Impact of urinary incontinence on medical rehabilitation inpatients.

AIMS: To determine the prevalence of urinary incontinence (UI) and its association with rehabilitation outcomes in patients receiving inpatient medical rehabilitation in the United States. METHODS: A retrospective, cohort study of 425,547 Medicare patients discharged from inpatient rehabilitation facilities (IRFs) in 2005. We examined prevalence of UI at admission and discharge for 5 impairment groups. We examined the impact of demographics, health, and functional status on the primary outcome, change in continence status, and secondary outcomes of discharge location and 6-month mortality. RESULTS: Approximately one-quarter (26.6%) of men were incontinent at admission compared to 22.2% of women. In all diagnostic groups, continence status remains largely unchanged from admission to discharge. Patients who are older, have cognitive difficulties, less functional improvement, and longer lengths of stay (LOS), are more likely to remain incontinent, compared to those who improved, after controlling for patient factors and clinical variables. UI was significantly associated with discharge to another post-acute setting (PAC). For orthopedic patients, UI was associated with a 71% increase in the likelihood of discharge to an institutional setting after controlling for patient factors and clinical variables. UI was not associated with death at 6 months post-discharge. CONCLUSIONS: UI is highly prevalent in IRF patients and is associated with increased likelihood of discharge to institutional care, particularly for orthopedic patients. Greater attention to identifying and treating UI in IRF patients may reduce medical expenditures and improve other outcomes. Neurourol. Urodynam. 36:176-183, 2017. © 2015 Wiley Periodicals, Inc.

Comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after hip fracture repair.

OBJECTIVE: To examine differences in rehabilitation outcomes across 3 post-acute care (PAC) rehabilitation settings for patients after hip fracture repair. DESIGN: Prospective, observational cohort study. SETTING: Six skilled nursing facilities (SNFs), 4 inpatient rehabilitation facilities (IRFs), and 8 home health agencies (HHAs) in 10 states. PARTICIPANTS: Patients (N=181) receiving PAC rehabilitation following hip fracture with internal fixation (n=116) or total hip replacement (n=64), or no surgical intervention (n=1). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Self-care and mobility status at PAC discharge measured by the Inpatient Rehabilitation Facility Patient Assessment Instrument. RESULTS: IRF and HHA patients had lower self-care function at discharge relative to SNF patients controlling for patient characteristics, severity, comorbidities, and services. Adding length of stay (LOS) resulted in nonsignificant differences between IRFs and SNFs. In contrast, there was no setting-specific advantage in discharge mobility for patients with or without the addition of LOS. The average LOS of HHA patients was 2 weeks longer than that of SNF patients, whose average LOS was 9 days longer than that of IRF patients (average, 15d). IRF and SNF patients received about the same total minutes of therapy over their PAC stays (∼2100min on average), whereas HHA patients received only approximately 25% as many minutes. CONCLUSIONS: Setting-specific effects varied depending on whether self-care or mobility was the outcome of focus. It remains unclear to what extent rehabilitation intensity or natural recovery effects changes in functional status for patients with hip fracture. This study points to important directions for PAC setting comparative effectiveness studies in the future, including uniform measurement, limited consensus on factors affecting recovery, accounting for selection bias, and using end-point data collection that is at the same follow-up time periods for all settings.

Association of functional status with changes in physical activity: insights from a behavioral intervention for participants with arthritis.

