A comparison of prognosis calculators for geriatric trauma: A Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium study.

BACKGROUND: The nine-center Prognostic Assessment of Life and Limitations After Trauma in the Elderly consortium has validated the Geriatric Trauma Outcome Score (GTOS) as a prognosis calculator for injured elders. We compared GTOS' performance to that of the Trauma Injury Severity Score (TRISS) in a multicenter sample. METHODS: Three Prognostic Assessment of Life and Limitations After Trauma in the Elderly centers not submitting subjects to the GTOS validation study identified subjects aged 65 years to 102 years admitted from 2000 to 2013. GTOS was specified using the formula [GTOS = age + (Injury Severity Score [ISS] × 2.5) + 22 (if transfused packed red cells (PRC) at 24 hours)]. TRISS uses the Revised Trauma Score (RTS), dichotomizes age (<55 years = 0 and ≥55 years = 1), and was specified using the updated 1995 beta coefficients. TRISS Penetrating was specified as [TRISSP = -2.5355 + (0.9934 × RTS) + (-0.0651 × ISS) + (-1.1360 × Age)]. TRISS Blunt was specified as [TRISSB = -0.4499 + (0.8085 × RTS Total) + (-0.0835 × ISS) + (-1.7430 × Age)]. Each then became the sole predictor in a separate logistic regression model to estimate probability of mortality. Model performances were evaluated using misclassification rate, Brier score, and area under the curve. RESULTS: Demographics (mean + SD) of subjects with complete data (N = 10,894) were age, 78.3 years ± 8.1 years; ISS, 10.9 ± 8.4; RTS = 7.5 ± 1.1; mortality = 6.9%; blunt mechanism = 98.6%; 3.1 % of subjects received PRCs. The penetrating trauma subsample (n = 150) had a higher mortality rate of 20.0%. The misclassification rates for the models were GTOS, 0.065; TRISSB, 0.051; and TRISSP, 0.120. Brier scores were GTOS, 0.052; TRISSB, 0.041; and TRISSP, 0.084. The area under the curves were GTOS, 0.844; TRISSB, 0.889; and TRISSP, 0.897. CONCLUSION: GTOS and TRISS function similarly and accurately in predicting probability of death for injured elders. GTOS has the advantages of a single formula, fewer variables, and no reliance on data collected in the emergency room or by other observers. LEVEL OF EVIDENCE: Prognostic, level II.

The Impact of Mild Cognitive Impairment on Gait and Balance: A Systematic Review and Meta-Analysis of Studies Using Instrumented Assessment.

BACKGROUND: In addition to cognitive deficits, people with mild cognitive impairment (MCI) can experience motor dysfunction, including deficits in gait and balance. Objective, instrumented motor performance assessment may allow the detection of subtle MCI-related motor deficits, allowing early diagnosis and intervention. Motor assessment under dual-task conditions may increase diagnostic accuracy; however, the sensitivity of different cognitive tasks is unclear. OBJECTIVE: To systematically review the extant literature focusing on instrumented assessment of gait and balance parameters for discriminating MCI patients from cognitively intact peers. METHODS: Database searches were conducted in PubMed, EMBASE, Cochrane Library, PsycINFO and Web of Science. Inclusion criteria were: (1) clinically confirmed MCI; (2) instrumented measurement of gait and/or balance; (3) English language, and (4) reporting gait or balance parameters which could be included in a meta-analysis for discriminating between MCI patients and cognitively intact individuals based on weighted effect size (d). RESULTS: Fourteen studies met the inclusion criteria and reported quantitative gait (n = 11) or postural balance (n = 4) parameters to be included in the meta-analysis. The meta-analysis revealed that several gait parameters including velocity (d = -0.74, p < 0.01), stride length (d = -0.65, p < 0.01), and stride time (mean: d = 0.56, p = 0.02; coefficient of variation: d = 0.50, p < 0.01) discriminated best between MCI and healthy controls under single-task conditions. Importantly, dual-task assessment increased the discriminative power of gait variables wherein gait variables with counting tasks appeared to be more sensitive (range d = 0.84-1.35) compared to verbal fluency tasks such as animal naming (range d = 0.65-0.94). Balance parameters identified as significant discriminators were anterior-posterior (d = 0.49, p < 0.01) and mediolateral (d = -0.34, p = 0.04) sway position in the eyes-open condition but not eyes-closed condition. CONCLUSION: Existing studies provide evidence that MCI affects specific gait parameters. MCI-related gait changes were most pronounced when subjects are challenged cognitively (i.e., dual task), suggesting that gait assessment with an additional cognitive task is useful for diagnosis and outcome analysis in the target population. Static balance seems to also be affected by MCI, although limited evidence exists. Instrumented motor assessment could provide a critical opportunity for MCI diagnosis and tailored intervention targeting specific deficits and potentially slowing progression to dementia. Further studies are required to confirm our findings.

Preparing for an Aging World: Engaging Biogerontologists, Geriatricians, and the Society.

