Promoting sustainable community change in support of older adult physical activity: evaluation findings from the Southeast Seattle Senior Physical Activity Network (SESPAN).

Researchers have identified as effective and worthy of broader dissemination a variety of intervention strategies to promote physical activity among older adults. This paper reports results of a community-organizing approach to disseminating evidence-based interventions in a sustainable way: The Southeast Seattle Senior Physical Activity Network (SESPAN). SESPAN was implemented in Southeast Seattle, a group of multicultural neighborhoods extending 8 miles southeast of downtown Seattle, with a population of 56,469 in 2000, with 12% (7,041) aged 65 and older. The SESPAN organizing strategy involved networking to: (1) make connections between two or more community organizations to create new senior physical activity programs; and (2) build coalitions of community groups and organizations to assist in making larger scale environmental and policy changes to increase senior physical activity. The SESPAN evaluation used an uncontrolled prospective design focusing on sustainable community changes, including new or modified programs, policies, and practices. Networking among organizations led to the creation of 16 ongoing exercise classes and walking groups, serving approximately 200 older adults in previously underserved Southeast Seattle communities. In addition, the project's health coalition is sustaining current activities and generating new programs and environmental changes. The success of the SESPAN organizing model depended on identifying and involving champions in partner organizations who provided support and resources for implementing programs.

Health care costs and participation in a community-based health promotion program for older adults.

INTRODUCTION: EnhanceWellness (EW) is a community-based health promotion program that helps prevent disabilities and improves health and functioning in older adults. A previous randomized controlled trial demonstrated a decrease in inpatient use for EW participants but did not evaluate health care costs. We assessed the effect of EW participation on health care costs. METHODS: We performed a retrospective cohort study in King County, Washington. Enrollees in Group Health Cooperative (GHC), a mixed-model health maintenance organization, who were aged 65 years or older and who participated in EW from 1998 through 2005 were matched 1:3 by age and sex to GHC enrollees who did not participate in EW. We matched 218 EW participants by age and sex to 654 nonparticipants. Participants were evaluated for 1 year after the date they began the program. The primary outcome was total health care costs; secondary outcomes were inpatient costs, primary care costs, percentage of hospitalizations, and number of hospital days. We compared postintervention outcomes between EW participants and nonparticipants by using linear regression. Results were adjusted for prior year costs (or health care use), comorbidity, and preventive health care-seeking behaviors. RESULTS: Mean age of participants and nonparticipants was 79 years, and 72% of participants and nonparticipants were female. Adjusted total costs in the year following the index date were $582 lower among EW participants than nonparticipants, but this difference was not significant. CONCLUSION: Although EW participation demonstrated health benefits, participation does not appear to result in significant health care cost savings among people receiving health care through a health maintenance organization.

A community-organizing approach to promoting physical activity in older adults: the southeast senior physical activity network.

This article describes a community organizing approach to promoting physical activity among underserved older adults in southeast Seattle: the Southeast Senior Physical Activity Network (SESPAN). The organizing strategy involves networking with a variety of community-based organizations, with two broad objectives: (a) program objective-to make connections between two (or more) community-based organizations to create senior physical activity programs where none existed before; and (b) coalition objective-to build a broader network or coalition of groups and organizations to assist in making larger scale environmental and policy changes. Networking among organizations led to the creation of a number of potentially sustainable walking and exercise programs that are reaching previously underserved communities within Southeast Seattle. In addition, a major community event led to the establishment of a health coalition that has the potential to continue to generate new broad-based programs and larger scale environmental changes.

Secondary prevention of myocardial infarction with nonpharmacologic strategies in a Medicaid cohort.

