Association of medication attitudes with non-persistence and non-compliance with medication to prevent fractures.

UNLABELLED: Our objective was to assess the association of self-reported non-persistence (stopping fracture-prevention medication for more than 1 month) and self-reported non-compliance (missing doses of prescribed medication) with perceived need for fracture-prevention medication, concerns regarding long-term harm from and/or dependence upon medications, and medication-use self-efficacy (confidence in one's ability to successfully take medication in the context of their daily life). INTRODUCTION: Non-persistence (stopping medication prematurely) and non-compliance (not taking medications at the prescribed times) with oral medications to prevent osteoporotic fractures is widespread and attenuates their fracture reduction benefit. METHODS: Cross-sectional survey and medical record review of 729 patients at a large multispecialty clinic in the United States prescribed an oral bisphosphonate between January 1, 2006 and March 31, 2007. RESULTS: Low perceived necessity for fracture-prevention medication was strongly associated with non-persistence independent of other predictors, but not with non-compliance. Concerns about medications were associated with non-persistence, but not with non-compliance. Low medication-use self-efficacy was associated with non-persistence and non-compliance. CONCLUSIONS: Non-persistence and non-compliance with oral bisphosphonate medication have different, albeit overlapping, sets of predictors. Low perceived necessity of fracture-prevention medication, high concerns about long-term safety of and dependence upon medication , and low medication-use self-efficacy all predict non-persistence with oral bisphosphonates, whereas low medication-use self-efficacy strongly predicts non-compliance with oral bisphosphonate medication. Assessment of and influence of these medication attitudes among patients at high risk of fracture are likely necessary to achieve better persistence and compliance with fracture-prevention therapies.

Care of the aged: old problems in need of new solutions.

Long-term care for the aged in the United States is overly dependent upon the nursing home. This hospital-like model for long-term care is particularly inappropriate since it imposes a medical solution on a variety of social problems. An adequate long-term care program requires a range of resources in the community as well as in institutions; sheltered housing options seem a desirable alternative to the nursing home. To ensure the quality of nursing home care, the present focus on setting standards for care activities should be abandoned in favor of a focus on care outcomes (physical, mental, and social). In an effort to change our present perverse incentives in the nursing home industry, the proposal is made that nursing homes be reimbursed according to the degree to which patient outcomes meet predicted outcomes.

The mentally ill in nursing homes. New back wards in the community.

The reduction in state hospital populations in the last two decades is most often attributed to psychotropic medication and community mental health centers. The role the proprietary nursing home has played in this reduction has not been adequately studied. Using data routinely collected for Medicaid utilization review, we studied characteristics of psychiatric nursing home patients in Utah. One third of the nursing home patients had a psychiatric diagnosis; more than half of this group were classified as psychotic. Most psychotic patients were significantly younger than their nonpsychiatric counterparts. Nonpsychiatric patients received a higher mean number of psychoactive drugs than did psychiatric or mentally retarded patients. Over time, all groups of patients showed an increase in prescribed psychoactive medication and a decrease in activity. The consequence of this pattern of care raise serious questions about our current reliance on nursing homes for the care of the psychiatric patient.

Relationship between persistence of abdominal symptoms and successful outcome after cholecystectomy.

BACKGROUND: Patients frequently have persistent abdominal symptoms after undergoing cholecystectomy. The relationship between abdominal symptoms and biliary dysfunction is often unclear. OBJECTIVES: To describe the persistence rate of abdominal symptoms in a large cohort of patients after elective cholecystectomy, to identify predictors of symptom persistence and operative success, to understand which symptoms improve after cholecystectomy, and to describe the important determinants of an unsuccessful operation. METHODS: Secondary analysis of a prospective, multisite cohort study of 2481 patients undergoing elective cholecystectomy. RESULTS: The mean +/- SD number of abdominal symptoms per patient decreased from 3.1 +/- 2.0 to 1.1 +/- 1.3; 27% of patients who identified a symptom as most bothersome before surgery still had the symptom 6 months after surgery. Symptom persistence rates ranged from 5.6% (vomiting) to 40.2% (gas/flatulence). A balance score that quantified the abdominal symptom mix between dyspeptic and biliary symptoms shifted after surgery to the dyspeptic category. Predictors of persistence of a most bothersome symptom were dyspeptic symptom category, worse operative risk and self-rated health status, symptom duration longer than 6 months, and no previous episodes of acute cholecystitis. The major correlate of not achieving a very successful outcome (15.2% of patients) was the presence of postoperative abdominal pain. Other predictors included worse self-rated health status and physical functioning, symptom duration longer than 6 months before surgery, and no previous episodes of acute cholecystitis. CONCLUSIONS: Symptoms categorized as dyspeptic were more likely to persist than were biliary symptoms, although all symptoms showed a decrease in prevalence after cholecystectomy. More attention to the rationale for gallbladder removal and clarification of patient expectations for symptom relief might be necessary to improve outcomes after elective cholecystectomy.

