Racial differences in running and landing measures associated with injury risk vary by sex.

It is unknown whether running and landing mechanics differ between racial groups despite injury disparities between African Americans (AA) and white Americans (WA). This study aimed to identify potential racial differences in running and landing mechanics and understand whether anthropometric, strength, and health status factors contribute to these differences. Venous blood samples, anthropometry, lower-extremity strength, and health status assessments were collected (n = 84, 18-30y). Three-dimensional motion capture and force plate data were recorded during 7 running and 7 drop vertical jump trials. Racial effects were determined, and regression models evaluated explanatory factors. AA females ran with longer stance times (p = 0.003) than WA females, while AA males ran with smaller loading rates (p = 0.046) and larger peak vertical ground reaction forces (p = 0.036) than WA males. Frontal plane knee range of motion during landing was greater in AA females (p = 0.033) than WA females; larger waist circumference and weaker knee extension strength accounted for this significance. Although outcome measures were associated with physiologic, anthropometric, and activity measures, their explanatory power for race was ambiguous, except for knee range of motion in females. Modifiable factors explaining racial effects during landing in females are potential intervention targets to reduce racial health disparities in running and landing injuries.

Long term impact of Hurricane Sandy on hospital admissions of older adults.

RATIONALE: In the weeks and months following a disaster, acute illness and injuries requiring hospital admission increase. It is not known whether disaster exposure is associated with increased risk for hospitalization in the years after a disaster. OBJECTIVE: We examined the extent to which disaster exposure is associated with hospitalization two years after Hurricane Sandy. The analyses fill a clinical gap in our understanding of long-term physical health consequences of disaster exposure by identifying older adults at greatest risk for hospitalization two years after disaster exposure. METHOD: Survey data from a longitudinal panel study collectedbefore and after Hurricane Sandy were linked with Medicare inpatient files in order to assess the impact of Hurricane Sandy on hospital admissions two years following the hurricane. RESULTS: We found that people who reported experiencing a lot of fear and distress in the midst of Hurricane Sandy were at an increased risk of being hospitalized two years after the hurricane [Hazard Ratio = 1.75; 95% CI (1.12-2.73)]. Findings held after controlling for pre-disaster demographics, social risks, chronic conditions, hospitalizations during the year before the hurricane, and decline in physical functioning. CONCLUSIONS: These findings are the first to show that disaster exposure increases the risk for hospital admissions two years after a disaster. Controlling for known risk factors for hospitalization, older adults who experience high levels of fear and distress during a disaster are more likely to be hospitalized two years following the disaster than older adults who do not have this experience.

Racial differences in gait mechanics.

The effect of race has rarely been investigated in biomechanics studies despite racial health disparities in the incidence of musculoskeletal injuries and disease, hindering both treatment and assessment of rehabilitation. The purpose of this study was to test the hypothesis that racial differences in gait mechanics exist between African Americans (AA) and white Americans (WA). Ninety-two participants (18-30 years old) were recruited with equal numbers in each racial group and sex. Self-selected walking speed was measured for each participant. 3D motion capture and force plate data were recorded during 7 walking trials at regular and fast set speeds. Step length, step width, peak vertical ground reaction force, peak hip extension, peak knee flexion, and peak ankle plantarflexion were computed for all trials at both set speeds. Multivariate and post-hoc univariate ANOVA models were fit to determine main and interaction effects of sex and race (SPSS V26, α = 0.05). Self-selected walking speed was slower in AA (p = 0.004, ƞp2 = 0.088). No significant interactions between race and sex were identified. Males took longer steps (regular: p < 0.001, ƞp2 = 0.288, fast: p < 0.001, ƞp2 = 0.193) and had larger peak knee flexion (regular: p = 0.007, ƞp2 = 0.081, fast: p < 0.001, ƞp2 = 0.188) and ankle plantarflexion angles (regular: p = 0.050, ƞp2 = 0.044, fast: p = 0.049, ƞp2 = 0.044). Peak ankle plantarflexion angle (regular: p = 0.012, ƞp2 = 0.071, fast: p < 0.001, ƞp2 = 0.137) and peak hip extension angle during fast walking (p = 0.007, ƞp2 = 0.083) were smaller in AA. Equivalency in gait measures between racial groups should not be assumed. Racially diverse study samples should be prioritized in the development of future research and individualized treatment protocols.

