Vincent Mor

The Karnofsky performance status scale: An examination of its reliability and validity in a research setting

The Karnofsky Performance Status Scale (KPS) is widely used to quantify the functional status of cancer patients. However, limited data exist documenting its reliability and validity. The KPS is used in the National Hospice Study (NHS) as both a study eligibility criterion and an outcome measure. As part of intensive training, interviewers were instructed in and tested on guidelines for determining the KPS levels of patients. After 4 months of field experience, interviewers were again tested based on narrative patient descriptions. The interrater reliability of 47 NHS interviewers was found to be 0.97. The construct validity of the KPS was analyzed, and the KPS was found to be strongly related (P < 0.001) to two other independent measures of patient functioning. Finally, the relationship of the KPS to longevity (r = 0.30) in a population of terminal cancer patients documents its predictive validity. These findings suggest the utility of the KPS as a valuable research tool when employed by trained observers.

Change in End-of-Life Care for Medicare Beneficiaries: Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009

IMPORTANCE A recent Centers for Disease Control and Prevention report found that more persons die at home. This has been cited as evidence that persons dying in the United States are using more supportive care. OBJECTIVE To describe changes in site of death, place of care, and health care transitions between 2000, 2005, and 2009. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of a random 20% sample of fee-for-service Medicare beneficiaries, aged 66 years and older, who died in 2000 (n = 270,202), 2005 (n = 291,819), or 2009 (n = 286,282). A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics. Based on billing data, patients were classified as having a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia in the last 180 days of life. MAIN OUTCOME MEASURES Site of death, place of care, rates of health care transitions, and potentially burdensome transitions (eg, health care transitions in the last 3 days of life). RESULTS Our random 20% sample included 848,303 fee-for-service Medicare decedents (mean age, 82.3 years; 57.9% female, 88.1% white). Comparing 2000, 2005, and 2009, the proportion of deaths in acute care hospitals decreased from 32.6% (95% CI, 32.4%-32.8%) to 26.9% (95% CI, 26.7%-27.1%) to 24.6% (95% CI, 24.5%-24.8%), respectively. However, intensive care unit (ICU) use in the last month of life increased from 24.3% (95% CI, 24.1%-24.5%) to 26.3% (95% CI, 26.1%-26.5%) to 29.2% (95% CI, 29.0%-29.3%). (Test of trend P value was <.001 for each variable.) Hospice use at the time of death increased from 21.6% (95% CI, 21.4%-21.7%) to 32.3% (95% CI, 32.1%-32.5%) to 42.2% (95% CI, 42.0%-42.4%), with 28.4% (95% CI, 27.9%-28.5%) using a hospice for 3 days or less in 2009. Of these late hospice referrals, 40.3% (95% CI, 39.7%-40.8%) were preceded by hospitalization with an ICU stay. The mean number of health care transitions in the last 90 days of life increased from 2.1 (interquartile range [IQR], 0-3.0) to 2.8 (IQR, 1.0-4.0) to 3.1 per decedent (IQR, 1.0-5.0). The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) to 12.4% (95% CI, 12.3%-2.5%) to 14.2% (95% CI, 14.0%-14.3%). CONCLUSION AND RELEVANCE Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000, a lower proportion died in an acute care hospital, although both ICU use and the rate of health care transitions increased in the last month of life.

Randomised trial of impact of model of integrated care and case management for older people living in the community

Abstract Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 (

RISK OF FUNCTIONAL DECLINE AMONG WELL ELDERS

1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community. Key messages Responsibility for management of care of elderly people living in the community is poorly defined Integration of medical and social services together with care management programmes would improve such care in the community In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

Functional transitions among the elderly: patterns, predictors, and related hospital use.

Active lifestyles may delay the onset of the functional consequences of chronic disease, potentially increasing active life expectancy. We analyzed the Longitudinal Study of Aging (LSOA) to test the hypothesis that elders participation in an active lifestyle prevents loss of function. Focusing on the cohort aged 70-74 who reported being able to carry 25 lb, walk 1/4 mile, climb 10 steps and do heavy housework without help and without difficulty at baseline, decline was defined as no longer being able to perform these tasks independently and without difficulty 2 years later. Using multivariate logistic regression, results reveal that those who did not report regularly exercising or walking a mile were 1.5 times more likely to decline than those who did, controlling for reported medical conditions and demographic factors. Similar findings (with different models) were observed for both men and women. Findings suggest the potential value of programs oriented toward the primary prevention of functional decline.

A National Study of the Location of Death for Older Persons with Dementia

OBJECTIVES This paper describes 6-year rates and correlates of functional change in the elderly, as well as associated hospital use. METHODS The Longitudinal Study on Aging (n = 7527) and matched Medicare claims were used to calculate 6-year functional status transition rates and hospital use rates. A hierarchical measure that incorporated activities of daily living, instrumental activities of daily living, and competing risks of institutionalization and death was used to assess functional status. Multinomial logistic regression was used to predict 1990 status. RESULTS The functional status of 12% of men and women 70 to 79 years of age who were initially impaired in instrumental activities of daily living improved, and about half of the initially independent people in that age group remained so. Multivariate analyses revealed that age, baseline functioning, self-rated health, and comorbidity predicted 1990 status. Both baseline functioning and functional change were related to hospitalization. CONCLUSIONS This study supports others that have shown some long-term functional improvement, but more commonly decline, in the elderly. Furthermore, it documents the link between functional decline and increased hospital use.

The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: effects on process quality.

Objectives: To describe where older Americans with dementia die and to compare the state health system factors related to the location of dementia‐related deaths with those of cancer and all other conditions in this population.

A commitment to change: revision of HCFA's RAI.

OBJECTIVE: To characterize changes in key aspects of process quality received by nursing home residents before and after the implementation of the national nursing home Resident Assessment Instrument (RAI) and other aspects of the Omnibus Budget Reconciliation Act (OBRA) nursing home reforms.

Does Receipt of Hospice Care in Nursing Homes Improve the Management of Pain at the End of Life

OBJECTIVE: To describe the reliability of new assessment items and their clinical utility as judged by experienced nurse assessors, based on the results from the field test of Version 2.0 of the Resident Assessment Instrument (RAI).

End-of-life transitions among nursing home residents with cognitive issues.

To compare analgesic management of daily pain for dying nursing home residents enrolled and not enrolled in Medicare hospice.