Sex differences in osteoporosis self-efficacy among community-residing older adults presenting for DXA.

The Osteoporosis Self Efficacy Scale was determined to equivalently measure calcium and exercise beliefs in both sexes. Despite data illustrating men's and women's similar self-efficacy, gender differences in clinical predictors of self-efficacy imply that efforts to improve care must account for more than self-efficacy. INTRODUCTION: To understand the extent to which the Osteoporosis Self Efficacy (OSE) Scale is reliable for both men and women. A secondary objective was to evaluate sex differences in OSE. METHODS: For this cross-sectional study, we analyzed data collected as part of the Patient Activation after DXA Result Notification (PAADRN) pragmatic trial which enrolled 7749 community-residing adults aged 50 and older reporting for bone densitometry. We used univariable methods, item analysis, exploratory and confirmatory factor analyses, and linear regression to evaluate sex differences in OSE responses and measurement. RESULTS: In this sample, the confirmatory factor analysis model for OSE both overall and within groups indicated a poor fit. The sex differences in the measurement model, however, were minor and reflected configural invariance (i.e., constructs were measuring the same things in both men and women), confirming that the OSE was measuring the same constructs in men and women. Men overall had higher exercise self-efficacy and women higher calcium self-efficacy. Overall, education, hip fracture, and self-reported health status predicted exercise self-efficacy whereas prior DXA, self-reported osteoporosis, and history of pharmacotherapy use did not. Predictors of calcium self-efficacy differed by gender. CONCLUSION: The OSE can be used to measure calcium and exercise self-efficacy in all older adults. However, gender differences in clinical predictors of self-efficacy and the lack of an association of prior DXA with self-efficacy imply that interventions to improve self-efficacy may be insufficient to drive significant improvement in rates of osteoporosis evaluation and treatment. TRIAL REGISTRATION: Patient Activation after DXA Result Notification (PAADRN), NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.

Validity, reliability, and responsiveness to change of the "Osteoporosis and You" knowledge scale.

We studied the Osteoporosis and You knowledge scale in 7749 participants enrolled in a clinical trial. Results confirmed its psychometric properties in a diverse audience. Baseline scores were associated with better recall of bone mineral density test results at follow-up; however, the scale was not responsive to knowledge change. INTRODUCTION: The goal of this study was to confirm the measurement properties of the Osteoporosis and You (O&Y) knowledge scale using classic test theory methods in the 7749 men and women participating in the Patient Activation After DXA Result Notification (PAADRN) randomized controlled trial. We hypothesized a simple factor structure that would reflect the four-factor model previously published. METHODS: We conducted psychometric analyses which included item analysis, internal consistency reliability, construct validity using exploratory and confirmatory factor analysis (EFA and CFA), comparing knowledge levels across pre-specified groups, and responsiveness to change. RESULTS: PAADRN participants were predominantly college educated, White females with low bone density, and a moderate level of 10-year fracture risk. EFA revealed four domains closely matching those in two previous reports. While overall scale reliability was minimally acceptable at 0.68, the reliabilities of the domain subscales were unacceptably low (0.59, 0.64, 0.45, and 0.36 for the Biological, Lifestyle, Consequences, and Prevention and Treatment subscales). CFA revealed the data fit the hypothesized model reasonably well with the items loading on their expected latent variable. The scale was not responsive to change, but although not significant, improved knowledge indicated better DXA result recall at 12 and 52 weeks. CONCLUSIONS: In the PAADRN population, the O&Y knowledge scale had psychometric properties similar to those previously reported. Over 12 and 52 weeks, participants did not demonstrate significant changes in knowledge, but those with higher knowledge at baseline were more likely to accurately recall their baseline DXA result.

The effects of a patient activation intervention on smoking and excessive drinking cessations: results from the PAADRN randomized controlled trial.