BACKGROUND: The quality of health care after myocardial infarction (MI) may be lacking; in particular, guidelines for nonpharmacologic interventions (cardiac rehabilitation, smoking cessation) may receive insufficient priority. We identified gaps between secondary prevention guidelines and ambulatory care received by Medicaid enrollees after an MI. METHODS: MI survivors were selected by using 2004 Washington State Medicaid administrative claims. Deidentified data were abstracted for hospitalizations, ambulatory care, and prescriptions for 365 days after the MI. Cox regression analysis compared utilization of guideline-directed secondary prevention strategies with death and recurrent hospitalization. RESULTS: The sample size was 372. Fifty patients died during the year after the MI, and 144 were rehospitalized. Only 2 patients attended a cardiac rehabilitation program. Tobacco cessation counseling was associated with a 66% reduction in death, but only 72.6% of smokers were counseled. Less than half (45.4%) of patients saw a primary care provider within 90 days of their MI, and 7.5% never contacted a health care provider. Receiving regular primary care was associated with a decreased risk for death (hazard ratio, 0.91; 95% confidence interval, 0.84-0.97, P < .01). A protective trend was associated with care by a cardiologist, but only 21.5% received specialist care. CONCLUSION: Analysis of Medicaid claims data suggests rates of secondary prevention are less than optimal. To improve survival and reduce rehospitalization after an MI, policy changes (tobacco cessation benefits, expansion of rehabilitation programs), health care capacity (training, referral patterns, and coordination of care), and improvements to access (removing barriers, increasing facilities, targeting minority populations) could be implemented.

Using Targeted mHealth Messages to Address Hypertension and Diabetes Self-Management in Cambodia: Protocol for a Clustered Randomized Controlled Trial.

BACKGROUND: Hypertension and diabetes represent the first and third highest contributors to global disability. While mobile health (mHealth) messaging programs have rapidly increased in low- and middle-income countries (LMIC), adaptations for specific patient health needs is a new approach to manage chronic conditions. OBJECTIVE: The primary aim of this study is to develop and test an mHealth communication intervention using electronic data capture (by tablet) and voice messaging to improve hypertension and diabetes self-management in Cambodia. The secondary aim is to share results with the Cambodian Ministry of Health and development partners to inform health policy and develop strategies for hypertension and diabetes control. METHODS: The study design is a cluster randomized controlled clinical trial randomizing each of 75 Community peer educators (PEs), trained and coordinated by MoPoTsyo Patient Information Center in Phnom Penh, into one of 3 groups of 25 (approximately 60 patients each) to receive either tablet+messages, tablet only, or no intervention (control). The total sample within each group includes 25 clusters and approximately 1500 patients located in 7 Operational Districts in rural regions or urban slums in Cambodia. The interventions (groups 1 and 2) were compared with usual PE monitoring without the tablet or mHealth messaging interventions. Focus groups and informant interviews were conducted to develop messages according to specific themes-medications adherence, laboratory testing, physician visits, obesity, smoking, and general lifestyle issues. Using the data received at monthly PE monitoring meetings, patients will receive specific messages based on their individual health challenges. Following the intervention completion, clinical and process outcomes will be compared with baseline metrics between groups. RESULTS: PEs were randomized in July 2017, and the intervention was implemented in September 2017 through June 2018. Analyses are underway. CONCLUSIONS: This project is unique in its combination of electronic data transfer, which can be accessed immediately, with voice messages most relevant to individual patients' needs. Positive results will indicate the value of using targeted messaging in patient-specific, self-management issues to improve hypertension and diabetes control. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11614.

Depression and use of a health plan-sponsored physical activity program by older adults.

BACKGROUND: The purpose of this study was to determine the associations between depression and the likelihood of enrollment in a health plan-sponsored physical activity program and pattern of program participation over 2 years; a secondary aim was to examine the association between participation dose and depression risk. There are no published studies on how depression influences participation in health plan-sponsored physical activity programs and how participation affects depression risk in older adults in nonresearch settings. METHODS: This study used administrative data from a Medicare Advantage plan. Participants (n=4766) were enrolled in the plan for at least 1 year prior to participating in the plan-sponsored health club benefit (Silver Sneakers). Controls were age- and gender-matched to participants (n=9035). Members were identified as having depression based on ICD-9-CM codes. Multivariate regression and generalized estimating equations models were used. Data were collected between 1998 and 2003 and analyzed in 2008. RESULTS: Members who had a history of depression were as likely to participate in Silver Sneakers as nondepressed members (OR: 1.03; 95% CI=0.89, 1.20; p=0.67). The risk of lapse in Silver Sneakers attendance was 28%-55% (p<0.05) higher for depressed participants during months 15-24. For nondepressed Silver Sneakers participants, attendance of at least 2 visits/week during Year 1 was significantly associated with lower risk of depression in Year 2 (OR=0.54; 95% CI=0.37, 0.79; p=0.002); a similar but statistically nonsignificant association was observed for previously depressed participants (OR=0.51; 95% CI=0.26, 1.02; p=0.06). CONCLUSIONS: While depressed older adults are as likely to enroll in a health plan-sponsored physical activity as nondepressed members, they were at higher risk of attendance lapses. Greater participation in the physical activity program was associated with lower depression risk.

