Patient Satisfaction and Perceived Quality of Care Among Younger Medicare Beneficiaries According to Activity Limitation Stages.

OBJECTIVE: To examine the association between activity limitation stages and patient satisfaction and perceived quality of medical care among younger Medicare beneficiaries. DESIGN: Cross-sectional study. SETTING: Medicare Current Beneficiary Survey (MCBS) for calendar years 2001-2011. PARTICIPANTS: A population-based sample (N=9323) of Medicare beneficiaries <65 years of age living in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physician (PCP), interpersonal skills of PCP, and quality of information provided by PCP. Persons were classified into an activity limitation stage (0-IV) which was derived from self-reported difficulty performing activities of daily living (ADL) and instrumental activities of daily living (IADL). RESULTS: Compared to beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (95% confidence intervals) for stage I (mild) to stage IV (complete) for satisfaction with access barriers ranged from 0.62 (0.53-0.72) at stage I to a minimum of 0.31 (0.22-0.43) at stage IV. Similarly, compared to beneficiaries at IADL stage 0, satisfaction with access barriers ranged from 0.66 (0.55-0.79) at stage I to a minimum of 0.36 (0.26-0.51) at stage IV. Satisfaction with care coordination and quality and perceived quality of medical care were not associated with activity limitation stages. CONCLUSIONS: Younger Medicare beneficiaries with disabilities reported decreased satisfaction with access to medical care, highlighting the need to improve access to health care and human services and to enhance workforce capacity to meet the needs of this patient population.

Patient Satisfaction and Prognosis for Functional Improvement and Deterioration, Institutionalization, and Death Among Medicare Beneficiaries Over 2 Years.

OBJECTIVE: To examine how patient satisfaction with care coordination and quality and access to medical care influence functional improvement or deterioration (activity limitation stage transitions), institutionalization, or death among older adults. DESIGN: National representative sample with 2-year follow-up. SETTING: Medicare Current Beneficiary Survey from calendar years 2001 to 2008. PARTICIPANTS: Community-dwelling adults (N=23,470) aged ≥65 years followed for 2 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A multinomial logistic regression model taking into account the complex survey design was used to examine the association between patient satisfaction with care coordination and quality and patient satisfaction with access to medical care and activities of daily living (ADL) stage transitions, institutionalization, or death after 2 years, adjusting for baseline socioeconomics and health-related characteristics. RESULTS: Out of 23,470 Medicare beneficiaries, 14,979 (63.8% weighted) remained stable in ADL stage, 2508 (10.7% weighted) improved, 3210 (13.3% weighted) deteriorated, 582 (2.5% weighted) were institutionalized, and 2281 (9.7% weighted) died. Beneficiaries who were in the top quartile of satisfaction with care coordination and quality were less likely to be institutionalized (adjusted relative risk ratio [RRR], .68; 95% confidence interval [CI], .54-.86). Beneficiaries who were in the top quartile of satisfaction with access to medical care were less likely to functionally deteriorate (adjusted RRR, .87; 95% CI, .79-.97), be institutionalized (adjusted RRR, .72; 95% CI, .56-.92), or die (adjusted RRR, .86; 95% CI, .75-.98). CONCLUSIONS: Knowledge of patient satisfaction with medical care and risk of functional deterioration may be helpful for monitoring and addressing disability-related health care disparities and the effect of ongoing policy changes among Medicare beneficiaries.

Disparities in receipt of recommended care among younger versus older medicare beneficiaries: a cohort study.