Patients may exhibit risky bone health behaviors. In a large pragmatic clinical trial, we tested whether a tailored patient activation DXA result letter accompanied by a bone health brochure led to smoking and excessive drinking cessations. The intervention did not, however, alter these risky bone health behaviors. INTRODUCTION: Besides dual-energy x-ray absorptiometry (DXA) screening and pharmacotherapy when indicated, beneficial bone health behaviors including proper calcium and vitamin D intake and weight-bearing and muscle-strengthening exercise should be encouraged. Similarly, risky bone health behaviors like smoking and excessive drinking should be discouraged. We examined whether a direct-to-patient activation intervention led to smoking and excessive drinking cessations. METHODS: The Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial enrolled 7749 patients between February 2012 and August 2014. Interviews occurred at baseline and 12 and 52 weeks later. Intervention subjects were mailed an individually tailored DXA results letter accompanied by a bone health educational brochure 4 weeks post-DXA. Usual care subjects were not sent these materials. Smoking and excessive drinking were assessed by self-report at each interview. Intention-to-treat linear probability models were used. RESULTS: Mean age was 66.6 years, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Smoking was reported at baseline by 7.6% of the intervention group vs. 7.7% of the usual care group (p = 0.873). Excessive drinking was reported at baseline by 6.5% of the intervention group vs. 6.5% of the usual care group (p = 0.968). Intention-to-treat analyses indicated no significant differences between the intervention vs. usual care groups at either 12 or 52 weeks post-DXA (all p values ≥ 0.346). CONCLUSION: An individually tailored DXA result letter accompanied by an educational brochure did not lead to smoking or excessive drinking cessations in patients who received DXA. TRIAL REGISTRATION: clinicaltrials.gov identifier NCT01507662.

The cost of a patient activation intervention for achieving successful outcomes: results from the PAADRN randomized controlled trial.

In a large, pragmatic clinical trial, we calculated the costs of achieving four successful patient-centered outcomes using a tailored patient activation DXA result letter accompanied by a bone health brochure. The cost to achieve one successful outcome (e.g., a 0.5 standard deviation improvement in care satisfaction) ranged from $127.41 to $222.75. INTRODUCTION: Pragmatic randomized controlled trials (RCTs) should focus on patient-centered outcomes and report the costs for achieving those outcomes. We calculated per person incremental intervention costs, the number-needed-to-treat (NNT), and incremental per patient costs (cost per NNT) for four patient-centered outcomes in a direct-to-patient bone healthcare intervention. METHODS: The Patient Activation after DXA Result Notification (PAADRN) pragmatic RCT enrolled 7749 patients presenting for DXA at three health centers between February 2012 and August 2014. Interviews occurred at baseline and 52 weeks post-DXA. Intervention subjects received an individually tailored DXA result letter accompanied by an educational bone health brochure 4 weeks post-DXA, while the usual care subjects did not. Outcomes focused on patients (a) correctly identifying their results, (b) contacting their providers, (c) discussing their results with their providers, and (d) satisfaction with their bone healthcare. NNTs were determined using intention-to-treat linear probability models, per person incremental intervention costs were calculated, and costs per NNT were computed. RESULTS: Mean age was 66.6 years old, 83.8% were women, and 75.3% were non-Hispanic whites. The incremental per patient cost (costs per NNT) to increase the ability of a patient to (a) correctly identify their DXA result was $171.07; (b) contact their provider about their DXA result was $222.75; (c) discuss their DXA result with their provider was $193.55; and (d) achieve a 0.5 SD improvement in satisfaction with their bone healthcare was $127.41. CONCLUSION: An individually tailored DXA result letter accompanied by an educational brochure can improve four patient-centered outcomes at a modest cost. TRIAL REGISTRATION: clinicaltrials.gov identifier NCT01507662.

Predictors of bone mineral density testing among older women on Medicare.