OBJECTIVE: To analyze change over 6 months in accelerometer-measured physical activity for participants with arthritis in a physical activity promotion trial. We tested the hypothesis that participants with the highest baseline functional capacity, regardless of their intervention status, experienced the greatest increases in physical activity levels at 6-month follow-up. DESIGN: At baseline, participants were interviewed in person, completed a 5-minute timed walk, and wore a biaxial accelerometer for 1 week, with a subsequent week of accelerometer wear at 6 months. We present data on the changes in accelerometer-measured physical activity across baseline function quartiles derived from participants' walking speed. Analyses were controlled for sociodemographic, health status, and seasonal covariates as well as exposure to the study's behavioral intervention. SETTING: A Midwest academic medical center. PARTICIPANTS: Participants (N=226) with knee osteoarthritis or rheumatoid arthritis currently enrolled in the Improving Motivation for Physical Activity in Persons With Arthritis Clinical Trial. INTERVENTION: Counseling by physical activity coaches versus control group physician advice to exercise. MAIN OUTCOME MEASURE: Change in average daily counts between baseline and 6-month follow-up. RESULTS: Contrary to our hypothesis, and after controlling for other predictors of change, the lowest quartile function participants had the largest mean absolute and relative physical improvement over baseline, regardless of intervention group status. CONCLUSIONS: Participants at a higher risk of immanent mobility loss may have been more committed to improve lifestyle physical activity, reflecting the wisdom of targeting older adults at risk of mobility loss for physical activity behavior change interventions.

Gender differences in cholesterol-lowering medication prescribing in peripheral artery disease.

Among 320 patients with lower extremity peripheral artery disease (PAD) and low-density lipoprotein-cholesterol (LDL-C) levels > 70 mg/dl, we determined whether male sex, higher education, and greater self-efficacy for willingness to request therapy from one's physician were associated with increases in LDL-C-lowering medication and achievement of an LDL-C level < 70 mg/dl at 1-year follow-up. Participants were enrolled in a randomized controlled clinical trial to determine whether a telephone counseling intervention can help PAD patients achieve an LDL-C level < 70 mg/dl, compared to usual care and attention control conditions, respectively. Adjusting for age, race, comorbidities, PAD severity, and other covariates, male sex (odds ratio = 3.33, 95% confidence interval = 1.64 to 6.77, p = 0.001) was associated with a higher likelihood of adding cholesterol-lowering medication during follow-up, but was not associated with achieving an LDL-C < 70 mg/dl (odds ratio = 1.09, 95% confidence interval = 0.55 to 2.18). No associations of education level or self-efficacy with study outcomes were identified. In conclusion, male PAD patients with baseline LDL-C levels ≥ 70 mg/dl were more likely to intensify LDL-C-lowering medication during 1-year follow-up than female PAD patients. Despite greater increases in LDL-C-lowering medication among female PAD patients, there was no difference in the degree of LDL-C lowering during the study between men and women with PAD.

A comparison of discharge functional status after rehabilitation in skilled nursing, home health, and medical rehabilitation settings for patients after lower-extremity joint replacement surgery.

OBJECTIVE: To examine differences in outcomes of patients after lower-extremity joint replacement across 3 post-acute care (PAC) rehabilitation settings. DESIGN: Prospective observational cohort study. SETTING: Skilled nursing facilities (SNFs; n=5), inpatient rehabilitation facilities (IRFs; n=4), and home health agencies (HHAs; n=6) from 11 states. PARTICIPANTS: Patients with total knee (n=146) or total hip replacement (n=84) not related to traumatic injury. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Self-care and mobility status at PAC discharge measured by using the Inpatient Rehabilitation Facility Patient Assessment Instrument. RESULTS: Based on our study sample, HHA patients were significantly less dependent than SNF and IRF patients at admission and discharge in self-care and mobility. IRF and SNF patients had similar mobility levels at admission and discharge and similar self-care at admission, but SNF patients were more independent in self-care at discharge. After controlling for differences in patient severity and length of stay in multivariate analyses, HHA setting was not a significant predictor of self-care discharge status, suggesting that HHA patients were less medically complex than SNF and IRF patients. IRF patients were more dependent in discharge self-care even after controlling for severity. For the full discharge mobility regression model, urinary incontinence was the only significant covariate. CONCLUSIONS: For the patients in our U.S.-based study, direct discharge to home with home care was the optimal strategy for patients after total joint replacement surgery who were healthy and had social support. For sicker patients, availability of 24-hour medical and nursing care may be needed, but intensive therapy services did not seem to provide additional improvement in functional recovery in these patients.

Correlates of improvement in walking ability in older persons in the United States.