Differential drawing size associated with unilateral brain damage.

Size of Greek Cross reproductions was compared using 35 persons having unilateral right (RHD), 35 having unilateral left (LHD) hemisphere damage and 38 non-neurologic controls. With right hand tapping speed statistically controlled, RHD drawings were significantly larger than LHD reproductions. Spatial Relations scores were significantly associated with drawing size in the RHD group only, following adjustment for right hand tapping speed. Aphasia Screening scores were unrelated to drawing size. These data demonstrate that LHD/RHD drawing size differences are independent of any basic motor impairment and that for RHD subjects, drawing size is positively correlated with visuospatial impairment.

Diurnal cycles of salivary cortisol in older adults.

Cortisol has a well-documented circadian pattern. However, recent studies have demonstrated that individual variation in diurnal cortisol patterns occurs in young adult populations. Since older adults experience altered sleep-wake cycles and changes in circadian rhythmicity, we may see even greater variations in diurnal cortisol patterns in older adults. This study examined salivary cortisol patterns in 48 community dwelling older adults. Participants (mean age 76+/-6) collected saliva every 2 h over a three-day period. Cortisol was assayed by using RIA. Cortisol cycles were defined as inconsistent, typical or flat based on the slopes of two sequential daily cortisol patterns. Demographic, physical, psychological and behavioral measures were tested for group differences using t-tests and chi-square analyses. Forty-eight percent of the sample had inconsistent cycles, 50% had typical cycles and 2% had flat cycles. This sample had a higher percentage of inconsistent cycles and fewer flat cycles than reported for young adults (p=0.008) (Psychoneuroendocrinology 22 (1997) 89). Those with inconsistent cycles were younger and reported higher caffeine and food intake than those with typical cycles. This study demonstrates that normal diurnal rhythms of cortisol can be maintained in older adults, while day-to-day variation may increase.

Scaling the heights of quality of life.

Measuring always involves abstracting reality. Measuring an abstraction like quality of life is a daunting task. Numerous conceptual and methodological issues must be addressed, but the challenges should not deter the journey.

Methodology for measuring health-state preferences--III: Population and context effects.

In addition to the scaling method, there are many other aspects of the measurement process that may affect rater judgments of the relative desirability of health states. Although we find little compelling evidence of population differences in preferences due to demographic characteristics, there is some evidence suggesting that medical knowledge and/or experience with illness may influence raters' valuations of health states. Other aspects of the rating process that affect rater judgments can be classified as one of two types: inconsistencies due to limitations in human judgment, and inconsistencies due to situation-specific variables. When inconsistencies are due to limitations in human judgment, such as framing effects, a reasonable solution is to help the rater to see and correct the inconsistency. When inconsistencies are due to situation-specific variables, such as the way the health state is defined and presented, investigators should attempt to standardize conditions across studies.

Methodology for measuring health-state preferences--I: Measurement strategies.

Values play a critical part in decision making at both the individual and policy levels. Numerous methodologies for determining the preferences of individuals and groups have been proposed, but agreement has not been reached regarding their scientific adequacy and feasibility. This is the first of a four-part series of papers that analyzes and critiques the state-of-the-art in measuring preferences, particularly the measurement of health-state preferences. In this first paper we discuss the selection of relevant attributes to comprise the health-state descriptions, and the relative merits of three measurement strategies: holistic, explicitly decomposed, and statistically inferred decomposed. The functional measurement approach, a statistically inferred decomposed strategy, is recommended because it simultaneously validates the process by which judges combine attributes, the scale values they assign to health states, and the interval property of the scale.