Health Burden, Support Adequacy, and Depressive Symptoms in Older Men With HIV.

BACKGROUND AND OBJECTIVES: Older adults with HIV face greater health burden than HIV-uninfected counterparts. Little is known about resources that might mediate the influence of physiological health burden on psychological well-being. Informed by the stress process model, we assessed the influence of multifaceted health burden indicators on depressive symptoms and evaluated the mediating effects of social support adequacy. RESEARCH DESIGN AND METHODS: This cross-sectional study used structural equation modeling with data from 640 older men who participated in the Research on Older Adults with HIV study in the United States. Health burden assessment included number of age-related chronic conditions, multiple HIV-related chronic conditions, and self-rated health. Perceptions of instrumental and emotional support adequacy measured support as a coping resource. Depressed mood as assessed by the 10-item Center for Epidemiologic Studies Depression Scale was the indicator of psychological well-being. RESULTS: Higher incidence of age-related conditions and worse self-rated health was significantly associated with more depressed mood. Self-rated health and HIV-related conditions showed a significant indirect effect on depressed mood via emotional support adequacy. DISCUSSION AND IMPLICATIONS: Each dimension of health burden demonstrated a distinct pathway to psychological well-being for men with HIV, which should be considered when prioritizing care plans. Complementing research on medical interventions for people with HIV, these findings suggest that nonpharmacological interventions may be important for improving overall well-being.

Effects of Perceived Discrimination on Depressive Symptoms Among Black Men Residing in the United States: A Meta-Analysis.

Research reports that perceived discrimination is positively associated with depressive symptoms. The literature is limited when examining this relationship among Black men. This meta-analysis systematically examines the current literature and investigates the relationship of perceived discrimination on depressive symptoms among Black men residing in the United States. Using a random-effects model, study findings indicate a positive association between perceived discrimination and depressive symptoms among Black men ( r = .29). Several potential moderators were also examined in this study; however, there were no significant moderation effects detected. Recommendations and implications for future research and practice are discussed.

Unmet Need for Help With Activities of Daily Living Disabilities and Emergency Department Admissions Among Older Medicare Recipients.

Purpose of the Study: This study determined whether self-reports of unmet need for help with activities of daily living (ADL) disabilities are prognostic of emergency department (ED) utilization. Design and Methods: This prospective cohort study of 2,194 community-living, ADL-disabled subjects combined 2004 National Long-Term Care Survey responses with linked Medicare data through 2005. A negative binomial count model was computed to assess the association between unmet ADL need and number of subsequent ED admissions while statistically adjusting for predisposing, enabling, and need characteristics associated with ED admissions among older adults. Results: The adjusted annual incidence rate (IR) for ED admissions was 19% higher for unmet versus met need (IR = 1.19; 95% confidence interval [CI] = 1.00-1.40; p = .047). The IR for ED admissions for falls and injuries was higher for those with unmet ADL versus met ADL need (IR = 1.43; 95% CI = 1.10-1.86), and trended toward significance for ED admissions for skin breakdown (IR = 2.02; 95% CI = 0.97-2.88), but was not significant for ED admissions for dehydration (IR = 1.13; 95% CI= 0.79-1.63). Implications: Unmet ADL need is prognostic of ED admissions, especially for falls and injuries. Future research is needed to determine whether resolution of unmet ADL need reduces ED utilization.

The modeling of medical expenditure data from a longitudinal survey using the generalized method of moments (GMM) approach.