OBJECTIVES: We analyzed factors associated with improvement in walking ability among respondents to the nationally representative Health and Retirement Study. METHODS: We analyzed data from 6574 respondents aged 53 years or older who reported difficulty walking several blocks, 1 block, or across the room in 2000 or 2002. We examined associations between improvement (versus no change, deterioration, or death) and baseline health status, chronic conditions, baseline walking difficulty, demographic characteristics, socioeconomic status, and behavioral risk factors. RESULTS: Among the 25% of the study population with baseline walking limitations, 29% experienced improved walking ability, 40% experienced no change in walking ability, and 31% experienced deteriorated walking ability or died. In a multivariate analysis, we found positive associations between walking improvement and more recent onset and more severe walking difficulty, being overweight, and engaging in vigorous physical activity. A history of diabetes, having any difficulty with activities of daily living, and being a current smoker were all negatively associated with improvement in walking ability. After we controlled for baseline health, improvement in walking ability was equally likely among racial and ethnic minorities and those with lower socioeconomic status. CONCLUSIONS: Interventions to reduce smoking and to increase physical activity may help improve walking ability in older Americans.

Patient-reported changes in communication after computer-based script training for aphasia.

OBJECTIVE: To evaluate changes in patient-reported communication difficulty after a home-based, computer-delivered intervention designed to improve conversational skills in adults with aphasia. DESIGN: Delayed treatment design with baseline, preintervention, postintervention, and follow-up observations. SETTING: Outpatient rehabilitation. PARTICIPANTS: Twenty subjects with chronic aphasia. INTERVENTIONS: Sessions with the speech-language pathologist to develop personally relevant conversational scripts, followed by 9 weeks of intensive home practice using a computer program loaded on a laptop, and weekly monitoring visits with the speech-language pathologist. MAIN OUTCOME MEASURE: Communication Difficulty (CD) subscale of the Burden of Stroke Scale (BOSS). RESULTS: The intervention resulted in a statistically and clinically significant decrease of 6.79 points (P=.038) in the CD subscale of the BOSS during the intervention, maintained during the follow-up period. CONCLUSIONS: The findings of this study provide positive albeit preliminary and limited support for the use of a home-based, computer-delivered language intervention program for improving patient-reported communication outcomes in adults with chronic aphasia. Additional research will be required to examine the efficacy and effectiveness of this intervention.

Assisted living pilot program: utilization and cost findings.

Objective. The Department of Veterans Affairs funded assisted living, adult family home, and adult residential care for the first time in the Assisted Living Pilot Program (ALPP). This article compares the use and cost for individuals that entered ALPP and a comparison group. Method. This was a nonrandomized study. The comparison group consisted of VA patients who were eligible but did not enter an ALPP facility. The ALPP (n = 393) and comparison (n = 259) groups were followed for 12 months to assess ALPP facility, case management, and health care costs. Results. ALPP facility and ALPP case management costs were respectively $5,560 and $2,830 per individual. Total health care costs, including ALPP costs, were $11,533 higher for the ALPP group compared to the comparison group after adjusting for baseline differences. Discussion. Although ALPP successfully helped individuals transition to longer term care in these facilities, it was more costly than the comparison group.

Assisted living pilot program: health outcomes.

Objectives. Assisted living programs demonstrate variation in structure and services. The Department of Veterans Affairs funded this care for the first time in the Assisted Living Pilot Program (ALPP). This article presents resident health outcomes and the relationship between facility characteristics and outcomes. Method. This article presents results on 393 ALPP residents followed for 12 months after admission to 95 facilities. Results. A total of 19.8% residents died, and the average activities of daily living impairment did not change significantly. Half of the residents remained in an ALPP facility, with the average resident spending 315 days in the community during the 12-month follow-up period. This article found a limited number of characteristics of structure and staffing to be significantly associated with outcomes. Discussion. If differences among facility characteristics are not clearly related to differences in outcomes, then choices among type of setting can be based on the match of needs to available services, location, or preferences.

Differences in medical care expenditures for adults with depression compared to adults with major chronic conditions.

