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

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

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

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

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

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

Agitation and Irritability in Alzheimer's Disease: Evidenced-Based Treatments and the Black-Box Warning.

More than five million Americans suffer from Alzheimer's disease (AD), and this number is expected to triple by 2050. While impairments in cognition, particularly memory, are typically the defining features of the clinical syndrome, behavioral symptoms are extremely common, affecting up to 90% of patients. Behavioral symptoms in AD can be difficult to manage and may require a combination of non-pharmacological and pharmacological approaches. The latter is complicated by FDA "black-box warnings" for the medication classes most often used to target these symptoms, and currently there are initiatives in place to limit their use. In this review, we describe common behavioral symptoms of AD-with a particular focus on the challenging symptoms of "agitation" and "irritability"-and discuss evidence-based approaches to their management. Ultimately, multidimensional approaches must be tailored to the patient and their environment, though evidence-based practices should define the treatment of agitation and irritability in AD.

Understanding non-performance reports for instrumental activity of daily living items in population analyses: a cross sectional study.

BACKGROUND: Concerns about using Instrumental Activities of Daily Living (IADLs) in national surveys come up frequently in geriatric and rehabilitation medicine due to high rates of non-performance for reasons other than health. We aim to evaluate the effect of different strategies of classifying "does not do" responses to IADL questions when estimating prevalence of IADL limitations in a national survey. METHODS: Cross-sectional analysis of a nationally representative sample of 13,879 non-institutionalized adult Medicare beneficiaries included in the 2010 Medicare Current Beneficiary Survey (MCBS). Sample persons or proxies were asked about difficulties performing six IADLs. Tested strategies to classify non-performance of IADL(s) for reasons other than health were to 1) derive through multiple imputation, 2) exclude (for incomplete data), 3) classify as "no difficulty," or 4) classify as "difficulty." IADL stage prevalence estimates were compared across these four strategies. RESULTS: In the sample, 1853 sample persons (12.4 % weighted) did not do one or more IADLs for reasons other than physical problems or health. Yet, IADL stage prevalence estimates differed little across the four alternative strategies. Classification as "no difficulty" led to slightly lower, while classification as "difficulty" raised the estimated population prevalence of disability. CONCLUSIONS: These analyses encourage clinicians, researchers, and policy end-users of IADL survey data to be cognizant of possible small differences that can result from alternative ways of handling unrated IADL information. At the population-level, the resulting differences appear trivial when applying MCBS data, providing reassurance that IADL items can be used to estimate the prevalence of activity limitation despite high rates of non-performance.

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

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

Psychological and social resources relate to biomarkers of allostasis in newly admitted nursing home residents.

OBJECTIVES: This paper presents preliminary baseline data from a prospective study of nursing home adaptation that attempts to capture the complexity of residents' adaptive resources by examining psychological, social, and biological variables from a longitudinal conceptual framework. Our emphasis was on validating an index of allostasis. METHOD: In a sample of 26 long-term care patients, we measured 6 hormone and protein biomarkers to capture the concept of allostasis as an index of physiological resilience, related to other baseline resources, including frailty, hope and optimism, social support, and mental health history, collected via interview with the resident and collaterals. We also examined the performance of self-report measures reflecting psychosocial and well-being constructs, given the prevalence of cognitive impairment in nursing homes. RESULTS: Our results supported both the psychometric stability of our self-report measures, and the preliminary validity of our index of allostasis. Each biomarker was associated with at least one other resilience resource, suggesting that our choice of biomarkers was appropriate. As a group, the biomarkers showed good correspondence with the majority of other resource variables, and our standardized summation score was also associated with physical, social, and psychological resilience resources, including those reflecting physical and mental health vulnerability as well as positive resources of social support, optimism, and hope. CONCLUSION: Although these results are based on a small sample, the effect sizes were large enough to confer some confidence in the value of pursuing further research relating biomarkers of allostasis to psychological and physical resources and well-being.

Older adults recently started on psychotropic medication: where are the symptoms?