BACKGROUND: Although health disparities have been documented between Medicare beneficiaries based on age (<65 years vs. older age groups), underuse of recommended medical care in younger beneficiaries has not been thoroughly investigated. In this study, we aim to identify and characterize vulnerabilities of the younger Medicare age group (aged <65 years) in relation to older age groups (aged 65-74 years and ≥75 years) and to explore age group as a determinant of use of recommended care among Medicare beneficiaries. METHODS: We conducted a cohort study of community-dwelling Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey between 2001 and 2008 (N = 30,117). Age group characteristics were compared using cross-sectional data at baseline. During follow-up, we assessed the association between age and receipt of recommended care on 38 recommended care indicators, adjusting for sociodemographic and clinical characteristics. Follow-up periods differed by component indicator. RESULTS: At baseline, a higher proportion of younger beneficiaries experienced social disadvantage, disability and certain morbidities than older age groups. During follow-up, younger beneficiaries were significantly less likely to receive overall recommended care compared to those 65-74 years of age (adjusted odds ratio and 95% confidence interval: 0.75, 0.70-0.80). In addition, male gender, non-Hispanic black race, less than high school education, living alone, with children or with others, psychiatric disorders and higher activity limitation stages were all associated with underuse of recommended care. CONCLUSIONS: Younger Medicare beneficiary status appears to be an independent risk factor for underuse of appropriate care. Support to ameliorate disparities in different social and health aspects may be warranted.

Identifying neuropsychiatric disorders in the Medicare Current Beneficiary Survey: the benefits of combining health survey and claims data.

BACKGROUND: To address the impact of using multiple sources of data in the United States Medicare Current Beneficiary Survey (MCBS) compared to using only one source of data to identify those with neuropsychiatric diagnoses. METHODS: Our data source was the 2010 MCBS with associated Medicare claims files (N = 14, 672 beneficiaries). The MCBS uses a stratified multistage probability sample design to select a nationally representative sample of Medicare beneficiaries. We excluded those participants in Medicare Health Maintenance Organizations (n = 3894) and performed a cross-sectional analysis. We classified neuropsychiatric conditions according to four broad categories: intellectual/developmental disorders, neurological conditions affecting the central nervous system (Neuro-CNS), dementia, and psychiatric conditions. To account for different baseline prevalence differences of the categories we calculated the relative increase in prevalence that occurred from adding information from claims in addition to the absolute increase to allow comparison among categories. RESULTS: The estimated proportion of the sample with neuropsychiatric disorders increased to 50.0 (both sources) compared to 38.9 (health survey only) and 33.2 (claims only) with an overlap between sources of only 44.1 %. Augmenting health survey data with claims led to an increase in estimated percentage of intellectual/developmental disorders, psychiatric disorders, Neuro-CNS disorders and dementia of 1.3, 5.9, 11.5 and 3.8 respectively. In the community sample, the largest relative increases were seen for dementia (147.6 %) and Neuro-CNS disorders (87.4 %). With the exception of dementia, larger relative increases were seen in the facility sample with the greatest being for intellectual/developmental disorders (121.5 %) and Neuro-CNS disorders (93.8 %). CONCLUSIONS: The magnitude of potentially underestimated sample proportions using health survey only data varied strikingly according to the category of diagnosis and setting. Augmentation of survey data with claims appears essential particularly when attempting to estimate proportion of the sample affected by conditions that cause cognitive impairment which may affect ability to self-report. Augmenting proxy survey data with claims data also appears to be essential when ascertaining proportion of the facility-dwelling sample affected by neuropsychiatric disorders.

How does geographic access affect in-hospital mortality for veterans with acute ischemic stroke?

OBJECTIVE: To examine the relationship between estimated travel time to admitting hospital and mortality for veterans with acute ischemic stroke, controlling for patient demographic, clinical, facility-level variables, as well as select in-hospital treatments and procedures. METHODS: A longitudinal observational population-based study. Information on all veterans discharged from a Veterans Administration Medical Center (VAMC) with an ischemic stroke diagnosis between October 1, 2006 and September 30, 2008 were examined. A total of 10,430 patients met the inclusion criteria for the study. Unadjusted differences between patients who died during the hospital stay versus those patients who were discharged alive, used χ analyses or Student t tests, as appropriate. Multivariable logistic regression was used to control for confounding effects of patient, treatment, and facility characteristics to examine the relationship between travel time and the bivariate outcome of in-hospital mortality. RESULTS: Travel time to the admitting VAMC, our primary variable of interest regarding the effect on in-hospital mortality, after adjusting for the patient, treatment, and facility characteristics showed that longer travel times significantly increased the odds of in-hospital mortality. Travel times ≥ 90 minutes had increased odds of in-hospital mortality (OR=1.476; 95% CI, 1.067-2.042) as compared with <30 minutes. CONCLUSIONS: Even after adjusting for the confounding effects of patient, treatment, and facility characteristics, travel time from home to admitting VAMC was significantly associated with in-hospital mortality.

Patient Satisfaction and Perceived Quality of Care Among Older Adults According to Activity Limitation Stages.

OBJECTIVE: To examine whether patient satisfaction and perceived quality of medical care are related to stages of activity limitations among older adults. DESIGN: Cross-sectional study. SETTING: Medicare Current Beneficiary Survey (MCBS) for calendar years 2001 to 2011. PARTICIPANTS: A population-based sample (N=42,584) of persons aged ≥65 years living in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physicians, interpersonal skills of primary care physicians, and quality of information provided by primary care physicians. Persons were classified into a stage of activity limitation (0-IV) derived from self-reported difficulty levels performing activities of daily living (ADL) and instrumental ADL. RESULTS: Compared with older beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (ORs) for stage I (mild) to stage III (severe) for satisfaction with care coordination and quality ranged from .85 (95% confidence interval [CI], .80-.92) to .79 (95% CI, .70-.89). Compared with ADL stage 0, satisfaction with access barriers ranged from OR=.81 (95% CI, .76-.87) at stage I to a minimum of OR=.67 (95% CI, .59-.76) at stage III. Similarly, compared with older beneficiaries at ADL stage 0, perceived quality of the technical skills of their primary care physician ranged from OR=.87 (95% CI, .82-.94) at stage I to a minimum of OR=.81 (95% CI, .72-.91) at stage III. CONCLUSIONS: Medicare beneficiaries at higher stages of activity limitation, although not necessarily the highest stage of activity limitation, reported less satisfaction with medical care.

Factors influencing receipt of early rehabilitation after stroke.

OBJECTIVE: To identify patient-level characteristics associated with rehabilitation during the acute poststroke phase. DESIGN: Retrospective cohort. Generalized estimating equations modeled the likelihood of rehabilitation during the index hospitalization to account for patient clusters. SETTING: Rehabilitation facilities. PARTICIPANTS: Sample included veterans (N=9681; average age, 68.7y; 97.4% men) diagnosed with new stroke discharged from Veterans Affairs hospitals between October 1, 2006, and September 30, 2008. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Receipt of rehabilitation services. RESULTS: Of the total cohort, 73% received some type of rehabilitation. After adjustment, stroke patients with cerebral arteries occlusion were most likely to receive rehabilitation compared with other stroke types (P<.001). Patients with prestroke conditions of metastatic cancer (odds ratio [OR]=.68, P<.001) and psychosis (OR=.90, P=.045) were less likely to have rehabilitation, whereas those with hypertension (OR=1.26, P<.001) and other neurologic disorders (OR=1.29, P<.001) were more likely. Compared with patients admitted from home, patients transferred from a non-Veterans Affairs hospital (OR=1.4, P<.004) were more likely to receive rehabilitation, whereas patients admitted from extended care (OR=.59, P<.001) were less likely. Married veterans were less likely to receive rehabilitation services (OR=.87, P<.001) than unmarried veterans. CONCLUSIONS: Within the Veterans Health Administration, initiating rehabilitation in the acute phase poststroke appears to be influenced by patient clinical characteristics and living circumstances.

Development of a Survey of Sunscreen Use and Attitudes among Adults in Two Coastal States, 2019.

Skin cancer is the most common form of cancer in the United States, and regular use of broad-spectrum sunscreens can prevent skin cancer. However, a new law in Hawaii that limits sunscreen choices due to the belief that some UV (ultraviolet) filters may damage coral reefs may reduce sunscreen use and increase skin-cancer risk. Because of this, there is a need for measurement tools to help understand consumer behavior and determinants of sunscreen purchase and use. The objectives of this study were (1) to test new questionnaire measures relevant to the Hawaii Sunscreen Ban; and (2) to assess adults' knowledge, attitudes, and habits related to sunscreen in two other coastal states. This survey of adult residents of California and Florida was conducted in the summer of 2019. Newly developed scales addressed beliefs about effects of sunscreens on aquatic/marine environments and awareness of the Hawaii sunscreen ban. Respondents completed the survey twice to evaluate the test-retest reliability. Respondents (n = 162) were mainly female, White, and college-educated. New scales had moderate-to-high internal consistency and high test-retest reliability. Sunscreen use was high, sunburn was common, and knowledge and attitudes about sunscreen were modest. Most respondents did not know the specifics of the Hawaii Sunscreen Ban. In multivariate models, significant predictors of sunscreen use were being older, female, and having higher sunscreen knowledge. Sunscreen beliefs were not significantly associated with sunscreen use or sunburn. The findings support the use of the newly developed survey and suggest that more education about sunscreen and sunscreen ingredients is needed.

Factors influencing receipt of outpatient rehabilitation services among veterans following lower extremity amputation.

OBJECTIVE: To determine patient-, treatment-, and facility-level characteristics associated with receiving outpatient rehabilitation services after lower extremity amputation within the Veterans Affairs (VA) system. DESIGN: Observational study. SETTING: All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS: Veterans (N=4165) with lower extremity amputation discharged from VAMCs between October 1, 2002, and September 20, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Receipt of outpatient rehabilitation services up to 1 year postdischarge. A Cox proportional hazards model was used to determine the adjusted hazard ratio and 95% confidence interval of veterans to receive outpatient services. RESULTS: Sixty-five percent of veterans with lower extremity amputation received outpatient services. Older veterans, patients admitted for surgical amputation from extended care rather than transferred from another hospital, and those with transfemoral and/or bilateral rather than unilateral transtibial amputations were less likely to receive outpatient services. Those with serious comorbidities and those who had procedures for acute central nervous system disorders, active cardiac pathology, serious nutritional compromise, and severe renal disease during the surgical hospitalization less often initiated outpatient care. Patients who received inpatient consultative rehabilitation compared with inpatient specialized rehabilitation, and who were treated in the Northeast compared with the Southeast less often initiated outpatient care. Finally, those discharged to home or other locations rather than extended care had an initial increased likelihood of receiving outpatient service, but by 180 days postdischarge those discharged to extended care were more likely to initiate outpatient services. CONCLUSIONS: Both clinical characteristics and types of rehabilitation services received appear to influence the receipt of outpatient rehabilitation services. Geographic location also affected the receipt of outpatient rehabilitation, suggesting that care patterns are not standardized across the nation.

Cost-Effectiveness of Four Financial Incentive Programs for Smoking Cessation.

Rationale: A trial of four financial incentive programs, conducted at CVS Caremark, a large employer, documented their effectiveness in promoting sustained abstinence from smoking, but their cost-effectiveness is unknown, and the significant up-front cost of the incentives is a deterrent to their adoption. Objectives: To determine the cost-effectiveness of these incentives from the healthcare sector and employer perspectives. Methods: This study examines a decision model built with trial data, supplemented by data from the literature. Life-expectancy gains for quitters were projected on the basis of U.S. life tables. The two individual-oriented programs paid $800 for smoking cessation at 6 months; one required participants to deposit $150 at baseline. Payments in the two group-oriented programs varied with the group's success; again, one required participants to deposit $150. Results: Life-years, quality-adjusted life-years (QALYs), costs (2012 dollars), and cost-effectiveness ratios are described. From the healthcare sector perspective, costs ranged from $3,200 per life-year ($2,500 per QALY) for the competitive deposit program, compared with usual care, to $6,500 per life-year ($5,100 per QALY) for the individual reward program. From the employer perspective, costs ranged from $256,600 per life-year gained for the individual deposit program to $1,711,100 per life-year gained for the individual reward program; the cost per QALY ranged from $65,300 for the competitive deposit program to $128,800 for the individual reward program. Cost-effectiveness from the employer perspective improved with longer decision horizons. Including future medical costs reduced cost-effectiveness from both perspectives. Conclusions: Four financial incentive programs that paid smokers to quit are very cost-effective from the healthcare sector perspective. They are more expensive from the employer perspective but may be cost-effective for employers with longer decision horizons.

Effect of Financial Incentives and Environmental Strategies on Weight Loss in the Healthy Weigh Study: A Randomized Clinical Trial.

Importance: Modest weight loss can lead to meaningful risk reduction in adults with obesity. Although both behavioral economic incentives and environmental change strategies have shown promise for initial weight loss, to date they have not been combined, or compared, in a randomized clinical trial. Objective: To test the relative effectiveness of financial incentives and environmental strategies, alone and in combination, on initial weight loss and maintenance of weight loss in adults with obesity. Design, Setting, and Participants: This randomized clinical trial was conducted from 2015 to 2019 at 3 large employers in Philadelphia, Pennsylvania. A 2-by-2 factorial design was used to compare the effects of lottery-based financial incentives, environmental strategies, and their combination vs usual care on weight loss and maintenance. Interventions were delivered via website, text messages, and social media. Participants included adult employees with a body mass index (BMI; weight in kilograms divided by height in meters squared) of 30 to 55 and at least 1 other cardiovascular risk factor. Data analysis was performed from June to July 2021. Interventions: Interventions included lottery-based financial incentives based on meeting weight loss goals, environmental change strategies tailored for individuals and delivered by text messages and social media, and combined incentives and environmental strategies. Main Outcome and Measures: The primary outcome was weight change from baseline to 18 months, measured in person. Results: A total of 344 participants were enrolled, with 86 participants each randomized to the financial incentives group, environmental strategies group, combined financial incentives and environmental strategies group, and usual care (control) group. Participants had a mean (SD) age of 45.6 (10.5) years and a mean (SD) BMI of 36.5 (7.1); 247 participants (71.8%) were women, 172 (50.0%) were Black, and 138 (40.1%) were White. At the primary end point of 18 months, participants in the incentives group lost a mean of 5.4 lb (95% CI, -11.3 to 0.5 lb [mean, 2.45 kg; 95% CI, -5.09 to 0.23 kg]), those in the environmental strategies group lost a mean of a 2.2 lb (95% CI, -7.7 to 3.3 lb [mean, 1.00 kg; 95% CI, -3.47 to 1.49 kg]), and the combination group lost a mean of 2.4 lb (95% CI, -8.2 to 3.3 lb [mean, 1.09 kg; 95% CI, -3.69 to 1.49 kg]) more than participants in the usual care group. Financial incentives, environmental change strategies, and their combination were not significantly more effective than usual care. At 24 months, after 6 months without an intervention, the difference in the change from baseline was similar to the 18-month results, with no significant differences among groups. Conclusions and Relevance: In this randomized clinical trial, across all study groups, participants lost a modest amount of weight but those who received financial incentives, environmental change, or the combined intervention did not lose significantly more weight than those in the usual care group. Employees with obesity may benefit from more intensive individualized weight loss strategies. Trial Registration: ClinicalTrials.gov Identifier: NCT02878343.

The healthy food marketing strategies study: design, baseline characteristics, and supermarket compliance.

Identifying effective strategies to promote healthy eating and reduce obesity is a priority in the USA, especially among low-income and minority groups, who often have less access to healthy food and higher rates of obesity. Efforts to improve food access have led to more supermarkets in low-income, ethnically diverse neighborhoods. However, this alone may not be enough to reduce food insecurity and improve residents' diet quality and health. This paper summarizes the design, methods, baseline findings, and supermarket in-store marketing strategy compliance for a randomized trial of the impact of healthy food marketing on the purchase of healthier "target" food items. Thirty-three supermarkets in low-income, high-minority neighborhoods in the metropolitan Philadelphia area were matched on store size and percentage of sales from government food assistance programs and randomly assigned to the intervention or control group. Healthy marketing strategies, including increased availability of healthier "target" products, prime shelf-placement and call-out promotion signs, and reduced availability of regular "comparison" products, were implemented in 16 intervention stores for an 18 month period for over 100 individual food items. Six product categories were studied: bread, checkout cooler beverages, cheese, frozen dinners, milk, and salty snacks. The primary outcome measure was weekly sales per store in each product category for 1 year preintervention and 18 months during the intervention. Compliance with the marketing strategies was assessed twice per month for the first 6 months and once a month thereafter. Store and neighborhood characteristics were not significantly different between control and intervention stores. Intercept surveys with customers to assess shopping habits and grocery marketing environment assessments to examine the food promotion environment were completed in the same six food categories. In intercept surveys, 51.0% of shoppers self-identified as overweight and 60.6% wanted to change their weight. Shoppers who typically purchased one type of food over another commonly did so out of habit or because the item was on sale. Findings revealed that preintervention sales of healthier "target" or regular "comparison" items did not differ between intervention and control stores for 1 year prior to intervention implementation. Rates of compliance with the healthy marketing strategies were high, averaging 76.5% over the first 12 months in all 16 stores. If healthy in-store marketing interventions are effective in this scaled-up, longer-term study, they should be translated into wider use in community supermarkets.

Possible incremental benefits of specialized rehabilitation bed units among veterans after lower extremity amputation.

BACKGROUND: Little is known about the effect of different types of inpatient rehabilitation on outcomes of patients undergoing lower extremity amputation for nontraumatic reasons. OBJECTIVE: To compare outcomes between patients who received inpatient rehabilitation on specific rehabilitation bed units (specialized) to patients who received rehabilitation on general medical/surgical units (generalized) during the acute postoperative period. METHODS: This was an observational study including 1339 veterans who underwent lower extremity amputation between October 1, 2002 and September 30, 2004. Data were compiled from 9 administrative databases from the Veterans Health Administration. Propensity score risk adjustment methodology was used to reduce selection bias in looking at the effect of type of rehabilitation on outcomes (1-year survival, home discharge from the hospital, prescription of a prosthetic limb within 1 year post surgery, and improvement in physical functioning at rehabilitation discharge). RESULTS: After applying propensity score risk adjustment, there was strong evidence that patients who received specialized versus generalized rehabilitation were more likely to be discharged home (risk difference = 0.10), receive a prescription for a prosthetic limb (risk difference = 0.13), and improve physical functioning (gains on average 6.2 points higher). Specialized patients had higher 1-year survival (risk difference = 0.05), but the difference was not statistically significant. The sensitivity analysis demonstrated our findings to be unaffected by a moderately strong amount of unmeasured confounding. CONCLUSIONS: Receipt of specialized compared with generalized rehabilitation during the acute postoperative inpatient period was associated with better outcomes. Future studies will need to look at different intensity, timing, and location of rehabilitation services.

Factors influencing decisions to admit patients to veterans affairs specialized rehabilitation units after lower-extremity amputation.

UNLABELLED: Bates BE, Kwong PL, Kurichi JE, Bidelspach DE, Reker DM, Maislin G, Xie D, Stineman M. Factors influencing decisions to admit patients to Veterans Affairs specialized rehabilitation units after lower-extremity amputation. OBJECTIVE: To understand patient- and facility-level characteristics that influence decisions to admit veterans to a specialized rehabilitation unit (SRU) after a lower-extremity amputation. DESIGN: Database study. SETTING: All Veterans Affairs Medical Centers (VAMCs). PARTICIPANTS: Veterans with lower-extremity amputation discharged from VAMCs between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Admission to an SRU. RESULTS: There were a total of 2922 veterans with lower-extremity amputations; 616 patients were admitted to an SRU, whereas 2306 received consultative rehabilitation services only. Patients admitted to an SRU waited longer to have their first rehabilitation assessment after surgery and had middle-range physical and cognitive disabilities. Patients who received consultative rehabilitation services only tended to have greater illness burden. They were more likely to have previous amputation complication, paralysis, or renal failure and either very severe or minimal physical and cognitive disabilities. CONCLUSIONS: The selection of veterans with new lower-extremity amputations for admission to an SRU appears clinically reasonable and based on the likelihood of successful outcomes.

The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system.

OBJECTIVE: To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. DESIGN: An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias. SETTING: Data compiled from 9 administrative databases from Veterans Affairs Medical Centers. PARTICIPANTS: A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year. RESULTS: After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. CONCLUSIONS: The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.

A Risk Scoring System for the Prediction of Functional Deterioration, Institutionalization, and Mortality Among Medicare Beneficiaries.

OBJECTIVE: We sought to develop a risk scoring system for predicting functional deterioration, institutionalization, and mortality. Identifying predictors of poor health outcomes informs clinical decision-making, service provision, and policy development to address the needs of persons at greatest risk for poor health outcomes. DESIGN: This is a cohort study with 21,257 community-dwelling Medicare beneficiaries 65 yrs and older who participated in the 2001-2008 Medicare Current Beneficiary Survey. Derivation of the model was conducted in 60% of the sample and validated in the remaining 40%. Multinomial logistic regression model generated ß coefficients, which were used to create a risk scoring system. Our outcome was instrumental activity of daily living stage transitions (stable/improved function and functional deterioration), institutionalization, or mortality for 2 yrs of follow-up. RESULTS: A total of 18 factors were identified for functional deterioration (P < 0.05). In the derivation cohort, the likelihood of functional deterioration ranged from 6.27% to 33.51%, risk of institutionalization from 0.07% to 12.13%, and risk of mortality from 2.13% to 31.83%, in comparison with stable/improved function. CONCLUSIONS: A risk scoring system predicting Medicare beneficiaries' risk of functional deterioration, institutionalization, and mortality based on demographic and clinical indicators may feasibly be developed with implications for healthcare delivery.

Functional Impairments Associated With Patient Activation Among Community-Dwelling Older Adults.

OBJECTIVES: Activity of daily living stages and instrumental activity of daily living stages demonstrated ordered associations with mortality, risk of hospitalization, and receipt of recommended care. This article explores the associations of stages with the following three dimensions of patient activation: self-care efficacy, patient-doctor communication, and health-information seeking. We hypothesized that higher activity of daily living and instrumental activity of daily living stages (greater limitation) are associated with a lower level of patient activation. METHODS: Patient activation factors were derived from the 2004 and 2009 Medicare Current Beneficiary Survey. In this cross-sectional study (N = 8981), the associations of activity limitation stages with patient activation factors were assessed in latent factor models. RESULTS: Greater activity limitation was in general inversely associated with self-efficacy, patient-doctor communication, and health information seeking, even after adjusting for sociodemographic and clinical characteristics. For instance, the mean of self-care efficacy across activity of daily living stages I-IV (mild, moderate, severe, and complete limitation) compared with stage 0 (no limitation) decreased significantly by 0.17, 0.29, 0.34, and 0.60, respectively. Covariates associated with suboptimal patient activation were also identified. DISCUSSION: Our study identified multiple opportunities to improve patient activation, including providing support for older adults with physical impairments, at socioeconomic disadvantages, or with psychological or cognitive impairment.

Premorbid Activity Limitation Stages Are Associated With Posthospitalization Discharge Disposition.