Although dual-energy X-ray absorptiometry (DXA) is recommended for all women ≥65 and is covered by Medicare, 40 % of women on Medicare report never having had a DXA. In a longitudinal cohort of 3492 women followed for two decades, we identified several risk factors that should be targeted to improve DXA testing rates. INTRODUCTION: DXA is used to measure bone mineral density, screen for osteoporosis, and assess fracture risk. DXA is recommended for all women ≥65 years old. Although Medicare covers DXA every 24 months for women, about 40 % report never having had a DXA test, and little is known from prospective cohort studies about which subgroups of women have low use rates and should be targeted for interventions. Our objective was to identify predictors of DXA use in a nationally representative cohort of women on Medicare. METHODS: We used baseline and biennial follow-up survey data (1993-2012) for 3492 women ≥70 years old from the nationally representative closed cohort known as the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The survey data for these women were then linked to their Medicare claims (1991-2012), yielding 17,345 person years of observation. DXA tests were identified from the Medicare claims, and Cox proportional hazard regression models were used with both fixed and time-dependent predictors from the survey interviews including demographic characteristics, socioeconomic factors, health status, health habits, and the living environment. RESULTS: DXA use was positively associated with being Hispanic American, better cognition, higher income, having arthritis, using other preventative services, and living in Florida or other southern states. DXA use was negatively associated with age, being African-American, being overweight or obese, having mobility limitations, and smoking. CONCLUSIONS: Interventions to increase DXA use should target the characteristics that were observed here to be negatively associated with such screening.

Patient-activation and guideline-concordant pharmacological treatment after bone density testing: the PAADRN randomized controlled trial.

Patients often do not know or understand their bone density test results, and pharmacological treatment rates are low. In a clinical trial of 7749 patients, we used a tailored patient-activation result letter accompanied by a bone health brochure to improve appropriate pharmacological treatment. Treatment rates, however, did not improve. INTRODUCTION: Patients often do not know or understand their dual-energy x-ray absorptiometry (DXA) test results, which may lead to suboptimal care. We tested whether usual care augmented by a tailored patient-activation DXA result letter accompanied by an educational brochure would improve guideline-concordant pharmacological treatment compared to usual care only. METHODS: We conducted a randomized, controlled, double-blinded, pragmatic clinical trial at three health care centers in the USA. We randomized 7749 patients ≥50 years old and presenting for DXA between February 2012 and August 2014. The primary clinical endpoint at 12 and 52 weeks post-DXA was receiving guideline-concordant pharmacological treatment. We also examined four of the steps along the pathway from DXA testing to that clinical endpoint, including (1) receiving and (2) understanding their DXA results and (3) having subsequent contact with their provider and (4) discussing their results and options. RESULTS: Mean age was 66.6 years, 83.8 % were women, and 75.3 % were non-Hispanic whites. Intention-to-treat analyses revealed that guideline-concordant pharmacological treatment was not improved at either 12 weeks (65.1 vs. 64.3 %, p = 0.506) or 52 weeks (65.2 vs. 63.8 %, p = 0.250) post-DXA, even though patients in the intervention group were more likely (all p < 0.001) to recall receiving their DXA results letter at 12 weeks, correctly identify their results at 12 and 52 weeks, have contact with their provider at 52 weeks, and have discussed their results with their provider at 12 and 52 weeks. CONCLUSION: A tailored DXA result letter and educational brochure failed to improve guideline-concordant care in patients who received DXA.

Personal, financial, and structural barriers to immunization in socioeconomically disadvantaged urban children.

OBJECTIVE: To evaluate personal, financial, and structural barriers to vaccination in socioeconomically disadvantaged urban children in the first 2 years of life. DESIGN: Prospective cohort study. SETTING: A large municipal teaching hospital in the Midwest. PARTICIPANTS: Healthy term newborns discharged to the care of their mothers. Mothers were interviewed 24 to 72 hours postpartum regarding personal and financial barriers, and 2 years later regarding personal, financial, and structural barriers to care. MAIN OUTCOME MEASURE: Vaccination status at age 2 years. RESULTS: Of 399 children with documented vaccination status, 47% had not received all recommended vaccinations by 2 years of age. After adjusting for mother's age, race, and education, mothers who were unmarried (adjusted odds ratio [AOR] 1.74; 95% confidence interval [CI]: 1.05, 2.90), multiparous (AOR 2.10; 95% CI: 1.26, 3.52), not coresident with the child's grandmother (AOR 1.75; 95% CI: 1.01, 3.03), had not received adequate prenatal care (AOR 1.78; 95% CI: 1.12, 2.84), or lived in poverty (AOR 2.62; 95% CI: 1.44, 4.75) were more likely to have undervaccinated children, as were mothers who perceived less satisfaction with their child's health care (AOR 1.63; 95% CI: 1.01, 2.61), less control over their lives (AOR 2.01; 95% CI: 1.03, 3.94), or more benefit of medical care to prevent vaccine-related diseases (AOR 1.76; 95% CI: 1.25, 2.48). CONCLUSIONS: Family environment, a mother's history of prenatal care use, and financial barriers are important factors related to vaccination receipt among socioeconomically disadvantaged children at age 2 years. These factors, however, do not fully explain the variation in vaccination status.