BACKGROUND: Approximately 17.1 million adults report having a major depressive episode in 2004 which represents 8% of the adult population in the U.S. Of these, more than one-third did not seek treatment. In spite of the large and extensive literature on the cost of mental health, we know very little about the differences in out-of-pocket expenditures between adults with depression and adults with other major chronic disease and the sources of those expenditures. AIMS: For persons under age 65, compare total and out-of-pocket expenditures of those with depression to non-depressed individuals who have another major chronic disease. METHODS: This study uses two linked, nationally representative surveys, the 1999 National Health Interview Survey (NHIS) and the 2000 Medical Expenditure Panel Survey (MEPS), to identify the population of interest. Depression was systematically assessed using a short form of the World Health Organization's (WHO) Composite International Diagnostic Interview--Short Form (CIDI-SF). To control for differences from potentially confounding factors, we matched depressed cases to controls using propensity score matching. RESULTS: We estimate that persons with depression have about the same out-of-pocket expenditures while having 11.8% less total medical expenditures (not a statistically significant difference) compared to non-depressed individuals with at least one chronic disease. DISCUSSION: High out-of-pocket expenditures are a concern for individuals with chronic diseases. Our study shows that those with depression have comparable out-of-pocket expenses to those with other chronic diseases, but given their lower income levels, this may result in a more substantial financial burden. IMPLICATION FOR POLICY: High out-of-pocket expenditures are a concern for individuals with depression and other chronic diseases. For both depressed individuals and non-depressed individuals with other chronic diseases, prescription drug expenditures contribute most to out-of-pocket expenses. Given the important role medications play in treatment of depression, high copayment rates are a concern for limiting compliance with appropriate treatment.

Trends in the supply of inpatient rehabilitation facilities services: 1996 to 2004.

OBJECTIVES: Describe the supply of inpatient rehabilitation facilities (IRFs) services in 1996 and examine changes between 1996 and 2004, including the impact of the IRF prospective payment system (PPS) in 2002 on organizational trends. DESIGN: Retrospective pre-post design. SETTING: Freestanding and subprovider (distinct-part units) IRFs. PARTICIPANTS: IRFs (N=1424), including 257 freestanding IRFs and 1167 IRF units reported in the Healthcare Cost Report Information System database, from years 1996 to 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of IRF openings, IRF closures, beds, and inpatient days. RESULTS: The number of IRFs grew from 1037 to 1183 between 1996 and 2001 and grew to 1235 between 2001 and 2004. The likelihood of IRF closures trended lower after PPS, and there was a significant increase in the likelihood of openings when PPS was introduced. For-profit, rural, and small IRFs were more likely to open over the entire period. There was a 12.9% increase in the number of total inpatient days, somewhat less than the 15.7% growth in IRF beds over the period. There was no impact of PPS on beds available but a significant decline in total inpatient days after PPS. CONCLUSIONS: Inpatient days rose under the Tax Equity and Fiscal Responsibility Act and declined after 2002. Yet the likelihood of openings and closures did not appear to respond to these changes, perhaps because they were modest compared with changes in local IRF markets. The IRF PPS did little to affect service distribution in less well-served areas, although we did find growth in rural areas. Occupancy rates in 2004 were close to rates at the start of the period (70%). This observation implies that IRFs were implementing strategies to recruit a sufficient number of patients, even though bed numbers were increasing and length of stay was declining. Consequently, policy that limits the potential of IRFs to increase patient admissions, such as the limits on admissions to IRFs of patients with conditions other than those included in the 75% rule, is likely to produce substantial decreases in total inpatient days.

Racial/ethnic differences in the development of disability among older adults.

OBJECTIVES: We investigated differences in the development of disability in activities of daily living among non-Hispanic Whites, African Americans, Hispanics interviewed in Spanish, and Hispanics interviewed in English. METHODS: We estimated 6-year risk for disability development among 8161 participants 65 years or older and free of baseline disability. We evaluated mediating factors amenable to clinical and public health intervention on racial/ethnic difference. RESULTS: The risk for developing disability among Hispanics interviewed in English was similar to that among Whites (hazard ratio [HR]=0.99; 95% confidence interval [CI] = 0.6, 1.4) but was substantially higher among African Americans (HR=1.6; 95% CI=1.3, 1.9) and Hispanics interviewed in Spanish (HR=1.8; 95% CI=1.4, 2.1). Adjustment for demographics, health, and socioeconomic status reduced a large portion of those disparities (African American adjusted HR=1.1, Spanish-interviewed Hispanic adjusted HR=1.2). CONCLUSIONS: Higher risks for developing disability among older African Americans, and Hispanics interviewed in Spanish compared with Whites were largely attenuated by health and socioeconomic differences. Language- and culture-specific programs to increase physical activity and promote weight maintenance may reduce rates of disability in activities of daily living and reduce racial/ethnic disparities in disability.

