Changes in older adults' life space during lung cancer treatment: A mixed methods cohort study.

BACKGROUND: Maintenance of function during cancer treatment is important to older adults. Characteristics associated with pretreatment life-space mobility and changes during non-small cell lung cancer (NSCLC) treatment remain unknown. METHODS: This mixed methods cohort study recruited adults age ≥65 with advanced NSCLC starting palliative chemotherapy, immunotherapy, and/or targeted therapy from a Comprehensive Cancer Center, Veterans Affairs, and safety-net clinic. Patients completed geriatric assessments including Life-Space Assessment (LSA) pretreatment and at 1, 2, 4, and 6 months after treatment initiation. LSA scores range from 0 to 120 (greater mobility); LSA <60 is considered restricted. We used mixed-effects models to examine pretreatment LSA, change from 0 to 1 month, and change from 1 to 6 months. A subgroup participated in semistructured interviews pretreatment and at 2 and 6 months to understand the patient experience of life-space change. For each interview participant, we created joint displays of longitudinal LSA scores juxtaposed with illustrative quotes. RESULTS: Among 93 patients, median age was 73 (range 65-94). Mean pretreatment LSA score was 67.1. On average, LSA declined 10.1 points from pretreatment to 1 month and remained stable at 6 months. Pretreatment LSA score was associated with several demographic, clinical, geriatric assessment, and symptom characteristics. LSA decline at 1 month was greater among patients with high anxiety (slope = -12.6 vs. -2.3, p = 0.048). Pretreatment body mass index <21 kg/m2 was associated with LSA improvement from 1 to 6 months (slope = 4.1 vs. -0.04, p = 0.003). Joint displays illustrated the impact of different life-space trajectories on patients' lives in their words. CONCLUSION: Older adults with NSCLC have low pretreatment life space with many developing restricted life space during treatment. Incorporating life-space assessments into clinical cancer care may help older adults concretely visualize how treatment might impact their daily function to allow for informed decision making and identify early changes in mobility to implement supportive interventions.

Examining the association of social risk with heart failure readmission in the Veterans Health Administration.

BACKGROUND: Previous research has found that social risk factors are associated with an increased risk of 30-day readmission. We aimed to assess the association of 5 social risk factors (living alone, lack of social support, marginal housing, substance abuse, and low income) with 30-day Heart Failure (HF) hospital readmissions within the Veterans Health Affairs (VA) and the impact of their inclusion on hospital readmission model performance. METHODS: We performed a retrospective cohort study using chart review and VA and Centers for Medicare and Medicaid Services (CMS) administrative data from a random sample of 1,500 elderly (≥ 65 years) Veterans hospitalized for HF in 2012. Using logistic regression, we examined whether any of the social risk factors were associated with 30-day readmission after adjusting for age alone and clinical variables used by CMS in its 30-day risk stratified readmission model. The impact of these five social risk factors on readmission model performance was assessed by comparing c-statistics, likelihood ratio tests, and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: The prevalence varied among the 5 risk factors; low income (47 % vs. 47 %), lives alone (18 % vs. 19 %), substance abuse (14 % vs. 16 %), lacks social support (2 % vs. <1 %), and marginal housing (< 1 % vs. 3 %) among readmitted and non-readmitted patients, respectively. Controlling for clinical factors contained in CMS readmission models, a lack of social support was found to be associated with an increased risk of 30-day readmission (OR 4.8, 95 %CI 1.35-17.88), while marginal housing was noted to decrease readmission risk (OR 0.21, 95 %CI 0.03-0.87). Living alone (OR: 0.9, 95 %CI 0.64-1.26), substance abuse (OR 0.91, 95 %CI 0.67-1.22), and having low income (OR 1.01, 95 %CI 0.77-1.31) had no association with HF readmissions. Adding the five social risk factors to a CMS-based model (age and comorbid conditions; c-statistic 0.62) did not improve model performance (c-statistic: 0.62). CONCLUSIONS: While a lack of social support was associated with 30-day readmission in the VA, its prevalence was low. Moreover, the inclusion of some social risk factors did not improve readmission model performance. In an integrated healthcare system like the VA, social risk factors may have a limited effect on 30-day readmission outcomes.

Functional Outcomes After Transurethral Resection of the Prostate in Nursing Home Residents.

OBJECTIVES: To understand outcomes of transurethral resection of the prostate (TURP) or transurethral laser incision of the prostate (TULIP) for the treatment of bladder outlet obstruction in men with high levels of functional dependence, which are poorly understood. DESIGN: Retrospective cohort study. SETTING: U.S. nursing homes (NHs). PARTICIPANTS: Male NH residents aged 65 and older who underwent TURP or TULIP in the United States between 2005 and 2008 (N = 2,869). MEASUREMENTS: Changes in activities of daily living (ADLs), Foley catheter status, and survival up to 12 months after surgery were examined. Multivariate regression was used to determine risk of having a Foley catheter 1 year after surgery. RESULTS: Sixty-one percent of the cohort had a Foley catheter before the procedure. Of men with a Foley catheter at baseline, 64% had a Foley catheter, 4% had no Foley catheter, and 32% had died by 1-year after the procedure. Having a Foley catheter at baseline (risk ratio (RR) = 1.39, 95% confidence interval (CI) = 1.29-1.50) and poor baseline functional status (RR = 1.34, 95% CI = 1.18-1.52 for individuals in the worst quartile of function) were associated with greater risk of having a Foley catheter at 1-year. CONCLUSION: Poor baseline functional status and having a Foley catheter preoperatively were associated with greater risk of TURP or TULIP failure, as measured by the presence of a Foley catheter at 1 year. Preoperative measurement of ADLs may aid in surgical decision-making in this population.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women.