Further evidence supporting an SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life.

This study used the standard error of measurement (SEM) to evaluate intra-individual change on both the Chronic Respiratory Disease Questionnaire (CRQ) and the SF-36. After analyzing the reliability and validity of both instruments at baseline among 471 COPD outpatients, the SEM was compared to established minimal clinically important difference (MCID) standards for three CRQ dimensions. A value of one SEM closely approximated the MCID standards for all CRQ dimensions. This SEM-based criterion was then validated by cross-classifying the change status (improved, stable, or declined) of 393 follow-up outpatients using the one-SEM criterion and the MCID standard. Excellent agreement was achieved for all three CRQ dimensions. Although MCID standards have not been established for the SF-36, the one-SEM criterion was explored in these change scores. Among SF-36 scales demonstrating acceptable reliability and reasonable variance, the percent of individuals within each change category was consistent with those seen in the CRQ dimensions. These results replicate previous findings where a value of one SEM also closely approximated MCIDs for all dimensions of the Chronic Heart Disease Questionnaire among cardiovascular outpatients. The one-SEM criterion should be explored in other health-related quality of life instruments with established MCIDs.

Gender differences in the sequelae of hospitalization for acute myocardial infarction among older adults.

OBJECTIVE: To examine the effect of gender differences among older adults hospitalized for an acute myocardial infarction (AMI) on subsequent health outcomes. DESIGN: Secondary analysis of the Longitudinal Study on Aging. Data from baseline interviews (1984) and three biennial (1986, 1988, and 1990) re-interviews were linked to Medicare hospitalization and National Death Index records for 1984-1991. PARTICIPANTS: A total of 6071 community-dwelling adults aged 70 years or older at baseline. METHODS: Pooled and stratified multivariable models were used to examine gender differences in the independent effects of being hospitalized for an AMI on all-cause mortality, the risk and volume of subsequent hospitalization, and increases in the number of functional limitations. Two comparison groups were used. RESULTS: Three hundred fifty-seven AMI cases (6%; 172 women and 185 men) were compared with 3976 hospitalized controls and 1738 nonhospitalized controls. The risk of all-cause mortality for AMI cases was greater than that for either hospitalized controls or nonhospitalized controls (referent), and this increased risk was significantly (P < .001) stronger for women (adjusted hazards ratio (AHR) = 14.24, 95%CI = 10.99, 18.46) than for men (AHR = 9.91, 95%CI = 7.75, 12.67). Overall, AMI cases were also more likely to be hospitalized subsequently than the hospitalized controls (referent; adjusted odds ratio (AOR) = 1.47, 95%CI = 1.17, 1.85), although in the stratified analysis this association held for men (AOR = 1.73, 95%CI = 1.25, 2.41) but not for women (AOR = 1.25, 95%CI = .90, 1.73). Among those subsequently hospitalized, both women and men AMI cases consumed more hospital resources than the hospitalized controls, and there were gender differences suggesting that the effects on total charges and length of stay were greater for women than for men with AMI. Finally, although the AMI cases had greater adjusted mean increases in the number of instrumental activities of daily living limitations and lower body limitations than the nonhospitalized controls, they were no worse off than the hospitalized controls, and there were no gender differences in those effects. CONCLUSION: Relative to the appropriate comparison groups, hospitalization for an AMI increases the risk of death and the total costs and lengths of stay of subsequent hospitalizations for women more than for men. Therefore, increased primary prevention, diagnosis, and treatment efforts should be directed toward women.

The sequelae of hospitalization for congestive heart failure among older adults.