Characteristics of residents and providers in the assisted living pilot program.

PURPOSE: The number of residents in assisted living has rapidly increased, although these facilities still primarily serve people who can pay out of pocket. The U.S. Department of Veterans Affairs was authorized to provide this level of care for the first time in the Assisted Living Pilot Program (ALPP). We describe the residents and providers, comparing them across three facility types and other populations, to assess the characteristics and feasibility of this new approach. DESIGN AND METHODS: We assessed ALPP residents and providers across seven Veterans Affairs Medical Centers. We obtained information from medical records, assessment tools, and a provider survey. RESULTS: We report here on 743 residents placed from 2002 to 2004. The Department of Veterans Affairs contracted with 58 adult family homes, 56 assisted living facilities, and 46 residential care facilities. The average ALPP resident was a 70-year-old unmarried White man referred from an inpatient hospital and living in a private residence prior to placement. Adult family homes enrolled residents requiring greater levels of assistance with activities of daily living than other facility types. Assisted living facilities were less likely than adult family homes to admit residents with functional disabilities and less likely than either adult family homes or adult residential care facilities to admit residents with certain care needs. IMPLICATIONS: ALPP placed residents with a wide range of characteristics in community facilities that varied widely in size and services. This information can help determine the role of this type of care in and outside of the Department of Veterans Affairs.

Tension-free repair versus watchful waiting for men with asymptomatic or minimally symptomatic inguinal hernias: a cost-effectiveness analysis.

BACKGROUND: Watchful waiting (WW) has been shown to be an acceptable option in men with asymptomatic or minimally symptomatic inguinal hernias when clinical and patient-reported outcomes are considered. Although WW is likely to be less costly initially when compared with tension-free repair (TFR) because of the cost of the operation, it is not clear whether WW remains the least costly option when longer-term costs are considered. STUDY DESIGN: We conducted a cost-effectiveness analysis of a randomized controlled trial at six community and academic centers. We examined costs, quality-adjusted life-years (QALY), and cost-effectiveness at 2 years of followup. Costs were assessed by applying Medicare reimbursement rates to patients' health-care use, which was obtained by contacting patients' health-care providers. Quality of life was assessed using the Short Form-36 version 2 health-related quality-of-life survey. Of the 724 men randomized, 641 were available for the economic analysis: 317 were randomized to TFR and 324 were randomized to watchful waiting. RESULTS: At 2 years, TFR patients had $1,831 higher mean costs than WW patients (95% CI, $409-$3,044), with 0.031 higher QALY (95% CI, 0.001-0.058). The cost per additional QALY for TFR patients was $59,065 (95% CI, $1,358-$322,765). The probability that TFR was cost-effective at the $50,000 per QALY level was 40%. CONCLUSION: At 2 years, WW was a cost-effective treatment option for men with minimal or no hernia symptoms.

Gender differences across race/ethnicity in use of health care among Medicare-aged Americans.

