. There was a relationship between three-month physical activity and self-efficacy for physical activity. Conclusions. Future research is needed to evaluate the ability of self-efficacy-enhancing programs to increase physical activity in adults with arthritis.

Using patient-reported outcomes and PROMIS in research and clinical applications: experiences from the PCORI pilot projects

PurposeThe field of patient-centered outcomes research (PCOR) continues to develop. Patient-reported outcomes and, in particular the Patient-Reported Outcomes Measurement Information System (PROMIS) contribute complementary data to clinician-derived outcomes traditionally used in health decision-making. However, there has been little work to understand how PROMIS measures may inform or be integrated into PCOR or clinical applications.MethodsLead investigators from four pilot projects funded by the Patient-Centered Outcomes Research Institute (PCORI) collaborated to discuss lessons learned about the use of PROMIS in PCOR studies via virtual and in-person meetings. In addition, a qualitative data collection tool was used to assess the pilot projects’ experiences.ResultsLessons learned from the pilot projects centered on practical elements of research design, such as choosing the right outcomes to study, considering the advantages and limitations of the PROMIS short forms and computer adaptive technology versions, planning ahead for a feasible data collection process, maintaining the focus on patients by ensuring that the research is truly patient-centered, and helping patients and providers make the most of PROMIS in care.ConclusionThe PCORI pilot projects demonstrated that PROMIS can be successfully used to conduct research that will help patients make decisions about their care. Interest in PCOR continues to grow and the lessons learned from these projects about the use of PROMIS will be helpful to investigators. Given the numerous benefits of PROMIS, implementing this tool in research and care will hopefully lead to significant progress in measuring health outcomes that are meaningful and relevant to all stakeholders.

Increasing the public health impact of evidence-based interventions in behavioral medicine: new approaches and future directions

The dissemination and implementation of evidence-based behavioral medicine interventions into real world practice has been limited. The purpose of this paper is to discuss specific limitations of current behavioral medicine research within the context of the RE-AIM framework, and potential opportunities to increase public health impact by applying novel intervention designs and data collection approaches. The MOST framework has recently emerged as an alternative approach to development and evaluation that aims to optimize multicomponent behavioral and bio-behavioral interventions. SMART designs, imbedded within the MOST framework, are an approach to optimize adaptive interventions. In addition to innovative design strategies, novel data collection approaches that have the potential to improve the public-health dissemination include mHealth approaches and considering environment as a potential data source. Finally, becoming involved in advocacy via policy related work may help to improve the impact of evidence-based behavioral interventions. Innovative methods, if increasingly implemented, may have the ability to increase the public health impact of evidence-based behavioral interventions to prevent disease.

Characteristics of electronic patient-provider messaging system utilisation in an urban health care organisation

Introduction Research suggests that electronic messaging can improve patient engagement. Studies indicate that a ‘digital divide’ may exist, where certain patient populations may be using electronic messaging less frequently. This study aims to determine which patient characteristics are associated with different levels of usage of an electronic patient-provider messaging system in a diverse urban population. Methods Cross-sectional electronic health record data were extracted for patients 10 years of age or older who live in New York City and who visited a set of clinics between 1 July 2011 and 30 June 2012. Regression analyses determined which participant characteristics were associated with the sending of electronic messages. Results Older, female, English-speaking participants of white race who received more messages, had any diagnoses, more office visits and a provider who sent messages were more likely to send more messages. Non-Millennial, non-white participants who received fewer messages, had more office visits, any diagnoses, a provider who saw fewer patients with patient portal accounts, lived in a low socioeconomic status neighbourhood, and did not have private insurance were more likely to send zero messages. Conclusion This study found significant differences in electronic messaging usage based on demographic, socioeconomic and health-related patient characteristics. Future studies are needed to support these results and determine the causes of observed associations.

Increasing Trend of Fatal Falls in Older Adults in the United States, 1992 to 2005: Coding Practice or Reporting Quality?

To investigate whether changes in death certificate coding and reporting practices explain part or all of the recent increase in the rate of fatal falls in adults aged 65 and older in the United States.

Item response theory analysis of the modified Roland-Morris Disability Questionnaire in a population-based study.

Study Design. This is a secondary analysis of a cross-sectional population-based survey. Objective. Shorten the modified 23-item Roland (mRoland) scale using item response theory (IRT) methods and describe where in the functional disability range each scale is the most precise. Summary of Background Data. The Roland-Morris Disability Questionnaire is recommended for a functional disability outcome measure in patients with low back pain (LBP). One commonly used version is the Roland. It is unknown where in the functional disability range the Roland measures. Methods. One candidate individual with LBP in randomly selected households was interviewed, identifying 694 adults with chronic LBP. To justify the use of a unidimensional 2-parameter logistic IRT model, we performed both exploratory and confirmatory factor analysis. Results. Exploratory factor analysis revealed one dominant eigenvalue. Confirmatory factor analysis results indicate that the 1-factor model fit well. IRT analysis revealed variability in the slopes, in the range from 1.07 to 3.10. The marginal reliability, an IRT-based analog to coefficient &agr;, was 0.88. The mRoland produces reliable scores (i.e., with a standard error <0.3) from 1.4 standard deviations below the mean to roughly 0.2 above the mean. Conclusion. The mRoland measures one construct. The mRoland seems to be an excellent tool for measuring just-below-average levels of functional disability. The mRoland measures high levels of functional disability with relatively poor reliability and may be more appropriate for a less-disabled population with LBP. We demonstrate that the mRoland can be shortened to 11 items with minimal loss of information. We show that there are different ways to go about selecting the set of 11 items that yield short forms with different strengths. Level of Evidence: 3

Item Response Theory Analysis of Two Questionnaire Measures of Arthritis-Related Self-Efficacy Beliefs from Community-Based US Samples

Using item response theory (IRT), we examined the Rheumatoid Arthritis Self-efficacy scale (RASE) collected from a People with Arthritis Can Exercise RCT (346 participants) and 2 subscales of the Arthritis Self-efficacy scale (ASE) collected from an Active Living Every Day (ALED) RCT (354 participants) to determine which one better identifies low arthritis self-efficacy in community-based adults with arthritis. The item parameters were estimated in Multilog using the graded response model. The 2 ASE subscales are adequately explained by one factor. There was evidence for 2 locally dependent item pairs; two items from these pairs were removed when we reran the model. The exploratory factor analysis results for RASE showed a multifactor solution which led to a 9-factor solution. In order to perform IRT analysis, one item from each of the 9 subfactors was selected. Both scales were effective at measuring a range of arthritis SE.

Social support and older adult falls

BackgroundSocial support has been shown to be associated with various positive health outcomes among older adults but has not been previously examined in relation to falls, which are a serious health concern among older adults.FindingsThis study (n = 1000) uses multivariable logistic regression to evaluate the relationship between social contact and perceived availability of social support and falls among older adults. When adjusting for demographic and other covariates neither relationship was significant.ConclusionsThis study does not find evidence to suggest that social support could be a prevention measure for falls. Future research on this topic should focus on careful definition and precise measurement of the social support construct.