Translating a community-based motivational support program to increase physical activity among older adults with diabetes at community clinics: a pilot study of Physical Activity for a Lifetime of Success (PALS).

BACKGROUND: Regular physical activity is an important goal for elders with chronic health conditions. CONTEXT: This report describes Physical Activity for a Lifetime of Success (PALS), an attempt to translate a motivational support program for physical activity, Active Choices, for use by a group of diverse, low-income, community-dwelling elders with diabetes. METHODS: PALS linked physical activity assessment and brief counseling by primary care providers with a structured referral to a community-based motivational telephone support program delivered by older adult volunteers. People with diabetes aged 65 years or older who were receiving care at two community clinics were randomized to receive either immediate or delayed intervention. The main intended outcome measure was physical activity level; the secondary outcome measure was mean hemoglobin A1c. CONSEQUENCES: One-third of those offered referral to the PALS program in the clinic setting declined. Another 44% subsequently declined enrollment or were unreachable by the support center. Only 14 (21%) of those offered referral enrolled in the program. Among these 14, the percentage who were sufficiently active was higher at follow-up than at enrollment, though not significantly so. Using an intent-to-treat analysis, which included all randomized clinic patients, we found no significant change in mean hemoglobin A1c for the intervention group compared with controls. INTERPRETATION: A community-based referral and support program to increase physical activity among elderly, ethnically diverse, low-income people with diabetes, many of whom are not English-speaking, may be thwarted by unforeseen barriers. Those who enroll and participate in the PALS program appear to increase their level of physical activity.

Managed-Medicare health club benefit and reduced health care costs among older adults.

INTRODUCTION: Our study was undertaken to determine the association between use of a health plan-sponsored health club benefit by older adults and total health care costs over 2 years. METHODS: This retrospective cohort study used administrative and claims data from a Medicare Advantage plan. Participants (n = 4766) were enrolled in the plan for at least 1 year before participating in the plan-sponsored health club benefit (Silver Sneakers). Controls (n = 9035) were matched to participants by age and sex according to the index date of Silver Sneakers enrollment. Multivariate regression models were used to estimate health care use and costs and to make subgroup comparisons according to frequency of health club visits. RESULTS: Compared with controls, Silver Sneakers participants were older and more likely to be male, used more preventive services, and had higher total health care costs at baseline. Adjusted total health care costs for Silver Sneakers participants and controls did not differ significantly in year 1. By year 2, compared with controls, Silver Sneakers participants had significantly fewer inpatient admissions (-2.3%, 95% confidence interval, -3.3% to -1.2%; P < .001) and lower total health care costs (-$500; 95% confidence interval, -$892 to -$106; P = .01]. Silver Sneakers participants who averaged at least two health club visits per week over 2 years incurred at least $1252 (95% confidence interval, -$1937 to -$567; P < .001) less in health care costs in year 2 than did those who visited on average less than once per week. CONCLUSION: Regular use of a health club benefit was associated with slower growth in total health care costs in the long term but not in the short term. These findings warrant additional prospective investigations to determine whether policies to offer health club benefits and promote physical activity among older adults can reduce increases in health care costs.

Impact of a managed-Medicare physical activity benefit on health care utilization and costs in older adults with diabetes.

OBJECTIVE: The purpose of this article was to determine the effects of a managed-Medicare physical activity benefit on health care utilization and costs among older adults with diabetes. RESEARCH DESIGN AND METHODS: This retrospective cohort study used administrative and claims data for 527 patients from a diabetes registry of a staff model HMO. Participants (n = 163) were enrolled in the HMO for at least 1 year before joining the Enhanced Fitness Program (EFP), a community-based physical activity program for which the HMO pays for each EFP class attended. Control subjects were matched to participants according to the index date of EFP enrollment (n = 364). Multivariate regression models were used to determine 12-month postindex differences in health care use and costs between participants and control subjects while adjusting for age, sex, chronic disease burden, EFP attendance, prevention score, heart registry, and respective baseline use and costs. RESULTS: Participants and control subjects were similar at baseline with respect to age (75 +/- 5.5 years), A1C levels (7.4 +/- 1.4%), chronic disease burden, prevention score, and health care use and costs. After exposure to the program, there was a trend toward lower hospital admissions in EFP participants compared with control subjects (13.5 vs. 20.9%, P = 0.08), whereas total health care costs were not different (P = 0.39). EFP participants who attended > or = 1 exercise session/week on average had approximately 41% less total health care costs compared with those attending <1 session/week (P = 0.03) and with control subjects (P = 0.02). CONCLUSIONS: Although elective participation in a community-based physical activity benefit at any level was not associated with lower inpatient or total health care costs, greater participation in the program may lower health care costs. These findings warrant additional investigations to determine whether policies to offer and promote a community-based physical activity benefit in older adults with diabetes can reduce health care costs.