OBJECTIVE: The objective of this study is to understand the characteristics of older adults on newly prescribed psychotropic medication with minimal psychiatric symptoms. METHODS: Naturalistic cohort study of non-institutionalized older adults in Pennsylvania participating in the Pharmaceutical Assistance Contract for the Elderly. Persons newly prescribed antidepressant or anxiolytic monotherapy or combination therapy were contacted for clinical assessment by a telephone-based behavioral health service. The initial assessment included standardized mental health screening instruments and scales including the Blessed Orientation-Memory-Concentration test, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Medical Outcomes Survey (SF-12). In addition, patients were asked for their understanding of the prescription indication. RESULTS: Of the 254 participants who met minimal symptom criteria (Patient Health Questionnaire-9 < 5 and Generalized Anxiety Disorder-7 < 5), women comprised slightly more of the anxiolytic compared with antidepressant monotherapy group (88.9% vs. 76.7%, p = 0.04). The most common self-reported reason for prescription of an antidepressant or anxiolytic was depression or anxiety, respectively, despite near-absence of these symptoms on clinical assessment. Comparing monotherapy to combination therapy groups, those with combination therapy were more likely to report a history of depression (12.6% vs. 1.8%, p < 0.001) and also report depression as the reason for the prescription (40.2% vs. 21.0%, p < 0.01). CONCLUSIONS: In this sample of older adults on new psychotropic medication with minimal psychiatric symptoms, there are few patient characteristics that distinguish those on antidepressant versus anxiolytic monotherapy or those on monotherapy versus combination therapy. While quality of care in late-life mental health has focused on improving detection and treatment, there should be further attention to low-symptom patients potentially receiving inappropriate pharmacotherapy.

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

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

Telephone-based care management for older adults initiated on psychotropic medication.

OBJECTIVE: This study aimed to explore the longitudinal, 6-month symptom course of older adults newly started on an antidepressant or anxiolytic by non-psychiatrist physicians and enrolled in a care management program. METHOD: This is a naturalistic cohort study of older adults (age ≥65 years) receiving pharmacotherapy and telephone-based care management. Participants are non-institutionalized adults participating in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly who completed telephone-based clinical assessments including demographic data, self-report on history of psychiatric treatment and adherence, and standardized symptom scales. RESULTS: A total of 162 participants with an average age of 77.2 years (SD 6.8) were followed and, for analysis, split into two groups by PHQ-9 score: 75 (46.3%) scoring 0-4 (minimally symptomatic group, MSG) and 87 (53.7%) scoring ≥5 (symptomatic group, SG). Over 6 months, the SG improved with PHQ-9 scores beginning on average at 10.0 (SD 4.6) and falling to 5.4 (SD 4.2) (F(1, 86) = 29.53, p < 0.0001). The MSG had no significant change in depressive symptoms. Emotional health as measured by SF-12 Mental Composite Score mirrored the PHQ-9 change and lack thereof in the SG and MSG, respectively. No clinical or demographic features were associated with symptom improvement in the SG although they were more likely to report medication adherence (66.7% vs. 44.0%, χ(2) (1) = 8.4, p = 0.0037) compared with the MSG. CONCLUSIONS: Participation of symptomatic older adults initiated on psychotropic medication in a telephone-based care management program was associated with improvement in depressive symptoms and overall emotional well-being, notable findings given participants' advanced age, state-wide distribution, and history of limited utilization of mental health care.

Home accessibility, living circumstances, stage of activity limitation, and nursing home use.

OBJECTIVE: To explore the influence of physical home and social environments and disability patterns on nursing home (NH) use. DESIGN: Longitudinal cohort study. Self- or proxy-reported perception of home environmental barriers accessibility, 5 stages expressing the severity and pattern of activities of daily living (ADLs) limitations, and other characteristics at baseline were applied to predict NH use within 2 years or prior to death through logistic regression. SETTING: General community. PARTICIPANTS: Population-based, community-dwelling individuals (N=7836; ≥70y) from the Second Longitudinal Study of Aging interviewed in 1994 with 2-year follow-up that was prospectively collected. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: NH use within 2 years. RESULTS: Perceptions of home environmental barriers and living alone were both associated with approximately 40% increased odds of NH use after adjustment for other factors. Compared with those with no limitations at ADL stage 0, the odds of NH use peaked for those with severe limitations at ADL stage III (odds ratio [OR]=3.12; 95% confidence interval [CI], 2.20-4.41), then declined sharply for those with total limitations at ADL stage IV (OR=.96; 95% CI, .33-2.81). Sensitivity analyses for missing NH use showed similar results. CONCLUSIONS: Accessibility of home environment, living circumstance, and ADL stage represent potentially modifiable targets for rehabilitation interventions for decreasing NH use in the aging U.S. population.

Telephone-based behavioral health assessment for older adults starting a new psychiatric medication.