Medical expenditure data analysis has recently become an important problem in biostatistics. These data typically have a number of features making their analysis rather difficult. Commonly, they are heavily right-skewed, contain a large percentage of zeros, and often exhibit large numbers of missing observations because of death and/or the lack of follow-up. They are also commonly obtained from records that are linked to large longitudinal data surveys. In this manuscript, we suggest a novel approach to modeling these data through the use of generalized method of moments estimation procedure combined with appropriate weights that account for both dropout due to death and the probability of being sampled from among the National Long Term Care Survey (NLTCS) subjects. This approach seems particularly appropriate because of the large number of subjects relative to the length of observation period (in months). We also use a simulation study to compare our proposed approach with and without the use of weights. The proposed model is applied to medical expenditure data obtained from the 2004-2005 NLTCS-linked Medicare database. The results suggest that the amount of medical expenditures incurred is strongly associated with higher number of activities of daily living (ADL) disabilities and self-reports of unmet need for help with ADL disabilities. Copyright © 2016 John Wiley & Sons, Ltd.

Hospital readmission among older adults who return home with unmet need for ADL disability.

PURPOSE: This study determined whether returning to the community from a recent hospitalization with unmet activities of daily living (ADL) need was associated with probability of readmission. METHODS: A total of 584 respondents to the 1994, 1999, and/or 2004 National Long-Term Care Surveys (NLTCS) who were hospitalized within 90 days prior to the interview and reported ADL disability at the time of the interview were considered for analysis. Medicare claims linked to the NLTCS provided information about hospital episodes, so those enrolled in Health Maintenance Organizations or Veterans Affairs Medical Centers were not included (n = 62), resulting in a total sample size of 522. ADL disability was defined as needing human help or equipment to complete the task. Unmet ADL need was defined as receiving inadequate or no help for one or more ADL disabilities. Disability that began within 90 days of the interview was considered new disability. RESULTS: After adjusting for demographic, health, and functioning characteristics, unmet ADL need was associated with increased risk for hospital readmission (HR: 1.37, 95% CI: 1.03-1.82). Risk of readmission was greater for those with unmet need for new disabilities than those with unmet need for disabilities that were present before the index hospitalization (HR: 1.66, 95% CI: 1.01-2.73). IMPLICATIONS: Many older patients are discharged from the hospital with ADL disability. Those who report unmet need for new ADL disabilities after they return home from the hospital are particularly vulnerable to readmission. Patients' functional needs after discharge should be carefully evaluated and addressed.

Incremental dementia-related expenditures in a medicaid population.

OBJECTIVES: With the growing number of older adults, understanding expenditures associated with treating medical conditions that are more prevalent among older adults is increasingly important. The objectives of this research were to estimate incremental medical encounters and incremental Medicaid expenditures associated with dementia among Indiana Medicaid recipients 40 years or older in 2004. METHODS: A retrospective cohort design analyzing Indiana Medicaid administrative claims files was used. Individuals at least 40 years of age with Indiana Medicaid eligibility during 2004 were included. Patients with dementia were identified via diagnosis codes in claims files between July 2001 and December 2004. Adjusted annual incremental medical encounters and expenditures associated with dementia in 2004 were estimated using negative binomial regression and zero-inflated negative binomial regression models. RESULTS: A total of 18,950 individuals (13%) with dementia were identified from 145,684 who were 40 years or older. The unadjusted mean total annualized Medicaid expenditures for the cohort with dementia ($28,758) were significantly higher than the mean expenditures for the cohort without dementia ($14,609). After adjusting for covariates, Indiana Medicaid incurred annualized incremental expenditures of $9,829 per recipient with dementia. Much of the annual incremental expenditure associated with dementia was driven by the higher number of days in nursing homes and resulting nursing-home expenditures. Drug expenditures accounted for the second largest component of the incremental expenditures. On the basis of disease prevalence and per recipient annualized incremental expenditures, projected incremental annualized Indiana Medicaid spending associated with dementia for persons 40 or more years of age was $186 million. CONCLUSIONS: Dementia is associated with significant expenditures among Medicaid recipients. Disease management initiatives designed to reduce nursing-home use among recipients with dementia may have much potential to decrease Medicaid expenditures associated with dementia.