BACKGROUND: Despite Medicare, medical services are not equally used by elderly women and men in the United States. Our purpose is to examine gender differences in healthcare utilization among older Americans, the persistence of gender differences across race/ethnicity, and the roles of sociodemographic, health, and economic factors to explain differences. METHODS: Data from the 1998-2000 Health and Retirement Study are used to investigate gender differences in use of hospital, outpatient surgery, home health, and physician services. Analyses are controlled for sociodemographic, health (medical conditions, functional health), and economic (income, wealth, education, health insurance) factors. RESULTS: Women are significantly less likely to use hospital service (odds ratio [OR]=0.83) and outpatient surgery (OR=0.85) but are more likely to use home health care (OR=1.27) and physician services (OR=1.45), controlling for sociodemographics. Differences in health needs and economic resources partially mediate the gender differences in physician and home healthcare utilization but do not explain the gender differences in hospital service and outpatient surgery. Notably, African American, Hispanic, and white women compared with men show significantly less use of hospital services. CONCLUSIONS: Gender differences in medical use vary according to the type of services used and are largely consistent across racial/ethnic groups. As the size of the Medicare population increases, promoting equitable use of healthcare resources by both women and men is an important issue in developing healthcare policy and designing public health strategies.

Cardiovascular risk profile earlier in life and Medicare costs in the last year of life.

BACKGROUND: Health care costs are generally highest in the year before death, and much attention has been directed toward reducing costs for end-of-life care. However, it is unknown whether cardiovascular risk profile earlier in life influences health care costs in the last year of life. This study addresses this question. METHODS: Prospective cohort of adults from the Chicago Heart Association Detection Project in Industry included 6582 participants (40% women), aged 33 to 64 years at baseline examination (1967-1973), who died at ages 66 to 99 years. Medicare billing records (1984-2002) were used to obtain cardiovascular disease-related and total charges (adjusted to year 2002 dollars) for inpatient and outpatient services during the last year of life. Participants were classified as having favorable levels of all major cardiovascular risk factors (low risk), that is, serum cholesterol level lower than 200 mg/dL (<5.2 mmol/L), blood pressure 120/80 mm Hg or lower and no antihypertensive medication, body mass index (calculated as weight in kilograms divided by the square of height in meters) lower than 25, no current smoking, no diabetes, and no electrocardiographic abnormalities, or unfavorable levels of any 1 only, any 2 only, any 3 only, or 4 or more of these risk factors. RESULTS: In the last year of life, average Medicare charges were lowest for low-risk persons. For example, cardiovascular disease-related and total charges were lower by 10,367 dollars and 15,318 dollars compared with those with 4 or more unfavorable risk factors; the fewer the unfavorable risk factors, the lower the Medicare charges (P for trends <.001). Analyses by sex showed similar patterns. CONCLUSION: Favorable cardiovascular risk profile earlier in life is associated with lower Medicare charges at the end of life.

One-hour postload plasma glucose in middle age and Medicare expenditures in older age among nondiabetic men and women: the Chicago Heart Association Detection Project in Industry.

OBJECTIVE: To examine associations in nondiabetic individuals of 1-h postload plasma glucose measured in young adulthood and middle age with subsequent Medicare expenditures for cardiovascular disease (CVD), diabetes, cancer, and all health care at age 65 years or older using data from the Chicago Heart Association Detection Project in Industry (CHA). RESEARCH DESIGN AND METHODS: Medicare data (1984-2000) were linked with CHA baseline records (1967-1973) for 8,580 men and 6,723 women ages 33-64 years who were free of coronary heart disease, diabetes, and major electrocardiogram (ECG) abnormalities and who were Medicare eligible (65+ years) for at least 2 years. Participants were classified based on 1-h postload plasma glucose levels <120, 120-199, or > or =200 mg/dl. RESULTS: With adjustment for baseline age, cigarette smoking, serum cholesterol, systolic blood pressure, BMI, ethnicity, education, and minor ECG abnormalities, the average annual and cumulative Medicare, total, and diabetes- and CVD-related charges were significantly higher with higher baseline plasma glucose in women, while only diabetes-related charges were significantly higher in men. For example, in women, multivariate-adjusted CVD-related cumulative charges were, respectively, USD 14,260, 18,909, and 21,183 for the three postload plasma glucose categories (P value for trend = 0.035). CONCLUSIONS: These findings suggest that maintaining low glucose levels early in life has the potential to reduce health care costs in older age.

Relationship of fruit and vegetable consumption in middle-aged men to medicare expenditures in older age: the Chicago Western Electric Study.