Barriers and facilitators of diabetes services in Nepal: a qualitative evaluation.

For the past three decades, the burden of diabetes in Nepal has been steadily increasing, with an estimated 3% annual increase since the year 2000. Although the burden is increasing, the methods of addressing the challenge have remained largely unchanged. This study sought to assess the current state of diabetes services provided by health facilities and to identify the major barriers that people with diabetes commonly face in Nepal. For this qualitative study, we selected five health facilities of varying levels and locations. At each site, we employed three unique methods: a process evaluation of the diabetes treatment and prevention services available, in-depth interviews with patients and focus group discussions with community members without diabetes. We used thematic analysis to analyse the data. Our findings were organized into the five categories of the Ecological Model: Individual, Interpersonal, Organizational, Community and Public Policy. Sub-optimal knowledge and behaviors of patients often contributed to poor diabetes management, especially related to diet control, physical activity and initiation of drug treatment. Social support was often lacking. Organizational challenges included health provider shortages, long wait times, high patient loads and minimal time available to spend with patients, often resulting in incomprehensive care. Public policy challenges include limited services in rural settings and financial burden. The scarcity of financial and human resources for health in Nepal often results in the inability of the current healthcare system to provide comprehensive prevention and management services for chronic diseases. A multilevel, coordinated approach is necessary to address these concerns. In the short-term, adding community-based supplementary solutions outside of the traditional hospital-based model could help to increase access to affordable services.

Barriers and facilitators to treatment among patients with newly diagnosed hypertension in Nepal.

OBJECTIVE: Hypertension is a significant and rising burden in Nepal. The disease remains undetected and inadequately managed. However, no studies have been conducted to understand the inhibiting and facilitating factors to hypertension treatment among newly diagnosed cases. This qualitative study aimed to explore barriers and facilitators to treatment among patients with newly diagnosed hypertension aged ≥18 years in Dhulikhel, Nepal. METHODS: We conducted seven focus group discussions with 35 patients with newly diagnosed hypertension identified through community surveillance of the Dhulikhel Heart Study, an observational cohort of Dhulikhel Hospital, Kathmandu University. Audiotaped discussions were transcribed, inductively coded and analysed by the thematic framework method using Atlas.ti V.7. RESULTS: Hypertension was viewed as a rising problem in the community. Participants had limited knowledge and many misbeliefs regarding hypertension and its treatment. The major barriers included absence of symptoms, reluctance to take medicine, low perceived seriousness of the disease, challenges in behaviour change (diet and exercise), lack of family support, and lack of communication and trust with the provider. The major reported facilitating factors were fear of consequences of the disease, and family support in controlling diet and adhering to treatment. CONCLUSIONS: A number of factors emerged as barriers and facilitators to hypertension treatment. This information can be useful in designing appropriate health interventions to improve hypertension management.

The association of estimated salt intake with blood pressure in a Viet Nam national survey.

OBJECTIVE: To evaluate the association of salt consumption with blood pressure in Viet Nam, a developing country with a high level of salt consumption. DESIGN AND SETTING: Analysis of a nationally representative sample of Vietnamese adults 25-65 years of age who were surveyed using the World Health Organization STEPwise approach to Surveillance protocol. Participants who reported acute illness, pregnancy, or current use of antihypertensive medications were excluded. Daily salt consumption was estimated from fasting mid-morning spot urine samples. Associations of salt consumption with systolic blood pressure and prevalent hypertension were assessed using adjusted linear and generalized linear models. Interaction terms were tested to assess differences by age, smoking, alcohol consumption, and rural/urban status. RESULTS: The analysis included 2,333 participants (mean age: 37 years, 46% male, 33% urban). The average estimated salt consumption was 10g/day. No associations of salt consumption with blood pressure or prevalent hypertension were observed at a national scale in men or women. The associations did not differ in subgroups defined by age, smoking, or alcohol consumption; however, associations differed between urban and rural participants (p-value for interaction of urban/rural status with salt consumption, p = 0.02), suggesting that higher salt consumption may be associated with higher systolic blood pressure in urban residents but lower systolic blood pressure in rural residents. CONCLUSIONS: Although there was no evidence of an association at a national level, associations of salt consumption with blood pressure differed between urban and rural residents in Viet Nam. The reasons for this differential association are not clear, and given the large rate of rural to urban migration experienced in Viet Nam, this topic warrants further investigation.