OBJECTIVES: The purpose of this study is to explore behavioral health symptoms and characteristics of noninstitutionalized older adults newly started on an antidepressant, anxiolytic, or antipsychotic agent by nonpsychiatrist physicians. DESIGN: Naturalistic cohort study of older adults participating in the Pharmaceutical Assistance Contract for the Elderly (PACE) of the state of Pennsylvania. SETTING/PARTICIPANTS: Noninstitutionalized adults in Pennsylvania. MEASUREMENTS: Standardized scales including the Blessed Orientation-Memory-Concentration (BOMC) test, Mini International Neuropsychiatric Interview (including Psychosis, Mania, Generalized Anxiety Disorder [GAD], Panic Disorder, and Alcohol Abuse/Dependence modules), Patient Health Questionnaire-9 (PHQ-9), Paykel Scale for suicide ideation, and Medical Outcomes Survey (SF-12). RESULTS: Participants were mostly women (83.7%) with a mean age of 79.2 years (SD 7.1). The average PHQ-9 score for those on antidepressants was 5.8 (5.2), with no statistically significant difference between medication groups (F[2, 409] = 1.48, p = 0.23); just seven (4.9%) of those receiving anxiolytics met criteria for an anxiety disorder, which was not significantly different than other medication classes (χ (2) = 0.83, p = 0.66). Overall, 197 (47.8%) of the sample did not meet criteria for a mental health disorder. Just 69 (28.8%) of those on antidepressants reported depression as the self-reported reason for taking the medication, while 91 (22.8%) of the total reported poor sleep or stressful life events as the reason. CONCLUSIONS: In this sample, many older persons received psychotropic medications despite low symptomatology, increasing the costs of care and possible exposure to unnecessary side effects. It is important to understand perceived benefit to both patient and provider of such prescribing patterns and work towards minimizing unnecessary use.

AAGP position statement: disaster preparedness for older Americans: critical issues for the preservation of mental health.

The Disaster Preparedness Task Force of the American Association for Geriatric Psychiatry was formed after Hurricane Katrina devastated New Orleans to identify and address needs of the elderly after the disaster that led to excess health disability and markedly increased rates of hopelessness, suicidality, serious mental illness (reported to exceed 60% from baseline levels), and cognitive impairment. Substance Abuse and Mental Health Services Administration (SAMHSA) outlines risk groups which fail to address later effects from chronic stress and loss and disruption of social support networks. Range of interventions recommended for Preparation, Early Response, and Late Response reviewed in the report were not applied to elderly for a variety of reasons. It was evident that addressing the needs of elderly will not be made without a stronger mandate to do so from major governmental agencies (Federal Emergency Management Agency [FEMA] and SAMHSA). The recommendation to designate frail elderly and dementia patients as a particularly high-risk group and a list of specific recommendations for research and service and clinical reference list are provided.

A randomized, double-blind, placebo-controlled study of aripiprazole for the treatment of psychosis in nursing home patients with Alzheimer disease.

OBJECTIVE: To evaluate the efficacy and safety of aripiprazole treatment for psychotic symptoms associated with Alzheimer disease (AD). METHODS: In this parallel group, randomized, double-blind, placebo-controlled, flexible-dose trial, institutionalized subjects with AD and psychotic symptoms were randomized to aripiprazole (n = 131) or placebo (n = 125) for 10 weeks. The aripiprazole starting dose was 2 mg/day, and could be titrated to higher doses (5, 10, and 15 mg/day) based on efficacy and tolerability. RESULTS: No significant differences in mean change [2 x SD] from baseline between aripiprazole (mean dose approximately 9 mg/day at endpoint; range = 0.7-15.0 mg) and placebo were detected in the coprimary efficacy endpoints of Neuropsychiatric Inventory-Nursing Home Version (NPI-NH) Psychosis score (aripiprazole, -4.53 [9.23]; placebo, -4.62 [9.56]; F = 0.02, df = 1, 222, p = 0.883 [ANCOVA]) and Clinical Global Impression (CGI)-Severity score (aripiprazole, -0.57 [1.63]; placebo, -0.43 [1.65]; F = 1.67, df = 1, 220, p = 0.198 [ANCOVA]) at endpoint. However, improvements in several secondary efficacy measures (NPI-NH Total, Brief Psychiatric Rating Scale Total, CGI - improvement, Cohen-Mansfield Agitation Inventory and Cornell Depression Scale scores) indicated that aripiprazole may confer clinical benefits beyond the primary outcome measures. Treatment-emergent adverse events (AEs) were similar in both groups, except for somnolence (aripiprazole, 14%; placebo, 4%). Somnolence with aripiprazole was of mild or moderate intensity, and not associated with accidental injury. Incidence of AEs related to extrapyramidal symptoms was low with aripiprazole (5%) and placebo (4%). CONCLUSIONS: In nursing home residents with AD and psychosis, aripiprazole did not confer specific benefits for the treatment of psychotic symptoms; but psychological and behavioral symptoms, including agitation, anxiety, and depression, were improved with aripiprazole, with a low risk of AEs.