Although the demographic revolution has produced hundreds of millions people aged 65 and older, a substantial segment of that population is not enjoying the benefits of extended healthspan. Many live with multiple chronic conditions and disabilities that erode the quality of life. The consequences are also costly for society. In the United States, the most costly 5% of Medicare beneficiaries account for approximately 50% of Medicare's expenditures. This perspective summarizes a recent workshop on biomedical approaches to best extend healthspan as way to reduce age-related dysfunction and disability. We further specify the action items necessary to unite health professionals, scientists, and the society to partner around the exciting and palpable opportunities to extend healthspan.

Healthy aging rounds: using healthy-aging mentors to teach medical students about physical activity and social support assessment, interviewing, and prescription.

Medical students underestimate the health and functional status of community-dwelling older adults and have little experience in health promotion interviewing or prescribing physical activity. The goal was to provide third-year University of Arizona medical students with an opportunity to gain a broader and evidence-based understanding of healthy aging, with specific focus on physical activity and social engagement. Students engaged in one-on-one conversations with healthy older adult mentors and practiced assessment, interviewing and prescription counseling for physical activity and social support. This 2-hour mandatory interactive educational offering improved student attitudes and knowledge about healthy aging and provided hands-on health promotion counseling experience.

Comorbidities play a larger role in predicting health-related quality of life compared to having an ostomy.

BACKGROUND: Previous research suggests an ostomy worsens health-related quality of life (HR-QOL), but comorbidities also can affect HR-QOL. METHODS: Eligible patients had abdominal operation with ostomy (cases) or similar procedure without ostomy (controls). Patients were recruited for this case-control study from 3 Veterans Affairs hospital medical and pharmacy records. Comorbidities were assessed with Charlson-Deyo Comorbidity Index. Multinomial logistic regression evaluated the impact of comorbidities and having an ostomy on HR-QOL, measured using the Medical Outcomes Study Short Form 36 for Veterans. RESULTS: A total of 237 ostomates (cases) and 268 controls were studied. Average age was 69 years; 64% of cases had colostomy, 36% ileostomy. Twenty-nine percent of patients had a high level of comorbidities. Cases and controls were similar except for reasons for undergoing surgery. High comorbidity was a significant predictor of low HR-QOL in 6 domains of the Short Form 36 for Veterans; having an ostomy was a significant predictor in 4. CONCLUSIONS: High comorbidity significantly influences low HR-QOL and impacted more domains than having an ostomy.

Are health services research methods a match for CAM?

BACKGROUND: Many complementary and alternative medicine (CAM) researchers believe that a new set of research methods is needed to study CAM. Health services research (HSR) is listed as a new research goal in the National Center for Complementary and Alternative Medicine 2005-2009 strategic plan. Does HSR offer solutions to the research needs of CAM? This article presents an overview of HSR, a summary of the HSR studies that have been published in CAM, and discussions of what HSR might offer CAM and what studies of CAM might offer conventional HSR. DISCUSSION: Our literature search, which was performed at the University of Arizona, found 84 published CAM HSR studies. A comparison of the search results-mostly surveys of CAM users or providers and economic outcome studies-with the breadth of topics that may be studied using HSR, showed that research in this field has not reached its potential. More work, including studies of interactions between patient, provider, and the system as well as patient-centered outcomes studies, is needed. Several areas in which CAM could benefit from HSR were identified and discussed. These included studies supporting the integration of CAM and conventional medicine, insurance coverage for CAM therapies, the development practice guidelines, and studies of the effectiveness and cost-effectiveness of CAM therapies and whole medical systems. The study of CAM, especially studies focusing on patients' attraction to CAM, may also help expand the topics and methods of conventional HSR. SUMMARY: HSR methods may address many of CAM's methodological challenges and improve clinical, patient-centered, and economic outcomes across all systems of care-both conventional and CAM.

Development and validation of a diabetes mellitus severity index: a risk-adjustment tool for predicting health care resource use and costs.

STUDY OBJECTIVE: To develop and validate a diabetes mellitus-specific risk-adjustment tool--the diabetes severity index (DSI)--to assist in predicting health care costs and resources within populations of patients with diabetes. DESIGN: Retrospective analysis of clinical and resource use for patients with a diagnosis of diabetes mellitus. Model estimation was conducted with half the sample, and validation analysis was conducted with the other half. SETTING: Southern Arizona Veterans Affairs Health Care System. PATIENTS: Seven hundred thirty-four patients with diabetes (710 men, 24 women; mean age 66 yrs). MEASUREMENTS AND MAIN RESULTS: Clinical measures of diabetes severity (known as the DSI) were used to predict three health care resource outcomes: risk of hospitalization, and total and ambulatory health care costs. Validity of the DSI was assessed by comparing the DSI with the revised chronic disease score (CDS). The DSI weights ranged from -471.5-3081.2 for total health care costs, from -304.3-1582.1 for outpatient costs, and -0.19-0.93 for risk of hospitalization. The DSI explained 6-8% of the variance in total and ambulatory costs and performed significantly (p<0.05) better than demographics alone, but was similar to the CDS. When the DSI was used with the CDS, up to 8% of variability in costs and use were explained. CONCLUSION: The DSI was developed to stratify veterans with diabetes according to diabetes severity and comorbidity. Since additional variance in medical care costs were explained by combining the DSI and CDS, the two indexes may explain different dimensions of a patient's severity of diabetes. However, the utility of such an index based on clinical measures to predict short-term use may be limited due to low yet significant variability explained in the outcomes.