Awareness, treatment and control of hypertension in Nepal: findings from the Dhulikhel Heart Study.

OBJECTIVES: Although previous studies have suggested alarming rise in the prevalence of hypertension in Nepal, there is dearth of information on its awareness, treatment and control. In this cross-sectional study, we assessed awareness, treatment and control of hypertension among 298 hypertensive adults from the suburban town of Dhulikhel, Nepal. METHODS: This cross-sectional study is based on Dhulikhel Heart Study, which included 1073 adults, aged ≥18 years, recruited from randomly selected households. Comprehensive health interviews and blood pressure measurements were completed during home interviews. Hypertensives (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg or receiving antihypertensive medication) were further evaluated for awareness, treatment and control of hypertension. Multivariate regression model quantified the association of the sociodemographic characteristics and the cardiovascular disease (CVD) risk factors with hypertension awareness. Differences between sociodemographic characteristics and CVD risk factors with treatment and control of hypertension were tested using χ2 tests. RESULTS: A total of 43.6% of all hypertensives (n=298) were aware of their hypertension status. In multivariate analyses, hypertension awareness was associated with increasing age (p<0.001). More than three-fourth (76.1%) of those who were aware of their hypertension status (n=130) were currently on treatment. There were significant differences in treatment status by sex, occupation, age, income quartiles and body mass index. Only 35.3% of those on treatment (n=99) had blood pressure control. CONCLUSIONS: The levels of awareness, treatment and control of hypertension in this sample of Nepalese adults were low.

The public hospital mission at Seattle's Harborview Medical Center: high-quality care for the underserved and excellence in medical education.

United States public hospitals and medical schools commonly enter into partnerships that serve the patient care, education, and research missions of both institutions. Harborview Medical Center, the county hospital in Seattle, Washington, and the University of Washington School of Medicine (UWSOM) have enjoyed a long affiliation that began at the medical school's founding 60 years ago. A formal agreement in 1967 turned over responsibility for all Harborview operations to UWSOM at a time when Harborview's facilities had fallen into serious disrepair and public hospitals were closing across the United States. All faculty and staff based at Harborview are employed by the University of Washington. By the mid-1970s a revitalization was underway at Harborview. The Medic One paramedic program drew national acclaim for pioneering prehospital emergency cardiac care, and the trauma and burn centers grew rapidly to meet specialized intensive care needs of the Pacific Northwest. Today, the success of the trauma, specialty surgery, and rehabilitation services have allowed Harborview to consistently maintain a positive operating margin while caring for the county's uninsured and indigent patients ($98 million in charity care in 2005). The hospital also offers nationally recognized residency programs and supports nationally and internationally acclaimed research. Harborview faces significant challenges for the future, including rapid growth of the indigent patient load, continually changing expectations for physician training, and growing cost pressures.

Prompting primary providers to increase community exercise referrals for older adults: a randomized trial.

OBJECTIVES: To determine whether a clinic-based physical activity promotion intervention can lead to more community-based exercise referrals by providers and higher exercise motivation in patients. DESIGN: Cluster randomized, controlled trial. SETTING: Seattle Veterans Affairs General Internal Medicine Clinic. PARTICIPANTS: Thirty-one physicians and nurse practitioners were randomized to a physical activity counseling intervention or control condition (counseling about tobacco cessation). Three hundred thirty-six patients aged 50 and older and visiting a study provider were enrolled. INTERVENTION: Intervention providers were trained to offer referrals to community exercise programs for patients who reported before their clinic visit that they were "contemplative" about regular exercise. MEASUREMENTS: Process measures of health behavior assessment and provider advice, exercise stage-of-change, proportion of participants reporting regular physical activity. RESULTS: At baseline, 172 intervention patients and 164 controls were similar with respect to sex, age, comorbidity score, and exercise motivation level. Forty-five percent of all intervention patients and 35% of controls reported receiving exercise advice (P=.07). Intervention patients who were contemplative about exercise were even more likely to receive exercise advice than contemplative controls (59% vs 38%; P=.02). After 4 months, 35% of all intervention patients reported regular exercise, compared with 28% of controls (P=.06). CONCLUSION: Primary providers are more likely to offer exercise advice when informed whether patients are contemplative about exercise. Patients may be more likely to start regular exercise as a result of this advice.