BACKGROUND: High fruit and vegetable intake is associated with lower risk of hypertension, cardiovascular disease, and cancer. Little is known about the relationship of fruit and vegetable intake to health care expenditures. OBJECTIVE: Examine whether fruit and vegetable intake among middle-aged adults is related to Medicare charges-total, cardiovascular disease, cancer-related-in older age. DESIGN: Participants were grouped into one of three strata according to fruit and vegetable intake, determined from detailed dietary history (1958-1959): less than 14 cups per month, 14 to 42 cups per month, or more than 42 cups per month. Combined intake was classified as low, medium, or high. Medicare claims data (1984-2000) were used to estimate mean annual spending for eligible surviving participants (65 years and older) from the Chicago Western Electric Study: 1,063 men age 40 to 55 and without coronary heart disease, diabetes, and cancer at baseline (1957-1958). Cumulative charges before death (n = 401) were also calculated. RESULTS: Higher fruit and fruit plus vegetable intakes were associated with lower mean annual and cumulative Medicare charges (P values for trend .019 to .862). For example, with adjustment for baseline age, education, total energy intake, and multiple baseline risk factors, annual cardiovascular disease-related charges were 3,128 dollars vs 4,223 dollars for men with high vs low intake of fruit plus vegetables. Corresponding figures were 1,352 dollars vs 1,640 dollars for cancer-related charges and 10,024 dollars vs 12,211 dollars for total charges. Results were generally similar for vegetable intake. CONCLUSION: These findings, albeit mostly not statistically significant, suggest that for men high intake of fruits and fruits plus vegetables earlier in life has potential not only for better health status but also for lower health care costs in older age.

Comparison of two home care protocols for total joint replacement.

OBJECTIVES: To examine the effect of a more-efficient home care protocol to manage total joint replacement (TJR) patients after surgery. DESIGN: A randomized trial of two home care protocols for TJR management. SETTING: A hospital-affiliated home healthcare agency in a large midwestern city. PARTICIPANTS: Medicare-eligible individuals undergoing elective total hip or knee replacement surgery (N = 136). INTERVENTION: A home care protocol that included preoperative home visits by a nurse and a physical therapist and fewer postoperative visits (range of 9-12 visits) to the home than an existing protocol (range of 11-47 visits). MEASUREMENTS: Functional status, lower extremity functioning, health-related quality of life, satisfaction with care, and use and cost of healthcare services for 6 months postsurgery. RESULTS: There were no differences in functional status, health-related quality of life, or lower extremity functioning by group at 6 months. A marginally significant gain in satisfaction with access to care (P =.059) was found in the intervention group at 6 months. Home healthcare costs were 55% lower for the streamlined group (P <.001). Other costs did not differ significantly by group. CONCLUSION: TJR patients who received the more-efficient home care protocol experienced comparable outcomes to those who received the existing protocol. An abbreviated set of home care visits resulted in more-efficient delivery of care without compromising patient outcomes.

Gender and ethnic/racial disparities in health care utilization among older adults.

OBJECTIVE: We examine the role of economic access in gender and ethnic/racial disparities in the use of health services among older adults. METHODS: Data from the 1993-1995 study on the Asset of Health Dynamics Among the Oldest Old (AHEAD) were used to investigate differences in the 2-year use of health services by gender and among non-Hispanic White versus minority (Hispanic and African American) ethnic/racial groups. Analyses account for predisposing factors, health needs, and economic access. RESULTS: African American men had fewer physician contacts; minority and non-Hispanic White women used fewer hospital or outpatient surgery services; minority men used less outpatient surgery; and Hispanic women were less likely to use nursing home care, compared with non-Hispanic White men, controlling for predisposing factors and measures of need. Although economic access was related to some medical utilization, it had little effect on gender/ethnic disparities for services covered by Medicare. However, economic access accounted for minority disparities in dental care, which is not covered by Medicare. DISCUSSION: Medicare plays a significant role in providing older women and minorities access to medical services. Significant gender and ethnic/racial disparities in use of medical services covered by Medicare were not accounted for by economic access among older adults with similar levels of health needs. Other cultural and attitudinal factors merit investigation to explain these gender/ethnic disparities.