OBJECTIVES: To estimate the independent effect of hospitalization for congestive heart failure (CHF) on subsequent mortality, readmission for CHF, rehospitalization for any reason, and change in functional status. DESIGN: Secondary analysis of the nationally representative Longitudinal Study on Aging, Baseline (1984) interview data are linked to Medicare hospitalization and death records for 1984-1991 and to functional status reports at three biennial follow-ups. SETTING: In-home and telephone interviews. PARTICIPANTS: a total of 7527 noninstitutionalized older adults aged 70 years or older at baseline. MEASUREMENTS: Hospitalization for CHF was defined as having one or more episodes with primary or secondary discharge ICD9-CM codes of 428. Multivariable proportional hazards, logistic and linear regression, as well as multiple classification analysis, were used to estimate the independent effects of having been hospitalized for CHF. RESULTS: The adjusted risk ratios for having a primary or secondary hospital discharge diagnosis of CHF on mortality (compared with not having any CHF hospital discharge diagnoses) were 1.58 (CI95% = 1.40 to 1.78) and 1.29 (CI95% = 1.15 to 1.45), respectively (P < .001). CHF readmission and rehospitalization rates were substantial, ranging from 16.0 to 47.5% at 1 year, depending on the criteria employed. The adjusted odds ratios for having any subsequent hospitalizations associated with having a primary or secondary hospital discharge diagnosis of CHF (compared with not having any CHF hospital discharge diagnoses) were 7.70 (CI95% = 6.20 to 9.57) and 2.99 (CI95% = 2.51 to 3.56), respectively (P < .001). The percent increases in the number of hospital episodes, total charges, and total length of stay attributable to having been hospitalized for CHF were significant (P < .001) and ranged from 15.5 to 66.7%. Having been hospitalized for CHF was also related significantly to greater increases in the mean number of functional limitations at follow-up. CONCLUSION: Hospitalization for CHF among older adults increases substantially the risk of subsequent mortality, readmission for CHF, rehospitalization for any reason, and greater functional decline. Therefore, greater attention to the prevention and management of CHF is needed.

The sequelae of hospitalization for ischemic stroke among older adults.

OBJECTIVES: To estimate the independent effect of hospitalization for ischemic stroke on change in functional status, subsequent hospitalization, and mortality. DESIGN: Secondary analysis of the nationally representative Longitudinal Study on Aging. Baseline (1984) interview data were linked to Medicare hospitalization and death records for 1984-1991 and to functional status reports at three biennial follow-ups. SETTING: In-person and telephone interviews were conducted. PARTICIPANTS: A total of 6071 noninstitutionalized respondents 70 years old or older at baseline. MEASUREMENTS: Hospitalization for ischemic stroke was defined as having one or more episodes with primary discharge ICD9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Two reference groups were used: those who were hospitalized for something other than stroke, and those who were not hospitalized at all. The statistical methods employed were multivariable proportional hazards, logistic, and linear regression. RESULTS: The adjusted hazards ratio for having a primary hospital discharge diagnosis of ischemic stroke on mortality was 7.57 (CI95% = 6.47 to 8.85) versus 3.67 (CI95% = 3.28 to 4.10) for having been hospitalized for something other than stroke (both compared with the reference category of those not hospitalized at all). The adjusted odds ratio for having any subsequent hospitalization associated with having a primary hospital discharge diagnosis of ischemic stroke (compared with having been hospitalized for something other than stroke) was not significantly elevated (AOR = 1.16; CI95% = .94 to 1.42). However, the percent increases in the subsequent number of hospital episodes, total charges, and total length of stay for those who were hospitalized for ischemic stroke relative to those hospitalized for something other than stroke were significant (P < .001), and ranged from 16.3 to 39.0%. Hospitalization for ischemic stroke was also related significantly to greater increases in the regression-adjusted mean number of instrumental activities of daily living and lower body function limitations at follow-up. CONCLUSION: Hospitalization for ischemic stroke among older adults substantially increases the risk of subsequent mortality, the volume of hospital resource consumption, and greater functional decline, even when compared with hospitalization for something other than stroke. Therefore, greater attention to the prevention and management of ischemic stroke is needed.

Physical activity, disability, and the risk of hospitalization for breast cancer among older women.