Bolstering medical education to enhance critical care capacity in Cambodia.

The capacity to care for the critically ill has long been viewed as a fundamental element of established and comprehensive health care systems. Extending this capacity to health care systems in low- and middle-income countries is important given the burden of disease in these regions and the significance of critical care in overall health system strengthening. However, many practicalities of improving access and delivery of critical care in resource-limited settings have yet to be elucidated. We have initiated a program to build capacity for the care of critically ill patients in one low-income Southeast Asian country, Cambodia. We are leveraging existing international academic partnerships to enhance postgraduate critical care education in Cambodia. After conducting a needs assessment and literature review, we developed a three-step initiative targeting training in mechanical ventilation. First, we assessed and revised the current resident curriculum pertaining to mechanical ventilation. We addressed gaps in training, incorporated specific goals and learning objectives, and decreased the hours of lectures in favor of additional bedside training. Second, we are incorporating e-learning, e-teaching, and e-assessment into the curriculum, with both live, interactive and independent, self-paced online instruction. Third, we are developing a train-the-trainer program defined by bidirectional international faculty exchanges to provide hands-on, case-based, and bedside training to achieve competency-based outcomes. In targeting specific educational needs and a key population-the next generation of Cambodian intensivists-this carefully designed approach should address some existing gaps in the health care system and hopefully yield a lasting impact.

Effects of provider practice on functional independence in older adults.

OBJECTIVES: To examine provider determinants of new-onset disability in basic activities of daily living (ADLs) in community-dwelling elderly. DESIGN: Observational study. SETTING: King County, Washington. PARTICIPANTS: A random sample of 800 health maintenance organization (HMO) enrollees aged 65 and older participating in a prospective longitudinal cohort study of dementia and normal aging and their 56 primary care providers formed the study population. MEASUREMENTS: Incident ADL disability, defined as any new onset of difficulty performing any of the basic ADLs at follow-up assessments, was examined in relation to provider characteristics and practice style using logistic regression and adjusting for case-mix, patient and provider factors associated with ADL disability, and clustering by provider. RESULTS: Neither provider experience taking care of large numbers of elderly patients nor having a certificate of added qualifications in geriatrics was associated with patient ADL disability at 2 or 4 years of follow-up (adjusted odds ratio (AOR) for experience=1.29, 95% confidence interval (CI)=0.81-2.05; AOR for added qualifications=0.72, 95% CI=0.38-1.39; results at 4 years analogous). A practice style embodying traditional geriatric principles of care was not associated with a reduced likelihood of ADL disability over 4 years of follow-up (AOR for prescribing no high-risk medications=0.56, 95% CI=0.16-1.94; AOR for managing geriatric syndromes=0.94, 95% CI=0.40-2.19; AOR for a team care approach=1.35, 95% CI=0.66-2.75). CONCLUSION: Taking care of a large number of elderly patients, obtaining a certificate of added qualifications in geriatrics, and practicing with a traditional geriatric orientation do not appear to influence the development of ADL disability in elder, community dwelling HMO enrollees.

Outcomes of a community-based dissemination of the health enhancement program.