Volume of home- and community-based services and time to nursing-home placement.

OBJECTIVE: The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients' risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home. DATA SOURCES: Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs. STUDY DESIGN: Enrollees in Indiana Medicaid's Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk. PRINCIPAL FINDINGS: Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77-0.99). CONCLUSIONS: Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.

Volume of home- and community-based Medicaid waiver services and risk of hospital admissions.

OBJECTIVES: To evaluate whether type and volume of Medicaid Home- and Community-Based Services (HCBS) waiver program are associated with risk of hospitalization and whether this association changes over time. DESIGN: Prospective. SETTING: Indiana Medicaid claims data from June 2001 to December 2004. PARTICIPANTS: Medicaid recipients (N=1,354) who enrolled in the Aged and Disabled waiver program between January 2002 and June 2004. MEASUREMENTS: Time to hospital admission since enrollment in the HCBS waiver program, adjusted for demographics, comorbidities, prior use of health services, and volume of HCBS received, including attendant care, homemaking, and home-delivered meals. RESULTS: A greater volume of attendant care, homemaking services, and home-delivered meals was associated with a lower risk of hospitalization. This effect diminished over time for attendant care and homemaking. The risk of hospitalization for subjects receiving 5 hours of attendant care per month was 54% (hazard ratio (HR)=0.46, 95% confidence interval (CI)=0.38-0.57) lower during the first month of enrollment and 20% lower by Month 10 (HR=0.80, 95% CI=0.73-0.88) than for those receiving no attendant care. CONCLUSION: Greater volume of HCBS services was associated with lower risk of hospitalization. The findings highlight the potential importance of assessing and monitoring the volume of HCBS patients receive.

Concomitant use of anticholinergics with acetylcholinesterase inhibitors in Medicaid recipients with dementia and residing in nursing homes.

OBJECTIVES: To evaluate the extent of concomitant use of anticholinergic and cholinesterase inhibitor medications in Medicaid recipients with dementia residing in nursing homes. DESIGN: Cross-sectional survey of medical claims data. SETTING: Indiana Medicaid claims for 2004. PARTICIPANTS: Indiana Medicaid recipients continuously eligible for Medicaid in 2004 aged 65 and older with dementia who were residing in nursing homes and taking cholinesterase inhibitors. MEASUREMENTS: Rates of concomitant anticholinergic and cholinesterase inhibitor use, number of days residents experienced concomitant use, and concomitant use according to therapeutic class and level of anticholinergic activity were determined. RESULTS: A large proportion (46.7%) of 3,251 Medicaid beneficiaries living in nursing homes and taking cholinesterase inhibitors received anticholinergics concomitantly. Anticholinergics designated as Level 3, or having markedly anticholinergic adverse effects, accounted for most of the concomitant anticholinergic use. More than half (58.1%) of the individuals with concomitant anticholinergic use had 100 or more days of such use. CONCLUSION: Nearly half of Indiana Medicaid recipients with dementia residing in nursing homes who were taking cholinesterase inhibitors in 2004 were using anticholinergics concomitantly. Patterns of concomitant use in the population examined may assist practitioners in reviewing their prescribing decisions for this vulnerable population.

Cost of health care and quality outcomes of patients at nurse-managed clinics.

Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nurse-managed clinics are to remain viable.

Comparison of resource utilization for Medicaid dementia patients using nursing homes versus home and community based waivers for long-term care.