BACKGROUND: A recent investigation of physical activity, disability, and the risk of breast cancer among older women in the Iowa 65 + Rural Health Study reported a decreased risk of breast cancer among women with any disability compared with physically capable but inactive women (relative risk [RR] = 0.4. 95% confidence interval [CI] 0.2-0.9). Because of the intriguing nature of that association, those investigators urged replication before drawing any conclusions. METHODS: We replicated the Iowa approach using the Longitudinal Study on Aging (LSOA). a nationally representative, prospective cohort study. The 3131 community-dwelling women for whom we had complete data for these analyses ranged in age from 70 to 98 years old at baseline in 1984. Using ICD9-CM 174 codes, linked Medicare hospital claims identified 77 women with hospitalizations for breast cancer between 1984 and 1991. Multivariable proportional hazards regression was used to model the risk for this event among disabled, inactive, moderately active, and highly active women. RESULTS: No significant association between disability in older women and the risk of hospitalization for breast cancer relative to inactive older women was detected (adjusted hazard ratio [AHR]-0.78, 95% CI 0.41-1.5). Highly active older women had a significantly reduced risk of hospitalization for breast cancer (AHR-0.42, 95% CI 0.194).95). CONCLUSION: The intriguing finding from the Iowa 65+ Rural Health Study that disabled older women's risk for breast cancer was reduced could not be replicated in the LSOA, although power was limited. Highly active older women, however, had a significantly lower risk for breast cancer in both studies.

Hospitalization for pneumonia among older adults.

BACKGROUND: Hospitalizations and mortality due to pneumonia increase steadily with age. The purpose of this study is to describe the frequency, costs, and risk factors for hospitalization for pneumonia among older adults with particular attention to the effect of functional disability. METHODS: The Longitudinal Study of Aging (LSOA) is the follow-up to the Supplement on Aging, which was appended to the 1984 National Health Interview Survey. Participants included a nationally representative sample of 7,527 community-dwelling adults aged 70 and older in 1984 who were followed prospectively for 8 years. The LSOA data are linked to the National Death Index and to yearly abstracts from the Medicare Automated Data Retrieval System (1984-1991). RESULTS: From 1984 to 1991, 617 subjects (8.2%) had at least one hospitalization for pneumonia, 4,333 (57.5%) had at least one hospitalization for any reason, and 2,867 (38.1%) of the LSOA subjects died. The yearly frequency of hospitalization for pneumonia increased over time from 0.6% in 1984 to 2.4% in 1991. The median length of stay was 8 days, and the median hospital charge was $5,100. Over 8 years, median discounted charges for a pneumonia hospitalization increased 75% while length of stay remained relatively constant. Patients hospitalized for pneumonia had greater comorbidity, total hospital resource use, and mortality, but over 80% survived their first hospitalization for pneumonia. Hospitalization for pneumonia was associated with age, male gender, malnutrition, history of hip fracture, prior hospitalizations, and lower body limitations. CONCLUSIONS: Hospitalization for pneumonia was frequent and accounted for 6% of the Medicare expenditures over 8 years among this cohort of older adults. Hospitalization for pneumonia occurred most often among subjects with prior evidence of failing health, but most subjects survived the first hospitalization for pneumonia. Even controlling for comorbidity, prior hospitalizations, and functional impairment, hospitalization for pneumonia was independently associated with age.

Hospitalization for major depression among older Americans.