Methodology for measuring health-state preferences--II: Scaling methods.

This paper begins with a discussion of measurement principles relevant to determining health-state preferences. Six scaling methods are described and evaluated on the basis of their reliability, validity, and feasibility. They are the standard gamble, time trade-off, rating scale, magnitude estimation, equivalence, and willingness-to-pay methods. Reliability coefficients for most methods are acceptable although the low coefficients for measurements taken a year apart suggest that preferences change over time. Convergent validity among methods has been supported in some but not all studies, and there are limited data supporting hypothetical relationships between preferences and other variables. The category ratings method is easiest to administer and appears to yield valid scale values; thus, it is recommended for large-sample studies. However, decision-oriented methods, particularly the time trade-off and standard gamble, may be more effective in small-scale investigations and individual decision making.

Methodology for measuring health-state preferences--IV: Progress and a research agenda.

Remaining questions relative to the measurement of health-state preferences are outlined and applications discussed. We recommend more widespread use of functional measurement to better understand preference structures. Further research should be conducted on the reliability and validity of preference values produced by different scaling methods, including careful examination of the content validity of health-state descriptions. Construct validation studies using the multitrait-multimethod matrix would be useful as well as comparisons of stated preferences with revealed preferences. Despite the many unanswered measurement questions, preference values are currently being used in decision making at both the individual and societal levels. Several global health status measures incorporate preference values, and preferences are increasingly being used in cost-effectiveness studies. If preferences are to be used effectively, research on their measurement must accelerate to keep pace with the urgency for application.

Effects of using consumer and expert ratings of an activities of daily living scale on predicting functional outcomes of postacute care.

To test the effects of using preference weights for activities of daily living (ADL) outcome measures derived from different sources, data from a large study of the outcomes of postacute care (PAC study) were analyzed using two different weightings for the ADL measures. Both were developed using the same magnitude estimation technique; one from a panel of long-term care experts (the expert rating system); the other from a group of elderly Medicare beneficiaries (the consumer rating system). Neither group was directly involved in the PAC study. Although ADL scores generated by both rating systems were highly correlated prior to hospitalization and at hospital discharge, the consumer and expert rating systems generated significantly different functional outcomes measured by the change of ADL scores with a few exceptions. Compared to the consumer rating system, the expert rating system generated a greater change in functional outcomes at each of three follow-up time points after hospital discharge. This study suggests that the choice of weights for ADL items is important.

Forecasting the number of future disabled elderly using Markovian and mathematical models.

The accuracy of forecasting the number of future disabled elderly people depends on the accuracy of projecting mortality rates and the rates of transition to and from functional disability. We describe a new two-step method for constructing mathematical models that project these future rates dynamically. (1) A Markovian model of elders' transitions between functional states is specified. (2) A mathematical model of the probability of each transition is created. We conducted pilot studies of the fundamental mathematical processes of this method using data from the Longitudinal Study of Aging. First we constructed prototypic mathematical models of the probabilities of remaining functionally able and of making transitions to disability and to death within 2 years. Then we used these models to project hypothetical rates of transition for white women of selected ages, morbidity ratings and health statuses.

Differences in valuation of functional status components among consumers and professionals in Europe and the United States.

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor-patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

Improved survival for frail elderly inpatients on a geriatric evaluation unit (GEU): who benefits?

Previously reported data from a randomized controlled trial showed that admission to the geriatric evaluation unit (GEU) and follow-up clinic at the Sepulveda VA Medical Center leads to significantly improved outcomes for frail elderly hospital patients--including a 50% reduction of one-year mortality (p less than 0.005). In the present paper, two-year survival curves for GEU and control groups are reported. In addition, we subdivided the population by potential baseline risk factors (both patient- and treatment-related) and examined one-year survival using 12-month survival curves and odds ratios. There is evidence for GEU-related survival effects in specific subgroups of patients (e.g. patients with heart and pulmonary disease, patients with low baseline scores in functional status and mental status, and patients with high baseline morale scores). Finally, employing stepwise logistic regression, we determined the predictors of one-year survival in the pooled study population. These factors were: assignment to the GEU (adjusted odds ratio = 2.45; p less than 0.001); not having a heart diagnosis (2.24; p less than 0.001); and having primarily "geriatric/rehabilitation" problems (1.95; p less than 0.005). A predictive model derived from the regression defines patient subgroups likely to survive only when assigned to the GEU: cardiac patients with primarily "geriatric" or "rehabilitation" problems, and non-cardiac patients whose problems are primarily "medical". The dramatic effect of the GEU on survival appears to be concentrated on certain identifiable subgroups of patients who might be targeted to maximize program cost-effectiveness.