BACKGROUND: Medicaid waiver home and community-based long-term care services (HCBS) may provide a partial solution to the escalating costs of long-term care. Persons with dementia can have complex caregiving needs; it is unknown whether their expenditures and resource utilization differ between community-based versus institutional settings. OBJECTIVE: To compare expenditures and resource utilization for Medicaid recipients with dementia who received long-term care through a nursing home versus HCBS waivers. DESIGN: Twelve-month cohort study. SETTING: Indiana Medicaid administrative data from 2001 through 2004. PARTICIPANTS: Medicaid recipients with dementia who lived in the community 6 months before receiving long-term care through nursing homes (N = 1534) or HCBS waivers (N = 174). MEASUREMENTS: Monthly inpatient and emergency department rates and total expenditures adjusted for prior use, demographics, insurance status, and comorbidities. RESULTS: Adjusted rates of inpatient use were stable for nursing home patients (0.06) but significantly increased over 12 months for HCBS recipients (0.07-0.12; P = 0.048). Adjusted total expenditures increased over 12 months from $1419 to $2002 for HCBS recipients (P < 0.001), but remained stable for those in nursing homes ($3413-$3336). Long-term care expenditures were on average $1688 per month higher for those in nursing homes. CONCLUSIONS: The escalation in inpatient use for HCBS waiver recipients suggests that future development of HCBS programs should consider the unique needs of persons with dementia so as to optimize their health outcomes. Despite increasing inpatient use among HCBS recipients, their overall expenditures remained significantly lower than those of nursing home patients.

Prediction of mortality in community-living frail elderly people with long-term care needs.

OBJECTIVES: To develop and validate a prognostic index for mortality in community-living, frail elderly people. DESIGN: Cohort study of Program of All-Inclusive Care for the Elderly (PACE) participants enrolled between 1988 and 1996. SETTING: Eleven PACE sites, a community-based long-term care program that cares for frail, chronically ill elderly people who meet criteria for nursing home placement. PARTICIPANTS: Three thousand eight hundred ninety-nine PACE enrollees. The index was developed in 2,232 participants and validated in 1,667. MEASUREMENTS: Time to death was predicted using risk factors obtained from a geriatric assessment performed by the PACE interdisciplinary team at the time of enrollment. Risk factors included demographic characteristics, comorbid conditions, and functional status. RESULTS: The development cohort had a mean age of 79 (68% female, 40% white). The validation cohort had a mean age of 79 (76% female, 65% white). In the development cohort, eight independent risk factors of mortality were identified and weighted, using Cox regression, to create a risk score: male sex, 2 points; age (75-79, 2 points; 80-84, 2 points; > or = 85, 3 points); dependence in toileting, 1 point; dependence in dressing (partial dependence, 1 point; full dependence, 3 points); malignant neoplasm, 2 points; congestive heart failure, 3 points; chronic obstructive pulmonary disease, 1 point; and renal insufficiency, 3 points. In the development cohort, respective 1- and 3-year mortality rates were 6% and 21% in the lowest-risk group (0-3 points), 12% and 36% in the middle-risk group (4-5 points), and 21% and 54% in the highest-risk group (> 5 points). In the validation cohort, respective 1- and 3-year mortality rates were 7% and 18% in the lowest-risk group, 11% and 36% in the middle-risk group, and 22% and 55% in the highest-risk group. The area under the receiver operating characteristic curve for the point score was 0.66 and 0.69 in the development and validation cohorts, respectively. CONCLUSION: A multidimensional prognostic index was developed and validated using age, sex, functional status, and comorbidities that effectively stratifies frail, community-living elderly people into groups at varying risk of mortality.

Impact of patient selection criteria on prevalence estimates and prevalence of diagnosed dementia in a Medicaid population.

OBJECTIVES: This study estimated the prevalence of diagnosed dementia among Indiana Medicaid beneficiaries in 2004. The dependence of prevalence estimates upon use of several patient selection criteria to identify patients with dementia also was evaluated. METHODS: Indiana Medicaid claims data were analyzed for the period July 1, 2002 to December 31, 2004. An expert panel survey was conducted to assess perceived specificity of ICD codes used in previous studies to define dementia. Prevalence estimates were calculated with varying levels of each selection criteria, that is, ICD code set, interval of data examined, and number of occurrences of dementia-related claims. To assess specificity and sensitivity of the dementia patient selection criteria, Minimum Data Set data for a subset of beneficiaries that resided in a nursing home any time in 2004 were examined. RESULTS: Depending on the patient selection criteria used, estimates of prevalence of diagnosed dementia for individuals 40 years old or older varied from 7.7% to 15.3%, whereas prevalence estimates for individuals 60 years old or older varied from 14.5% to 26.6%. When the following selection criteria were used: (1) occurrence of one or more dementia-related claims, (2) the expert panel ICD set, and (3) up to 30 months of data for defining dementia, the prevalence estimates in the Indiana Medicaid population were 10.9% for individuals 40 years old or older and 20.3% for individuals 60 years old or older. CONCLUSIONS: Careful selection of claims-based criteria for identifying patients with dementia is important because the criteria may affect estimates by 100%. Prevalence of diagnosed dementia among Indiana Medicaid beneficiaries was 3 to 4 times higher than the reported prevalence from a decade ago in Medicaid populations of other states, even when the same patient selection criteria were used. A number of factors beyond increased occurrence of the disease including increased screening, greater likelihood of recording dementia codes in claims, or other factors may be responsible. The combination of patient selection criteria used in this study had good sensitivity, specificity, and accuracy when compared with Minimum Data Set data.

Rates of acute care admissions for frail older people living with met versus unmet activity of daily living needs.

OBJECTIVES: To determine whether older people who do not have help for their activity of daily living (ADL) disabilities are at higher risk for acute care admissions and whether entry into a program that provides for these needs decreases this risk. DESIGN: A longitudinal cohort study. SETTING: Thirteen nationwide sites for the Program of All-inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and long-term care to community-living older adults. PARTICIPANTS: Two thousand nine hundred forty-three PACE enrollees with one or more ADL dependencies. MEASUREMENTS: Unmet needs were defined as the absence of paid or unpaid assistance for ADL disabilities before PACE enrollment. Hospital admissions in the 6 months before PACE enrollment and acute admissions in the first 6 weeks and the 7th through 12th weeks after enrollment were determined. RESULTS: Those who lived with unmet ADL needs before enrollment were more likely to have a hospital admission before PACE enrollment (odds ratio (OR) = 1.28, 95% confidence interval (CI) = 1.01-1.63) and an acute admission in the first 6 weeks after enrollment (OR = 1.45, 95% CI = 1.00-2.09) but not after 6 weeks of receiving PACE services (OR = 0.86, 95% CI = 0.53-1.40). CONCLUSION: Frail older people who live without needed help for their ADL disabilities have higher rates of admissions while they are living with unmet ADL needs but not after their needs are met. With state governments under increasing pressure to develop fiscally feasible solutions for caring for disabled older people, it is important that they be aware of the potential health consequences of older adults living without needed ADL assistance.

Reports of financial disability predict functional decline and death in older patients discharged from the hospital.

BACKGROUND: The financial ability to pay for food and medical care is needed to maintain health in older persons following a serious illness. Therefore, we hypothesize that the inability to pay for basic needs, which we call financial disability, predicts adverse health outcomes in older patients discharged from the hospital. OBJECTIVES: To determine the frequency of reported financial disability in older adults being discharged from a hospital, to determine patient characteristics associated with financial disability, and to examine the relationship between financial disability and functional decline and mortality. DESIGN: Prospective cohort study. SETTING/PARTICIPANTS: Two thousand two hundred patients 70 years and older admitted to the general medicine services at two teaching hospitals in Ohio. MAIN OUTCOME MEASURES: Respondents were interviewed at the time of discharge to determine patients' financial ability to pay for 6 needs: groceries, general bills, medications, medical bills, a small emergency, and a major emergency. We determined functional decline in ability to perform activities of daily living from discharge to 90 days post-hospital discharge, and death 1 year after hospital discharge. RESULTS: Financial disability was reported to be severe (unable to pay for 3-6 needs) for 21% of patients and moderate (unable to pay for 1-2 needs) for 36%. Financial disability was more common and more severe (P<.001) in persons with an annual household income less than $10,000, in persons with fewer than 12 years of formal education, in African Americans, and in women. In patients with no financial disability, moderate financial disability, and severe financial disability, functional decline 3 months after hospital discharge occurred in 15%, 20%, and 25%, respectively (P=.001), and 1-year mortality rates were 24%, 27%, and 32%, respectively (P=.002). After adjustment for potential confounders, the association of financial disability with functional decline (P=.003) and mortality (P=.02) remained significant. CONCLUSION: Reports of financial disability at hospital discharge identified vulnerable older adults with increased risk for functional decline and death. Interventions that alleviate financial disability may improve health outcomes in older adults discharged from hospital.

Variation in care for nonmelanoma skin cancer in a private practice and a veterans affairs clinic.

BACKGROUND: Nonmelanoma skin cancer is the most common malignancy. Multiple therapies prevent recurrence but vary widely in cost. The most common therapies are local destruction, excision, and Mohs surgery (histologically guided tumor removal). Clinical variables that may affect treatment choices can be identified, but little is known about how clinicians choose among therapies. OBJECTIVE: The objective of this study was to learn if variations exist in the treatment of nonmelanoma skin cancer in different practice settings. RESEARCH DESIGN: Prospective cohort study. SUBJECTS: Subjects consisted of consecutive patients with nonmelanoma skin cancer at a university-affiliated private dermatology practice and the dermatology clinic at the nearby affiliated Veterans Affairs (VA) medical center. DATA: We studied data from medical records and patient surveys. RESULTS: Overall, 1777 nonrecurrent nonmelanoma skin cancers were diagnosed in 1375 patients. Compared with the VA site, patients at the private site were younger, more likely to be female, and less likely to be poor, and their tumors were smaller and less likely to be on visible areas of the body. Treatments varied between the 2 sites (P <0.001). The proportions of tumors treated at the private and VA sites, respectively, were 23% and 19% for destruction, 25% and 48% for excision, and 37% and 25% for Mohs surgery. In multiple clinical subgroups, Mohs surgery was more likely to be performed at the private site than at the VA. Moreover, in multivariable models controlling for clinical features that may have affected treatment choice, tumors at the private site were more likely than tumors at the VA to be treated with Mohs surgery (odds ratio, 2.39; 95% confidence interval, 1.54-3.70). CONCLUSIONS: Care for nonmelanoma skin cancer varied at 2 academic practice sites that are near each other and that share some clinician staff. These findings raise questions not only about overuse or underuse of procedures at the 2 sites, but also about systematic differences in patient preferences and/or physician incentives in prepaid and fee-for-service settings.

What explains differences between dementia patients' and their caregivers' ratings of patients' quality of life?

OBJECTIVE: The authors assessed the magnitude of discrepancy between patients' and caregivers' ratings of the patients' quality of life and sought to determine whether the discrepancies are associated with patient characteristics, caregiver characteristics, or the type of relationship between the patient and caregiver. METHODS: A sample of 91 patients with mild-to-moderately severe dementia and their primary family caregiver rated five domains of the patients' subjective quality of life. RESULTS: Agreement between patients and caregivers was low. Caregivers rated patients' quality of life lower than patients rated their own in all five domains. Discrepancies between patients' and caregivers' ratings were not associated with the patients' cognitive performance, level of functioning, nor caregivers' reports of aggressive, attention-seeking, or sexually inappropriate behaviors, nor whether the caregiver lived with or was married to the patient. However, discrepancies were associated with level of caregiver burden and the patients' report of depressive symptoms. Patients with depression reported low quality of life, which matched caregivers' low rating of patients' quality of life. Caregivers who reported higher levels of burden rated patients' quality of life lower than did patients in all five domains of quality of life. CONCLUSIONS: Discrepancies between dementia patients' and their caregivers' ratings of the patients' quality of life are associated with increased levels of caregiver burden, rather than lower levels of patients' functioning. The results of this study support the direct assessment of mild-to-moderate dementia patients about their subjective quality of life.