BACKGROUND: The objective of this study was to report the pattern of hospitalization for major depression among older Americans and to examine correlates of those hospitalizations. We sought to investigate the hypothesis that hospitalization for major depression would be more common among those respondents with declining functional status whose ability to adapt to this decline was impaired by inadequate social support systems or economic stressors. METHODS: The data were taken from Version 5 of the Longitudinal Study on Aging (LSOA), which includes 7,527 subjects who were aged 70 and older in 1984. We identified all subjects with any hospitalizations for which major depression was a discharge diagnosis (ICD9-CM codes 296.2, 296.3, 300.4, and 311), and all subjects for whom depression was the primary discharge diagnosis. Only patients with a first-listed discharge diagnosis of depression were considered to have been hospitalized for major depression. RESULTS: The yearly incidence of hospitalization for which depression was the primary discharge diagnosis was 0.1%. The mean length of stay was 14.6 days and the mean hospital charge was $6,742. Length of stay and charges did not vary by hospital type (general vs psychiatric), but both charges and length of stay were significantly longer when major depression was the primary discharge diagnosis rather than a secondary diagnosis. Patients with a hospitalization for major depression had more hospitalizations, longer total lengths of stay, and greater total hospital charges over the seven-year period as compared to patients with at least one hospitalization for any other reason. These differences in hospital resource use dissipated when hospitalizations for depression were excluded. Hospitalization for major depression was not associated with gender, race, education, or social support. Hospitalization for major depression was independently associated with a forced residential move, a history of nursing home stays, decline in household activities of daily living, younger age, and perceived health rated as less than excellent. CONCLUSIONS: One older American per thousand is hospitalized each year with a primary discharge diagnosis of major depression. These individuals did not have evidence of greater total hospital resource use if episodes of hospitalization for depression are eliminated. Hospitalization for major depression was more common among those with a loss of independent living.

Prevalence and impact of risk factors for lower body difficulty among Mexican Americans, African Americans, and whites.

BACKGROUND: The purpose of the study was to estimate the prevalence of sociodemographic, health behavior, chronic disease, and impairment factors and their impact on difficulty in lower body function among two age-cohorts (51-61 and 71-81 years) of Mexican Americans, African Americans, and Whites. METHODS: Reports from 8,727 and 4,510 self-respondents of the 1992 baseline Health and Retirement Survey and the 1993 baseline Assets and Health Dynamics Study, respectively, were used to estimate prevalence. Multiple linear regression of the 4-item lower body difficulty scale (alpha = .80) was used to estimate the direct effects of the risk factors within the age-cohort and ethnicity groups. RESULTS: Overall, the risk factors are more prevalent among both minority groups and the older age-cohort. Lower body deficits are particularly high among Mexican Americans and the younger age-cohort of African Americans. The impact of risk factors does not vary much by ethnicity or age-cohort. Female gender, pain, arthritis, and heart and lung disease are the major risk factors, and they account for about one-third of the variance in lower body difficulty for each group. CONCLUSIONS: Efforts to prevent or reduce lower body difficulty should pay particular attention to pain, arthritis, and heart and lung disease. The central role of sociodemographic and behavioral factors in chronic disease argues for their continued inclusion in disability modeling and prevention.

The risk of hospitalization for acute myocardial infarction among older adults.

BACKGROUND: The purpose of this study was to prospectively examine the risk of hospitalization for acute myocardial infarction (AMI) in a large, nationally representative sample of very old men and women. METHODS: We utilized secondary analysis of the Longitudinal Study of Aging. Baseline (1984) in-person interview data were linked to Medicare hospitalization records for 1984-1991. Subjects were 6,071 noninstitutionalized adults 70 years old or older at baseline. Hospitalization for AMI was defined as having primary discharge diagnoses containing ICD9-CM 410 codes. Multivariable proportional hazards regression was used to evaluate the epidemiologic risks for all persons, and separately for women, men, self-respondents, those with no previous AMIs, and those with no history of coronary heart disease. RESULTS: Of the sample, 357 persons (5.9%; 172 women and 185 men) had at least one primary discharge diagnosis of AMI. Significant (p<.05) risk factors for being hospitalized with an AMI (adjusted hazards ratios in parentheses) from the pooled analysis were male gender (1.86), having no more than a grade school education (1.35), atherosclerosis (1.43), hypertension (1.29), coronary heart disease (1.63), angina (1.60), previous AMI (1.52), diabetes (1.89), and four or more lower body limitations (1.43). The gender-specific analyses, however, revealed that hypertension, angina, diabetes, and lower body limitations were risk factors only for women, and that having no more than a grade school education was a risk factor only for men. CONCLUSION: Men, especially those with low education, women with diabetes, angina, hypertension, or lower body limitations, and either men or women with previous AMIs, coronary heart disease, or atherosclerosis have elevated risks for AMI resulting in hospitalization, and they should be considered for evaluation and monitoring. Current protocols for therapeutic management should be adopted, and compliance should be encouraged.