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

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

Improving Access to Collaborative Behavioral Health Care for Rural-Dwelling Older Adults.

OBJECTIVE: This study examined whether a telephone-delivered collaborative care intervention (SUpporting Seniors Receiving Treatment And INtervention [SUSTAIN]) improved access to mental health services similarly among older adults in rural areas and those in urban-suburban areas. METHODS: This cohort study of 8,621 older adults participating in the SUSTAIN program, a clinical service provided to older adults in Pennsylvania newly prescribed a psychotropic medication by a primary care or non-mental health provider, examined rural versus urban-suburban differences in rates of initial clinical interview completion, patient clinical characteristics, and program penetration. RESULTS: Participants in rural counties were more likely than those in urban-suburban counties to complete the initial clinical interview (27.0% versus 24.0%, p=.001). Program penetration was significantly higher in rural than in urban-suburban counties (p=.02). CONCLUSIONS: Telephone-based care management programs such as SUSTAIN may be an effective strategy to facilitate access to collaborative mental health care regardless of patients' geographic location.

Preventable hospitalizations, barriers to care, and disability.

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

Premorbid Activity Limitation Stages Are Associated With Posthospitalization Discharge Disposition.

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

Psychosocial Well-Being Associated With Activity of Daily Living Stages Among Community-Dwelling Older Adults.

Objectives: Activity of daily living (ADL) stages demonstrated ordered associations with risk of chronic conditions, hospitalization, nursing home use, and mortality among community-living elderly. This article explores the association of stages with psychosocial well-being. We hypothesized that higher ADL stages (greater ADL limitation) are associated with more restricted social networks, less perceived social support, greater social isolation, and poorer mental health. Methods: Cross-sectional data from the National Social Life, Health, and Aging Project (N = 3,002) were analyzed in regression models and latent factor models. Results: Although ADL stages had a nearly monotonic relationship with most mental health measures (e.g., Center for Epidemiologic Studies Depression Scale [CES-D]), only the complete limitation stage (Stage IV) showed significant disadvantage in the majority of social network measures. Discussion: The study may aid clinicians and policy makers to better understand the social and mental health needs of older adults at different ADL stages and provide well-planned social and mental health care.

Predicting 3-year mortality and admission to acute-care hospitals, skilled nursing facilities, and long-term care facilities in Medicare beneficiaries.

PURPOSE: The ability to predict mortality and admission to acute care hospitals, skilled nursing facilities (SNFs), and long-term care (LTC) facilities in the elderly and how it varies by activity of daily living (ADL) and instrumental ADL (IADL) status could be useful in measuring the success or failure of economic, social, or health policies aimed at disability prevention and management. We sought to derive and assess the predictive performance of rules to predict 3-year mortality and admission to acute care hospitals, SNFs, and LTC facilities among Medicare beneficiaries with differing ADL and IADL functioning levels. METHODS: Prospective cohort using Medicare Current Beneficiary Survey data from the 2001 to 2007 entry panels. In all, 23,407 community-dwelling Medicare beneficiaries were included. Multivariable logistic models created predicted probabilities for all-cause mortality and admission to acute care hospitals, SNFs, and LTC facilities, adjusting for sociodemographics, health conditions, impairments, behavior, and function. RESULTS: Sixteen, 22, 14, and 14 predictors remained in the final parsimonious model predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission, respectively. The C-statistic for predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission was 0.779, 0.672, 0.753, and 0.826 in the ADL activity limitation stage development cohorts, respectively, and 0.788, 0.669, 0.748, and 0.799 in the ADL activity limitation stage validation cohorts, respectively. CONCLUSIONS: Parsimonious models can identify elderly Medicare beneficiaries at risk of poor outcomes and can aid policymakers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.