Years of life with good and poor mental and physical function in the elderly.

A population of Roman Catholic sisters (nuns) were divided into a high education group (i.e. at least a Bachelor's degree) and a low education group (i.e. less than a Bachelor's degree). Prevalence data on 132, 75-94 year old, sisters indicated that the high-educated had better mobility and hand coordination, stronger handgrip, better distant and near visual acuity, and fewer mental impairments than the low-educated group. Life table analyses on 154 sisters indicated that the high-educated lived an average of 3.28 years longer after age 75 than the low-educated. Years of life with relatively good and poor mental and physical function after age 75 were estimated by a mathematical model that used mortality and prevalence data. According to the model, high-educated sisters lived an average of 3.57 years longer with good function and 0.29 of a year less with poor function than low-educated sisters.

Beyond caring: the challenge to geriatrics.

Geriatrics has established itself in the past decade as a recognized part of health care, but several issues remain unsolved about its place in the system. It has been addressed as both an approach to primary care of the elderly and a specialty in its own right. It relies excessively on the technology of assessment. Although geriatrics responds to a pervasive need for coordinating clinical and social care for a subset of the elderly, its potential contributions to this challenge have not yet been well modeled. As it comes of age, there is a need for greater conceptual clarity and a series of demonstrations that its abilities fit the needs identified.

Managed care as a vehicle for delivering more effective chronic care for older persons.

Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition.

Rethinking long-term care.

In the context of several proposals for financing long-term care (LTC), this article suggests three areas in which reform of the structure of LTC is needed to create more appropriate incentives for better care. The interfaces between short- and long-term care can be addressed by either a number of specific changes or more global approaches, such as one or another form of capitated care. Using the ratio of achieved/expected outcomes as a prominent part of a regulatory strategy offers a means to increase the flexibility of regulation to encourage innovation while retaining meaningful accountability. New combinations of housing and nursing care offer a way for both a better and more flexible way of living in the context of an approach that guarantees universal coverage of care together with an incentive to save to afford better accommodations.

HMO medical directors' perceptions of geriatric practice in Medicare HMOs.

OBJECTIVE: To determine the extent to which health maintenance organizations (HMOs) with Medicare risk contracts utilize geriatricians and selected aspects of "organized" geriatric practice. DESIGN: A telephone interview survey. PARTICIPANTS: Eighty-two percent (64 of 78) of the HMOs with Medicare risk contracts as of June 1991. MEASUREMENTS: Questions to medical directors of the Medicare HMOs on (1) the presence of geriatricians, (2) the roles of geriatricians, and (3) "organized" geriatric practice. MAIN RESULTS: Fifty-three percent of the Medicare HMOs have one or more geriatricians, but only 19% have attempted to recruit geriatricians. Geriatricians provide primary care in 76% of the HMOs with geriatricians and serve as specialist consultants in 61%. Geriatricians are reported to be used actively in 32% of the HMOs that have them. The proportion of HMOs utilizing "organized" geriatric activities ranges from a high of 58% for a general health information questionnaire to a low of 12% for a special form(s) for comprehensive geriatric assessment. While the percentage of HMOs using each of the "organized" strategies is higher for the HMOs with geriatricians than for those without, this is statistically significant for only one strategy--the use of special approaches or formal protocols for problems frequently found in the elderly (P = 0.04). CONCLUSIONS: The perception of Medicare HMO medical directors is that about half of the HMOs utilize geriatricians and that there is evidence of "organized" geriatric practice. However, it appears that geriatricians and many of the elements of organized geriatric practice are used to a much lesser extent than experts recommend. Medicare HMOs must themselves test the various components of organized geriatric practice in order to determine their utility.