BACKGROUND: More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. OBJECTIVE: We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. STUDY DESIGN: We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. RESULTS: Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. CONCLUSION: Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Lack of follow-up after fecal occult blood testing in older adults: inappropriate screening or failure to follow up?

BACKGROUND: It is unclear whether lack of follow-up after screening fecal occult blood testing (FOBT) in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up vs failure to complete follow-up in healthy patients. METHODS: A prospective cohort study of 2410 patients 70 years or older screened with FOBT was conducted at 4 Veteran Affairs (VA) medical centers from January 1 to December 31, 2001. The main outcome measure was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving a complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema), and medical records were reviewed to determine reasons for lack of follow-up. RESULTS: A total of 212 patients (9%) had positive FOBT results; 42% received a complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of a complete follow-up, which was similar among patients 70 to 74 years old with a Charlson score of 0 compared with patients 80 years or older with a Charlson score of 1 or higher (48% vs 41%; P=.28). The VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive a complete follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received a complete follow-up. CONCLUSIONS: While follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision making, including decisions to screen and decisions to follow up.

Impact of age and comorbidity on colorectal cancer screening among older veterans.

BACKGROUND: The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment. OBJECTIVE: To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies of 5 years or less. DESIGN: Cohort study. SETTING: Veterans Affairs (VA) medical centers in Minneapolis, Minnesota; Durham, North Carolina; Portland, Oregon; and West Los Angeles, California, with linked national VA and Medicare administrative claims. PATIENTS: 27 068 patients 70 years or older who had an outpatient visit at 1 of 4 VA medical centers in 2001 or 2002 and were due for screening. MEASUREMENTS: The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema in 2001 or 2002, on the basis of national VA and Medicare claims. Charlson-Deyo comorbidity scores at the start of 2001 were used to stratify patients into 3 groups ranging from no comorbidity (score of 0) to severe comorbidity (score > or =4), and 5-year mortality was determined for each group. RESULTS: 46% of patients were screened from 2001 through 2002. Only 47% of patients with no comorbidity were screened despite having life expectancies greater than 5 years (5-year mortality, 19%). Although the incidence of screening decreased with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies less than 5 years (5-year mortality, 55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and 4 or more visits had screening rates similar to or higher than those of healthier patients with fewer visits. LIMITATIONS: Some tests may have been performed for nonscreening reasons. The generalizability of findings to persons who do not use the VA system is uncertain. CONCLUSION: Advancing age was inversely associated with colorectal cancer screening, whereas comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies. primary funding source: VA Health Services Research and Development.

Risk of hip fracture in disabled community-living older adults.

OBJECTIVES: To determine the rate of hip fracture and risk factors associated with hip fractures in disabled older persons who enroll in the Program of All-Inclusive Care for the Elderly (PACE), a program providing comprehensive care to community-living nursing-home-eligible persons. DESIGN: Prospective cohort study between January 1990 and December 1997. SETTING: The twelve PACE demonstration sites: San Francisco, California; Columbia, South Carolina; Detroit, Michigan; Denver, Colorado; East Boston, Massachusetts; El Paso, Texas; Milwaukee, Wisconsin; Oakland, California; Portland, Oregon; Rochester, New York; Sacramento, California; and the Bronx, New York. PARTICIPANTS: Five thousand one hundred eighty-seven individuals in PACE; mean age 79, 71% female, 49% white, 47% with dementia. MEASUREMENTS: Functional status, cognitive status, demographics, and comorbid conditions were recorded on all the participants, who were tracked for occurrence of a hip fracture. The goals were to determine the rate of hip fracture and identify risk factors. RESULTS: Two hundred thirty-eight hip fractures (4.6%) occurred during follow-up. The rate of hip fracture was 2.2% per person-year. Four independent predictors of hip fracture were identified using Cox proportional hazard analysis: age of 75 and older (adjusted hazard ratio (HR) = 2.0, 95% confidence interval (CI) = 1.4-2.8); white ethnicity (HR = 2.1, 95% CI = 1.6-2.8); ability to transfer independently to and from bed, chair, and toilet (HR = 3.0, 95% CI = 1.2-7.2); and five or more Short Portable Mental Status Questionnaire errors (HR = 1.6, 95% CI = 1.3-2.1). The incidence of hip fracture ranged from 0.5% per person-year in persons with zero to one independent risk factors to 4.7% per person-year in those with all four independent risk factors. CONCLUSIONS: The rate of hip fracture in this cohort of disabled community-living older adults was similar to that reported in nursing home cohorts. Older age, white race, ability to transfer independently, and cognitive impairment were independent predictors of hip fracture. Persons with these risk factors should be targeted for preventive interventions, which should include strategies for making transferring safer.