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Biomedical subjects

A L Siu

Publications and source records attributed to A L Siu.

At least 55 records · