Life-space mobility and post-hospitalization outcomes among older Mexican American Medicare beneficiaries.

BACKGROUND: Older adults with limited mobility are at an increased risk of adverse health outcomes, an outcome inadequately investigated in older Mexican Americans. We explored whether pre-admission life-space mobility predicts post-hospitalization outcomes among hospitalized Mexican American Medicare beneficiaries. METHODS: Life-space mobility, using the Life-Space Assessment (LSA), was analyzed using quartiles and 5-point intervals. Using the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE) Waves 7 and 8 data linked to Medicare claims data, 426 older Mexican Americans with at least 2 months of Medicare coverage who were hospitalized within 2 years of completing the LSA were included. Logistic and Cox Proportional regression analyses estimated the association of pre-admission LSA with post-hospitalization outcomes. RESULTS: Prior to hospitalization, 85.4% reported limited life-space mobility. Most patients (n = 322, 75.6%) were hospitalized for medical reasons. About 65% were discharged to the community. Pre-admission LSA scores were not associated with community discharge (Odds Ratio [OR] = 1.02, 0.95-1.10). Higher pre-admission LSA scores were associated with 30-day readmission (OR = 1.11, 1.01-1.22). Patients in the highest pre-admission LSA quartile (i.e., greatest life-space mobility) were less likely to die within 2 years after hospital discharge (OR = 0.61, 0.39-0.97) compared to those with lower pre-admission LSA scores. CONCLUSIONS: Among older Mexican American Medicare beneficiaries, greater pre-admission LSA scores were associated with an increased risk of 30-day readmission and a decreased risk of mortality within 2 years following hospitalization. Future work should further investigate the relationship between LSA and post-hospitalization outcomes in a larger sample of Mexican American older adults.

Hospitalizations and Emergency Room Admissions by Mexican American Older Adults with and without Dementia and Caregiver Mental Health.

BACKGROUND: Evidence from predominately non-Hispanic White populations indicates that emergency room (ER) admissions and hospitalizations by older adults with and without dementia are associated with caregiver stress and depressive symptoms. These results may not generalize to Hispanic populations because of cultural differences in caregiving roles, responsibilities, and perspectives about care burden. OBJECTIVE: Investigate the association between ER admissions and hospitalizations by Mexican American older adults with and without dementia and symptoms of depression and stress among family caregivers. METHODS: Data came from the 2010/11 wave of the Hispanic Established Populations for the Epidemiologic Study of the Elderly and Medicare claims files. The final sample included 326 older adults and their caregivers. Negative binomial regression was used to model the association between hospitalizations and ER admissions by older adults in the previous two years and caregivers' depressive symptoms and stress in 2010/11. RESULTS: The number of older adult ER admissions and hospitalizations was not associated with caregiver depressive symptoms. Two or more ER admissions (incident rate ratio [IRR] = 1.26, 95% CI = 1.05-1.51) and two or more hospitalizations (IRR = 1.32, 95% CI = 1.07-1.61) were associated with significantly higher caregiver stress. Additionally, ER admissions and hospitalizations for a circulatory disease or injury and poisoning were associated with significantly higher caregiver stress. These associations were not modified by the care recipient's dementia status. CONCLUSION: Hospitalizations and ER admissions by older Mexican Americans were associated with greater caregiver stress but not depressive symptoms. These associations were similar for caregivers to older adults with and without dementia.

Characteristics Associated With Mexican-American Hospice Use: Retrospective Cohort Study Using the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE).

BACKGROUND: Hospice use is lower among ethnic/racial minorities in the United States, though little is known about trends, associated factors and duration of hospice use by Mexican-Americans. AIM: The purpose of this study is to examine Mexican-American characteristics associated with hospice stay, both ≤ and > 7 days. DESIGN: This retrospective cohort study used data from the Hispanic Established Population for the Epidemiological Study of the Elderly (H-EPESE) and the Centers for Medicare and Medicaid Services. Multivariate logistic regression models were used to estimate the ORs and 95% CIs for hospice stay among Mexican-Americans, both ≤ and > 7 days. SETTING AND PARTICIPANTS: The first cohort (N = 970) includes H-EPESE participants who died between 2004 and 2016 who had Medicare parts A and B. The second cohort (N = 403) includes participants who completed the H-EPESE survey within the last 2 years of life. RESULTS: Although hospice use increased among Mexican-Americans between 2004 and 2016 (OR 1.88, 95% CI 1.19-2.97), 38% of participants died within the first week of hospice care. Mexican-Americans in New Mexico and Arizona were 2-4 times more likely to use hospice than those in Texas and Colorado. Dementia was associated with hospice use (OR 1.47, 95% CI 1.11-1.94). Characteristics, like church attendance and living alone, were not associated with hospice use. CONCLUSIONS: The substantial proportion of Mexican-Americans with 7 days or less of hospice use underscores the need for early palliative/hospice intervention to mitigate variation in use.

Documentation of Dementia as a Cause of Death Among Mexican-American Decedents Diagnosed with Dementia.

BACKGROUND: Hispanic older adults are a high-risk population for Alzheimer's disease and related dementias (ADRD) but are less likely than non-Hispanic White older adults to have ADRD documented as a cause of death on a death certificate. OBJECTIVE: To investigate characteristics associated with ADRD as a cause of death among Mexican-American decedents diagnosed with ADRD. METHODS: Data came from the Hispanic Established Populations for the Epidemiologic Study of the Elderly, Medicare claims, and National Death Index. RESULTS: The final sample included 853 decedents diagnosed with ADRD of which 242 had ADRD documented as a cause of death. More health comorbidities (OR = 0.40, 95% CI = 0.28-0.58), older age at death (OR = 1.18, 95% CI = 1.03-1.36), and longer ADRD duration (OR = 1.08, 95% CI = 1.03-1.14) were associated with ADRD as a cause of death. In the last year of life, any ER admission without a hospitalization (OR = 0.45, 95% CI = 0.22-0.92), more physician visits (OR = 0.96, 95% CI = 0.93-0.98), and seeing a medical specialist (OR = 0.46, 95% CI = 0.29-0.75) were associated with lower odds for ADRD as a cause of death. In the last 30 days of life, any hospitalization with an ICU stay (OR = 0.55, 95% CI = 0.36-0.82) and ER admission with a hospitalization (OR = 0.67, 95% CI = 0.48-0.94) were associated with lower odds for ADRD as a cause of death. Receiving hospice care in the last 30 days of life was associated with 1.98 (95% CI = 1.37-2.87) higher odds for ADRD as a cause of death. CONCLUSION: Under-documentation of ADRD as a cause of death may reflect an underestimation of resource needs for Mexican-Americans with ADRD.

Changes in Health Care Use by Mexican American Medicare Beneficiaries Before and After a Diagnosis of Dementia.

BACKGROUND: Evidence from predominantly non-Hispanic White cohorts indicates health care utilization increases before Alzheimer's disease and related dementias (ADRD) is diagnosed. We investigated trends in health care utilization by Mexican American Medicare beneficiaries before and after an incident diagnosis of ADRD. METHODS: Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare claims files from 1999 to 2016 (n = 558 matched cases and controls). Piecewise regression and generalized linear mixed models were used to compare the quarterly trends in any (ie, one or more) hospitalizations, emergency room (ER) admissions, and physician visits for 1 year before and 1 year after ADRD diagnosis. RESULTS: The piecewise regression models showed that the per-quarter odds for any hospitalizations (odds ratio [OR] = 1.62, 95% CI = 1.43-1.84) and any ER admissions (OR = 1.40, 95% CI = 1.27-1.54) increased before ADRD was diagnosed. Compared to participants without ADRD, the percentage of participants with ADRD who experienced any hospitalizations (27.2% vs 14.0%) and any ER admissions (19.0% vs 11.7%) was significantly higher at 1 quarter and 3 quarters before ADRD diagnosis, respectively. The per-quarter odds for any hospitalizations (OR = 0.88, 95% CI = 0.80-0.97) and any ER admissions (OR = 0.89, 95% CI = 0.82-0.97) decreased after ADRD was diagnosed. Trends for any physician visits before or after ADRD diagnosis were not statistically significant. CONCLUSIONS: Older Mexican Americans show an increase in hospitalizations and ER admissions before ADRD is diagnosed, which is followed by a decrease after ADRD diagnosis. These findings support the importance of a timely diagnosis of ADRD for older Mexican Americans.

Frailty transitions predict healthcare use and Medicare payments in older Mexican Americans: a longitudinal cohort study.

BACKGROUND: Little is known regarding the impact of transitions in frailty on healthcare use and payment in older Mexican Americans. We address this gap in knowledge by investigating the effect of early transitions in physical frailty on the use of healthcare services and Medicare payments involving older Mexican Americans. METHODS: Longitudinal analyses were conducted using the Hispanic Established Populations for the Epidemiological Study of the Elderly (Hispanic-EPESE) survey data from five Southwest states linked to the Medicare claims files from the Centers for Medicare and Medicaid Services. Seven hundred and eighty-eight community-dwelling Mexican Americans 72 years and older in 2000/01 were studied. We used a modified Frailty Phenotype (unintentional weight loss, weakness, self-reported exhaustion and slow walking speed) to classify frailty status (non-frail, pre-frail or frail). Each participant was placed into one of 5 frailty transition groups: 1) remain non-frail, 2) remain pre-frail, 3) remain frail, 4) improve (pre-frail to non-frail, frail to non-frail, frail to pre-frail) and 5) worse (non-frail to pre-frail, non-frail to frail, pre-frail to frail). The outcomes for the one-year follow-up period (2000-2001) were: (a) healthcare use (hospitalization, emergency room [ER] admission and physician visit); and (b) Medicare payments (total payment and outpatient payment). RESULTS: Mean age was 78.8 (SD = 5.1) years and 60.3% were female in 1998/99. Males who remained pre-frail (Odds Ratio [OR] = 3.49, 1.13-10.8, remained frail OR = 6.92, 1.61-29.7) and transitioned to worse frail status (OR = 4.49, 1.74-11.6) had significantly higher hospitalization risk compared to individuals who remained non-frail. Males in the 'worsened' groups, and females in the 'improved' groups, had significantly higher Medicare payments than individuals who remained non-frail (Cost Ratio [CR] = 2.00, 1.30-3.09; CR = 1.53, 1.12-2.09, respectively]. CONCLUSIONS: Healthcare use and Medicare payments differed by frailty transition status. The differences varied by sex. Research is necessary to elucidate the relationship between frailty transitions and outcomes, sex difference and Medicare payment for older Mexican Americans living in the community.

Healthcare utilization of Mexican-American Medicare beneficiaries with and without Alzheimer's disease and related dementias.

BACKGROUND: Older adults with Alzheimer's disease and related dementias (ADRD) are high-risk to experience hospitalizations and emergency room (ER) admissions. Mexican-Americans have a high prevalence of ADRD, but there is limited information on the healthcare use of older Mexican-Americans with ADRD. We used data from a cohort of older Mexican-Americans that has been linked with Medicare files to investigate differences in hospitalizations, ER admissions, and physician visits according to ADRD diagnosis. We also identify sociodemographic, health, and functional characteristics that may contribute to differences in healthcare utilization between Mexican-American Medicare beneficiaries with and without an ADRD diagnosis. METHODS AND FINDINGS: Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare Master Beneficiary Summary Files, Medicare Provider Analysis and Review files, Outpatient Standard Analytic files, and Carrier files. The final analytic sample included 1048 participants. Participants were followed for two years (eight quarters) after their survey interview. Generalized estimating equations were used to estimate the probability for one or more hospitalizations, ER admissions, and physician visits at each quarter. ADRD was associated with higher odds for hospitalizations (OR = 1.65, 95%CI = 1.29-2.11) and ER admissions (OR = 1.57, 95%CI = 1.23-1.94) but not physician visits (OR = 1.23, 95%CI = 0.91-1.67). The odds for hospitalizations (OR = 1.24, 95%CI = 0.97-1.60) and ER admissions (OR = 1.27, 95%CI = 1.01-1.59) were reduced after controlling for limitations in activities of daily living and comorbidities. CONCLUSIONS: Mexican-American Medicare beneficiaries with ADRD had significantly higher odds for one or more hospitalizations and ER admissions but similar physician visits compared to beneficiaries without ADRD. Functional limitations and comorbidities contributed to the higher hospitalizations and ER admissions for older Mexican-Americans with ADRD.

Differences in hospitalizations, emergency room admissions, and outpatient visits among Mexican-American Medicare beneficiaries.

BACKGROUND: Few studies have investigated the healthcare utilization of Mexican-American Medicare beneficiaries. We used survey data that has been linked with Medicare claims records to describe the healthcare utilization of Mexican-American Medicare beneficiaries, determine common reasons for hospitalizations, and identify characteristics associated with healthcare utilization. METHODS: Data came from wave five (2004/05) of the Hispanic Established Populations for the Epidemiological Study of the Elderly. The final sample included 1187 participants aged ≥75 who were followed for two-years (eight-quarters). Generalized estimating equations were used to estimate the probability of ≥1 hospitalization, emergency room (ER) admissions, and outpatient visits. RESULTS: The percentage of beneficiaries who had ≥1 hospitalizations, ER admissions, and outpatient visits for each quarter ranged from 10.12-12.59%, 14.15-19.03%, and 76.61-80.68%, respectively. Twenty-three percent of hospital discharges were for circulatory conditions and 17% were for respiratory conditions. Hospitalizations for heart failure and simple pneumonia were most common. Older age was associated with significantly higher odds for ER admissions (OR = 1.49, 95% CI = 1.21-1.84) but lower odds for outpatient visits (OR = 0.74, 95% CI = 0.57-0.96). Spanish language and female gender were associated with significantly higher odds for hospitalizations (OR = 1.53, 95% CI = 1.14-2.06) and outpatient visits (OR = 1.82, 95% CI = 1.43-2.33), respectively. Having a middle-school or higher level of education was associated with significantly lower odds for ER admissions (OR = 0.71, 95% CI = 0.56-0.91). Participants who were deceased within two-years had significantly higher odds for hospitalizations (OR = 6.15, 95% CI = 4.79-7.89) and ER admissions (OR = 3.63, 95% CI = 2.88-4.57) than participants who survived at least three-years. CONCLUSION: We observed high healthcare utilization among Mexican-American Medicare beneficiaries. Forty percent of all hospitalizations were for circulatory and respiratory conditions with hospitalizations for heart failure and pneumonia being the most common. Older age, gender, education, language, and mortality were all associated with healthcare utilization. Continued research is needed to identify patterns and clusters of social determinants and health characteristics associated with healthcare utilization and outcomes in older Mexican-Americans.

The burden of health conditions for middle-aged and older adults in the United States: disability-adjusted life years.

BACKGROUND: Many adults are living longer with health conditions in the United States. Understanding the disability-adjusted life years (DALYs) for such health conditions may help to inform healthcare providers and their patients, guide health interventions, reduce healthcare costs, improve quality of life, and increase longevity for aging Americans. The purpose of this study was to determine the burden of 10 health conditions for a nationally-representative sample of adults aged 50 years and older in the United States. METHODS: Data from the 1998-2014 waves of the Health and Retirement Study were analyzed. At each wave, participants indicated if they were diagnosed with the following 10 conditions: cancer, chronic obstructive pulmonary disease (COPD), congestive heart failure, diabetes, back pain, hypertension, a fractured hip, myocardial infarction, rheumatism or arthritis, and a stroke. Years lived with a disability and years of life lost to premature mortality were summed for calculating DALYs. Sample weights were utilized in the analyses to make the DALY estimates nationally-representative. Results for the DALYs were presented in thousands. RESULTS: There were 30,101 participants included. Sex stratified DALY estimates ranged from 4092 (fractured hip)-to-178,055 (hypertension) for men and 13,621 (fractured hip)-to-200,794 (hypertension) for women. The weighted overall DALYs were: 17,660 for hip fractures, 62,630 for congestive heart failure, 64,710 for myocardial infarction, 90,337 for COPD, 93,996 for stroke, 142,012 for cancer, 117,534 for diabetes, 186,586 for back pain, 333,420 for arthritis, and 378,849 for hypertension. In total, there were an estimated 1,487,734 years of healthy life lost from the 10 health conditions examined over the study period. CONCLUSIONS: The burden of these health conditions accounted for over a million years of healthy life lost for middle-aged and older Americans over the 16 year study period. Our results should be used to inform healthcare providers and guide health interventions aiming to improve the health of middle-aged and older adults. Moreover, shifting health policy and resources to match DALY trends may help to improve quality of life during aging and longevity.

What Types of Treatment Are Provided for Patients With Carpal Tunnel Syndrome? A Retrospective Analysis of Commercial Insurance.

BACKGROUND: Treatment of carpal tunnel syndrome (CTS) in commercially insured patients across the spectrum of provider types rarely has been described. OBJECTIVE: To describe patterns of types of treatment for patients with CTS using a large commercial insurance database. DESIGN: Retrospective cohort descriptive study. SETTING: Administrative health data from the Clinformatics Data Mart (OptumInsight, Eden Prairie, MN). PATIENTS: Adults with a primary diagnosis of CTS seen from between January 2010 to December 2012 who had a total of 48 months of continuous data (12 months before diagnosis and 36 months after diagnosis) (n = 24,931). OUTCOMES: Frequency of types of treatment (heat, manual therapy, positioning, steroids, stretching, surgery) by number of treatments, number of visits, provider type, and characteristics. RESULTS: Fifty-four percent of patients received no reported treatment, and 50.4% had no additional visits. Surgery (42.5%) and positioning (39.8%) were the most frequent single treatments. Patients who were seen by orthopedist for their first visit more frequently received some treatment (75.1%) and at least 1 additional visit (74.1%) compared with those seen by general practitioners (59.5%, 57.5%, respectively) or other providers (65.4%, 68.4, respectively). Orthopedists more frequently prescribed positioning devices (26.8%) and surgery (36.8%) than general practitioners (18.8%, 14.1%, respectively) or other providers (15.7%, 19.7%, respectively). Older adults more frequently had CTS surgery, as did people who lived in the Midwest. Overall, only 24% of patients with CTS had surgery. CONCLUSIONS: For more than one-half of patients with CTS no treatment was provided after an initial visit. Surgery rates were much lower than what has previously been reported in the literature. Generally, patients with CTS receive treatments that are supported by current treatment guidelines. LEVEL OF EVIDENCE: NA.

Current Risk Adjustment and Comorbidity Index Underperformance in Predicting Post-Acute Utilization and Hospital Readmissions After Joint Replacements: Implications for Comprehensive Care for Joint Replacement Model.

OBJECTIVE: To compare the performances of 3 comorbidity indices, the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, and the Centers for Medicare & Medicaid Services (CMS) risk adjustment model, Hierarchical Condition Category (HCC), in predicting post-acute discharge settings and hospital readmission for patients after joint replacement. METHODS: A retrospective study of Medicare beneficiaries with total knee replacement (TKR) or total hip replacement (THR) discharged from hospitals in 2009-2011 (n = 607,349) was performed. Study outcomes were post-acute discharge setting and unplanned 30-, 60-, and 90-day hospital readmissions. Logistic regression models were built to compare the performance of the 3 comorbidity indices using C statistics. The base model included patient demographics and hospital use. Subsequent models included 1 of the 3 comorbidity indices. Additional multivariable logistic regression models were built to identify individual comorbid conditions associated with high risk of hospital readmissions. RESULTS: The 30-, 60-, and 90-day unplanned hospital readmission rates were 5.3%, 7.2%, and 8.5%, respectively. Patients were most frequently discharged to home health (46.3%), followed by skilled nursing facility (40.9%) and inpatient rehabilitation facility (12.7%). The C statistics for the base model in predicting post-acute discharge setting and 30-, 60-, and 90-day readmission in TKR and THR were between 0.63 and 0.67. Adding the Charlson Comorbidity Index, the Elixhauser Comorbidity Index, or HCC increased the C statistic minimally from the base model for predicting both discharge settings and hospital readmission. The health conditions most frequently associated with hospital readmission were diabetes mellitus, pulmonary disease, arrhythmias, and heart disease. CONCLUSION: The comorbidity indices and CMS-HCC demonstrated weak discriminatory ability to predict post-acute discharge settings and hospital readmission following joint replacement.

Variation in Functional Status After Hip Fracture: Facility and Regional Influence on Mobility and Self-Care.

BACKGROUND: Recent reports show substantial geographic variation in postacute health care spending. Little is known about variation in functional outcomes after postacute rehabilitation for patients with hip fracture. We examined variation in mobility and self-care after hip fracture rehabilitation across inpatient rehabilitation facilities (IRFs), hospital referral regions (HRRs) and states. METHODS: Retrospective cohort study using data from the Centers for Medicare and Medicaid Services (CMS) from 2006 to 2009. Study sample included 149,258 records from patients 66 years and older at 1,166 IRFs located within 292 HRRs and across 50 states. Hip fracture cases were defined by CMS impairment group codes (08.11, 08.12). Hierarchical generalized linear models were used to assess discharge mobility and self-care functional status, adjusting for individual patient characteristics and the random effect of IRFs, HRRs, and states. RESULTS: Variation in discharge mobility status as assessed by the intraclass correlation percentage (ICC%) was 8.8% across IRFs, 4.0% across HRRs, and 1.8% across states. For self-care, the ICCs were 10.2% across IRFs, 4.8% across HRRs, and 2.4% across states. The range of discharge mobility scores (maximum functional status rating to minimum functional status rating) showed a 9.6-point difference for IRFs, 6.5 for regions, and 2.6 for states. Range of discharge self-care scores were 13.1 for IRFs, 6.8 for HRRs, and 3.4 for states. CONCLUSION: Variation in functional status following postacute hip fracture rehabilitation appears to occur primarily at the level of facilities rather than geographic location.

Fear of Falling in Older Mexican Americans: A Longitudinal Study of Incidence and Predictive Factors.

OBJECTIVES: To determine predictors of fear of falling in older Mexican Americans over time. DESIGN: Longitudinal study. SETTING: Community-dwelling residents throughout California, Colorado, New Mexico, Arizona, and Texas. PARTICIPANTS: Community-dwelling Mexican Americans aged 72 and older participating in the Hispanic Established Populations for the Epidemiologic Study of the Elderly from 2000-01 to 2010-11 (N = 1,682). MEASUREMENTS: Fear of falling was measured at baseline and at each subsequent wave. Baseline demographic and clinical variables included social support, fall history, depression symptoms, Mini-Mental State Examination (MMSE) score, activity of daily living (ADL) and instrumental ADL (IADL) limitations, and chronic health conditions. RESULTS: Nine hundred fifty three (56.7%) subjects reported fear of falling at baseline, 262 of whom reported severe fear of falling. The predictors of reporting any fear of falling over time included female sex, frequent familial interaction, depression, chronic health conditions, IADL limitations, higher MMSE score, and three or more falls in the last 12 months. Predictors of severe fear of falling included older age, female sex, married, depressive symptoms, chronic health conditions, IADL limitations, higher MMSE score, and fall history. Protective factors included frequent friend interaction and higher levels of education. CONCLUSION: Fear of falling is prevalent in older Mexican-American adults. The presence of friends nearby was shown to be protective against, whereas the presence of family nearby was shown to be predictive of fear of falling.

Examining the Association Between Comorbidity Indexes and Functional Status in Hospitalized Medicare Fee-for-Service Beneficiaries.

BACKGROUND: Medicare data from acute hospitals do not contain information on functional status. This lack of information limits the ability to conduct rehabilitation-related health services research. OBJECTIVE: The purpose of this study was to examine the associations between 5 comorbidity indexes derived from acute care claims data and functional status assessed at admission to an inpatient rehabilitation facility (IRF). Comorbidity indexes included tier comorbidity, Functional Comorbidity Index (FCI), Charlson Comorbidity Index, Elixhauser Comorbidity Index, and Hierarchical Condition Category (HCC). DESIGN: This was a retrospective cohort study. METHODS: Medicare beneficiaries with stroke, lower extremity joint replacement, and lower extremity fracture discharged to an IRF in 2011 were studied (N=105,441). Data from the beneficiary summary file, Medicare Provider Analysis and Review (MedPAR) file, and Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) file were linked. Inpatient rehabilitation facility admission functional status was used as a proxy for acute hospital discharge functional status. Separate linear regression models for each impairment group were developed to assess the relationships between the comorbidity indexes and functional status. Base models included age, sex, race/ethnicity, disability, dual eligibility, and length of stay. Subsequent models included individual comorbidity indexes. Values of variance explained (R(2)) with each comorbidity index were compared. RESULTS: Base models explained 7.7% of the variance in motor function ratings for stroke, 3.8% for joint replacement, and 7.3% for fracture. The R(2) increased marginally when comorbidity indexes were added to base models for stroke, joint replacement, and fracture: Charlson Comorbidity Index (0.4%, 0.5%, 0.3%), tier comorbidity (0.2%, 0.6%, 0.5%), FCI (0.4%, 1.2%, 1.6%), Elixhauser Comorbidity Index (1.2%, 1.9%, 3.5%), and HCC (2.2%, 2.1%, 2.8%). LIMITATION: Patients from 3 impairment categories were included in the sample. CONCLUSIONS: The 5 comorbidity indexes contributed little to predicting functional status. The indexes examined were not useful as proxies for functional status in the acute settings studied.

Stability and Change in Activities of Daily Living Among Older Mexican Americans.

BACKGROUND: Longitudinal studies of activities of daily living (ADL) in older adults have identified numerous factors associated with declining ability. Analyses based on population averages may not observe distinct subgroups whose ADL trajectories differ. METHODS: We used latent class models to identify subgroups of trajectories in a sample from the Hispanic Established Populations for Epidemiologic Study of the Elderly, a population-based study of noninstitutionalized Mexican Americans aged 65 and older from five Southwestern states (n = 2584). RESULTS: Three distinct trajectories of ADL limitations were identified and characterized as stable, delayed, and rapid ADL increase. Sex (female), diabetes, and arthritis were associated with increased odds of membership in the delayed and rapid groups compared with the stable group. Stroke had a differential magnitude of effect on ADL limitations across the stable (ß = 1.11, p < .001), delayed (ß = 0.52, p < .001), and rapid groups (ß = 0.12, p < .05). Hip fracture was associated with increased limitations in the stable group (ß = 1.27, p < .001) but not in the rapid group. Church attendance was associated with fewer limitations in all groups with a larger effect in the stable group (ß = -0.87, p < .001) compared with the rapid group (ß = -0.10, p < .05). CONCLUSIONS: Substantial heterogeneity exists in changes in ADL disability over time among older Mexican Americans. Attempts at maintaining function may benefit from targeting reductions in comorbidities and acute health events associated with disability.

The Role of Physical Activity and Physical Function on the Risk of Falls in Older Mexican Americans.

We investigated the relationship between physical activity and physical function on the risk of falls over time in a cohort of Mexican-American adults aged 75 and older from the Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE). Participants were divided into four groups according to their level of physical activity and physical function: low physical activity and low physical function (n = 453); low physical activity and high physical function (n = 54); high physical activity and low physical function (n = 307); and high physical activity and high physical function (n = 197). Using generalized linear equation estimation, we showed that participants with high physical activity and low physical function had a greater fall risk over time, followed by the high physical activity and high physical function group. Participants seldom took part in activities that improve physical function. To prevent falls, modifications to physical activity should be made for older Mexican Americans.

Association Between Lower Extremity Performance and Health-Related Quality of Life in Elderly Mexican Americans.

OBJECTIVE: To examine the longitudinal association between levels of lower extremity performance (LEP) and health-related quality of life (HRQoL) in older Mexican Americans aged 72 years or older participating in the Hispanic Established Population for the Epidemiological Study of the Elderly (2000-2006). METHOD: LEP was measured in 621 non-institutionalized participants with the Short Physical Performance Battery (SPPB). Participants were divided into high (SPPB score 10-12), intermediate (SPPB score 7-9), and low (SPPB score 0-6) groups based on LEP. HRQoL was assessed using the Medical Outcomes Study Short Form (SF-36), which includes a Physical Composite Scale (PCS) and a Mental Composite Scale (MCS). RESULTS: Participants in the high LEP group had slower rates of decline in the PCS, and those in the intermediate LEP group had slower rates of decline in the MCS score over time. DISCUSSION: Increased LEP was associated with slower rates of decline in physical and mental HRQoL in older Mexican Americans.

Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service Medicare patients.

IMPORTANCE: The Centers for Medicare & Medicaid Services recently identified 30-day readmission after discharge from inpatient rehabilitation facilities as a national quality indicator. Research is needed to determine the rates and factors related to readmission in this patient population. OBJECTIVE: To determine 30-day readmission rates and factors related to readmission for patients receiving postacute inpatient rehabilitation. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study of records for 736,536 Medicare fee-for-service beneficiaries (mean age, 78.0 [SD, 7.3] years) discharged from 1365 inpatient rehabilitation facilities to the community in 2006 through 2011. Sixty-three percent of patients were women, and 85.1% were non-Hispanic white. MAIN OUTCOMES AND MEASURES: Thirty-day readmission rates for the 6 largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. RESULTS: Mean rehabilitation length of stay was 12.4 (SD, 5.3) days. The overall 30-day readmission rate was 11.8% (95% CI, 11.7%-11.8%). Rates ranged from 5.8% (95% CI, 5.8%-5.9%) for patients with lower extremity joint replacement to 18.8% (95% CI, 18.8%-18.9%). for patients with debility. Rates were highest in men (13.0% [ 95% CI, 12.8%-13.1%], vs 11.0% [95% CI, 11.0%-11.1%] in women), non-Hispanic blacks (13.8% [95% CI, 13.5%-14.1%], vs 11.5% [95% CI, 11.5%-11.6%] in whites, 12.5% [95% CI, 12.1%-12.8%] in Hispanics, and 11.9% [95% CI, 11.4%-12.4%] in other races/ethnicities), beneficiaries with dual eligibility (15.1% [95% CI, 14.9%-15.4%], vs 11.1% [95% CI, 11.0%-11.2%] for no dual eligibility), and in patients with tier 1 comorbidities (25.6% [95% CI, 24.9%-26.3%], vs 18.9% [95% CI, 18.5%-19.3%] for tier 2, 15.1% [95% CI, 14.9%-15.3%] for tier 3, and 9.9% [95% CI, 9.9%-10.0%] for no tier comorbidities). Higher motor and cognitive functional status were associated with lower hospital readmission rates across the 6 impairment categories. Adjusted readmission rates by state ranged from 9.2% to 13.6%. Approximately 50% of patients rehospitalized within the 30-day period were readmitted within 11 days of discharge. Medicare Severity Diagnosis-Related Group codes for heart failure, urinary tract infection, pneumonia, septicemia, nutritional and metabolic disorders, esophagitis, gastroenteritis, and digestive disorders were common reasons for readmission. CONCLUSIONS AND RELEVANCE: Among postacute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. Further research is needed to understand the causes of readmission.

Prevalence and factors associated with frailty among Peruvian older adults.

The objective of this study is to examine the prevalence and factors associated with frailty in Peruvian Navy Veteran's older adults and family members. A total of 311 non-institutionalized men and women aged 60 years and older, from the Geriatrics Service of the Peruvian Navy Medical Center (Centro Médico Naval "Cirujano Mayor Santiago Távara") were assessed between May and October 2010. Frailty was defined as having two or more of the following components: (1) unintentional weight-loss, (2) weakness (lowest 20% in grip-strength), (3) self-reported exhaustion, and (4) slow walking speed (lowest 20% 8-m walk-time in seconds). Additionally, information on socio-demographic factors, medical conditions, depressive symptoms, disability, and cognitive function were obtained. Of the 311 participants, 78 (25.1%) were not frail, 147 (47.3%) were pre-frail, and 86 (27.8%) were frail. Using logistic regression analysis, we found that older age, being married, falls in the last year and disability were factors significantly associated with being frail. We conclude that prevalence of pre-frail and frail status in Peruvian Navy Veterans and family members is high. Our data reports risk factors for frailty that have been reported in the past in other population groups. A larger sample and longitudinal follow-up are needed to design and implement comprehensive geriatric interventions that can benefit Peruvian Navy Veteran's older adults at risk of becoming frail.

Border health in the shadow of the Hispanic paradox: issues in the conceptualization of health disparities in older Mexican Americans living in the Southwest.

Mexican Americans have demonstrated lower than what would be expected mortality rates and disease prevalence, given their overrepresentation among those living in poverty. However, Mexican Americans living along the US-Mexico border have been documented as carrying a higher burden of disease and disability that seems to contradict or at least challenge evidence in support of a "Hispanic Paradox". The purpose of this paper is to evaluate the concept of border health as it relates to the conceptualization and measurement of health outcomes in older Mexican Americans living in the Southwest United States. Data for this study comes from the Hispanic Established Populations for the Epidemiologic Studies of the Elderly (Hispanic EPESE) wave 1 and mortality files up to wave 5. Border residence was determined using La Paz Agreement county and distance from a port of entry classifications. Statistical analysis was conducted to assess border versus non-border differences in cause of death, disability, disease prevalence and premature mortality. Adjusted regression models were used to predict cause of death, disability and disease-free life expectancy and premature mortality (i.e. occurring before life expectancy). Interaction models between border/non-border and median income were also performed. Finally, distance from the US-Mexico border was used to determine the effect of distance to the US-Mexico border in border-residing participants. The findings from this study indicate that participants in the HEPESE were more likely to be alive at Wave 5 if they resided in a border county, however more likely to transition into ADL disability status. These findings were not explained by behaviors, duration in the US or sociocultural characteristics of where they lived. Additionally, Hispanic EPESE subjects that lived in the border region were more likely to have died from old age and were less likely to be lost to follow up. Interaction models revealed significant effects for diabetes as a cause of death. Moreover, distance from a US-Mexico port of entry was significant for being alive at wave 5 for border-residing participants. Relative to non-border residing participants, border residing Mexican Americans in the Hispanic EPESE did not carry a uniformly higher burden of disease, however had a significantly greater odds of 10 year survival. These findings bring up issues of measurement and the importance of geographic location when it comes to evaluating disease burden and mortality in Mexican Americans.