Prenatal health behaviors as predictors of breast-feeding, injury, and vaccination.

OBJECTIVE: To identify maternal prenatal preventive health behaviors associated with breast-feeding, early childhood injuries, and vaccination. DESIGN: Secondary analysis of the 1988 National Maternal and Infant Health Survey. SETTING: Questionnaires were mailed to the mother's home. PATIENTS: The response rate to this nationally representative sample was 71%. These analyses include the 10,868 mothers whose infants had ever been at home. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Multivariable logistic regression was used to predict the following: (1) having "ever" breast-fed; (2) having breast-fed for at least 6 weeks; (3) "an accident or bad fall" during any of the first 6 months of the child's life ("early" injury) or (4) in the month prior to the interview ("recent" injury); (5) having received "any" vaccinations or (6) having received three diphtheria, pertussis, tetanus immunizations. RESULTS: Children of mothers who reduced alcohol consumption during the pregnancy, had higher incomes, and were white had the best preventive health outcomes. Adequacy of prenatal care was predictive of vaccination, but not of breast-feeding or injury. CONCLUSIONS: These data suggest that prenatal sociodemographic characteristics and maternal health behaviors have significant and continued effects on the preventive health outcomes of infants and children.

A preliminary validation of a nutritional risk measure for the elderly.

We used data from a two-stage random sample of 401 noninstitutionalized elderly individuals residing in 18 census tracts in south-central metropolitan St. Louis to establish the reliability and validity of a 16-item nutritional risk measure. Reliability analysis yielded a Cronbach's alpha of 0.603. Concurrent predictive validity was demonstrated by the prediction of physician, emergency room, and hospital use. Individuals with high scores displayed a consistent pattern of higher rates of known nutrition-related problems and their sequelae than did those with low scores, providing evidence of known groups validity. Statistical correlations with components of an established theoretical model of the elderly's health and illness behavior demonstrate preliminary support for construct validity. The advantages of our nutritional risk measure include its ease of administration and telephone portability.

Why physicians choose different types of practice settings.

This paper presents an extension of Freidson's typology concerning the four medical practice settings which physicians may enter. First, Freidson's typology is modified to contain only three medical practice settings: 1) solo practices; 2) small group practices (partnerships or associations consisting of two to seven physicians); and, 3) large group practices (having eight or more physicians). Then, it is argued that the most interesting sociological difference between these three medical practice settings is the differential probability for effective peer regulation, with that probability lowest in solo practices, highest in large group practices, and lying somewhere between these extremes in small group practices. Finally, it is argued that because physicians recognize these differential probabilities for peer regulation, they seek out those niches (i.e., medical practice settings) which most closely reflect their preferences. This extended version of Freidsonian theory is then incorporated into an analytic model using the sociodemographic, environmental, and attitudinal characteristics of physicians to predict their practice choices. Data from a 1979 national survey of approximately 4,500 physicians are used to assess the model empirically. The results obtained from these analyses conform quite well with both our general and specific expectations. The implications of these findings for the future configuration of the American health care delivery system are discussed with special reference to health maintenance organizations.

Further assessment of the reliability and validity of a Nutritional Risk Index: analysis of a three-wave panel study of elderly adults.

This paper reports on the further assessment of the reliability and validity of a short (16-item), portable method for assessing nutritional risk which is easily administered in the typical social survey setting. Data were obtained from a three-wave panel study of 401 randomly selected, noninstitutionalized elderly persons (age 65 and over) in St. Louis. Reliability was assessed by both internal consistency and test-retest methods. Reliability coefficients (internal consistency) of .603, .544, and .515 were obtained at T-1, T-2, and T-3, respectively. Cross-panel intercorrelations (test-retest) ranged between .67 and .71. Validity was assessed using factor analysis and various outcome measure comparisons for those at risk versus those not at risk. A five-factor orthogonally rotated solution explained 47.9 percent of the variance in the 16 items. Individuals with higher risk scores had significantly poorer health as measured by other standard indexes, and used significantly more health services than those with lower risk scores. These results underscore the potential of the Nutritional Risk Index (NRI) as a screening device for use among the elderly.