OBJECTIVES: We previously found in an efficacy trial that a health promotion program prevented functional decline and reduced hospitalizations in community-dwelling older people with chronic conditions. We sought to evaluate the effectiveness of the program in its dissemination phase. DESIGN: Outcome evaluation using a within-group, pretest-posttest design. SETTING: Fourteen senior centers located throughout western Washington. PARTICIPANTS: Three hundred four community-dwelling men and women aged 65 and older. INTERVENTION: A disability-prevention, chronic disease-self-management program. MEASUREMENTS: Participant characteristics, risk factors for disability, change in health and functional status, and healthcare use over 1 year of enrollment; participant satisfaction. RESULTS: Participants were 71% female, had a mean age of 76, and reported three chronic health conditions on average. The percentage of participants found to be depressed decreased (28% at time of enrollment vs 17% at 1-year follow-up, P =.005). The percentage of physically inactive participants decreased (56% vs 38%, P =.001). Physical activity level and exercise readiness improved (Physician-based Assessment and Counseling for Exercise mean score 4.3 vs 5.1, P =.001). At follow-up, 83% rated their health the same as or better than a year ago, compared with 73% at time of enrollment. The proportion with impaired functional status, as measured by bed days and restricted activity days, stayed the same. The proportion hospitalized remained stable (23% at enrollment and follow-up, P = 1.0). CONCLUSIONS: Under real world conditions, the Health Enhancement Program reaches older people at risk of functional decline. Those enrolled for 1 year experience a reduction in disability risk factors, improvement in health status, no decrements in functional status, and no increase in self-reported healthcare use.

Activities of daily living function and disability in older adults in a randomized trial of the health enhancement program.

BACKGROUND: Disability in basic activities of daily living (ADLs) implies a loss of independence and increases the risk for hospitalization, nursing home admission, and death. Little is known about ways by which ADL disability can be prevented or reversed. The authors evaluated the efficacy of the Health Enhancement Program in preventing and reducing ADL disability in community-dwelling older adults. METHODS: The authors analyzed data from a 12-month, randomized, single-blinded, controlled trial of a disability prevention, chronic disease self-management program involving 201 adults aged 70 years and older that was conducted from February 1995 to June 1996 at a senior center in western Washington state. Activities of daily living disability incidence, improvement, and worsening were assessed using intention-to-treat methods. RESULTS: The cumulative incidence of ADL disability among those who were not ADL disabled at baseline (n = 56 in the intervention group, n = 57 in the control group) was modestly lower in the intervention group than in the control group at 12 months (14.3% vs 21.3%, p = .466). Cumulative improvement in ADL function among those who reported any ADL disability at baseline (n = 41 in the intervention group, n = 43 in the control group) was greater in the intervention group at 12 months (80.5% vs 46.5%, p = .026). The likelihood for ADL improvement was greater in the intervention group compared with controls at 12 months (adjusted hazard ratio, 1.84; 95% confidence interval, 1.05 to 3.22; p = .020). Cumulative worsening of ADL function was slightly lower in the intervention group at 12 months (18.6% vs 26.5%, p = .237). Intervention participants tended to be at lower risk for ADL worsening (adjusted hazard ratio, 0.71; 95% confidence interval, 0.38 to 1.30; p = .266) compared with control participants. CONCLUSION: The Health Enhancement Program intervention led to improved ADL functioning in those who were disabled initially and thereby offers a promising strategy for limiting or reversing functional decline in disabled elderly persons.

Community exercise program use and changes in healthcare costs for older adults.

BACKGROUND: Regular exercise is associated with many health benefits. Community-based exercise programs may increase exercise participation, but little is known about cost implications. METHOD: A retrospective, matched cohort study was conducted to determine if changes in healthcare costs for Medicare-eligible adults who choose to participate in a community-based exercise program were different from similar individuals who did not participate. Exercise program participants included 1114 adults aged > or = 65 years, who were continuously enrolled in Group Health Cooperative of Puget Sound (GHC) between October 1, 1997 and December 31, 2000 and who participated in the Lifetime Fitness (exercise) Program Copyright (LFP) at least once; three GHC enrollees who never attended LFP were randomly selected as controls for each participant by matching on age and gender. Cost and utilization estimates from GHC administrative data for the time from LFP enrollment to December 31, 2000 were compared using multivariable regression models. RESULTS: The average increase in annual total healthcare costs was less in participants compared to controls (+642 dollars vs +1175 dollars; p=0.05). After adjusting for differences in age, gender, enrollment date, comorbidity index, and pre-exposure cost and utilization levels, total healthcare costs for participants were 94.1% (95% confidence interval [CI], 85.6%-103.5%) of control costs. However, for participants who attended the exercise program at an average rate of > or = 1 visit weekly, total adjusted follow-up costs were 79.3% (95% CI, 71.3%-88.2%) of controls. CONCLUSIONS: Including a community exercise program as a health insurance benefit shows promise as a strategy for helping some Medicare-eligible adults to improve their health through exercise.