OBJECTIVE: Activity of daily living stages and instrumental activity of daily living stage have demonstrated associations with mortality and health service use among older adults. This cohort study aims to assess the associations of premorbid activity limitation stages with acute hospital discharge disposition among community-dwelling older adults. DESIGN: Study participants were Medicare beneficiaries aged 65 yrs or older who enrolled in the Medicare Current Beneficiary Survey between 2001 and 2009. Associations of premorbid stages with discharge dispositions were estimated with multinomial logistic regression models adjusted for covariates. RESULTS: The proportions of elderly Medicare patients discharged to home with self-care, home with services, postacute care facilities, and other dispositions were 59%, 15%, 19%, and 7%, respectively. The following adjusted relative risk ratios and 95% confidence intervals of postacute care facilities versus home with self-care discharge increased with higher premorbid activity limitation stages (except nonfitting stage III): 1.7 (1.5-2.0), 2.4 (2.0-2.9), 2.4 (1.9-3.0), and 2.5 (1.6-4.1) for activity of daily living stages I-IV; a similar pattern was found for instrumental activity of daily living stages. The adjusted relative risk ratios of discharge to home with services also increased with higher premorbid activity limitation stages compared with no limitation. CONCLUSIONS: Routinely assessed activity limitation stages predict posthospitalization discharge disposition among older adults and may be used to anticipate postacute care and services use by elderly Medicare beneficiaries.

Preventable hospitalizations, barriers to care, and disability.

The AHRQ's Prevention Quality Indicators assume inpatient hospitalizations for certain conditions, referred as ambulatory-care sensitive (ACS) conditions, are potentially preventable and may indicate reduced access to and a lower quality of ambulatory care. Using a cohort drawn from the Medicare Current Beneficiary Survey (MCBS) linked to Medicare claims, we examined the extent to which barriers to healthcare are associated with ACS hospitalizations and related costs, and whether these associations differ by beneficiaries' disability status. Our results indicate that the regression-adjusted cost of ACS hospitalizations for elderly Medicare beneficiaries with no disabilities was $799. This cost increased six-fold, by $5148, among beneficiaries with mild disability, by $9045 for beneficiaries with moderate disability, by $5513 for those with severe disability, and by $8557 for persons with complete disability (P < 0.001). Persons reporting having foregone or delayed needed medical care because of financial difficulties (+$2082, P = .05), those experiencing low satisfaction with care coordination (+$1714, P = .01), and those reporting low satisfaction with access to care (+$1237, P = .02) also incurred significant excess ACS hospitalization costs relative to persons reporting no such barriers. This pattern held true for those with and without a disability, but were especially marked among persons with no functional limitations. These findings suggest that a better understanding of how public policy might effectively improve care coordination and reduce financial barriers to care is essential to formulating programs that reduce excess hospitalizations among the large and growing number of elderly Medicare beneficiaries.

Clinical factors associated with prescription of a prosthetic limb in elderly veterans.

OBJECTIVES: To determine how advanced age influences prosthetic prescription. DESIGN: Retrospective cohort analysis with theory-driven logistic regression models. A Post Amputation Quality-of-Life (PAQ) framework of outcomes was proposed and empirically tested. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Two thousand three hundred seventy-five veterans with lower extremity amputations discharged between October 1, 2002, and September 30, 2003. MEASUREMENTS: Prosthetic prescription within 1 year of amputation. RESULTS: Patients younger than 76 were 4.5 times as likely to receive a prescription compared to those aged 86 and older (odds ratio=4.51, 95% confidence interval=1.36-14.99) after controlling for sex, marital status, living circumstance before hospitalization, anatomical level, etiologies, comorbidities, medical acuity, and initial functional status. Patients admitted from extended care and patients with peripheral vascular disease, systemic sepsis, renal failure, congestive heart failure, psychoses, metastatic cancer, paralysis, or other neurological disorders were less likely to receive a prescription, as were patients who underwent procedures for acute central nervous system disorders, severe renal disease, or serious nutritional compromise. Veterans evaluated initially as more cognitively and physically able had higher likelihood of prosthetic prescription, and those with transtibial amputations had higher likelihood of prosthetic prescription than those with transfemoral amputations. CONCLUSION: Amputees aged 75 and older are less likely to receive a prosthetic limb prescription than younger individuals, even after controlling for comorbidities and functional status. Findings support the PAQ framework, in which contexts, etiologies, anatomic level, comorbidities, medical acuity, and initial function are determinants of outcome. Medical and functional conditions that adversely affect level of energy, ability to move independently, or ability to exercise judgment reduce the likelihood of prosthetic prescription.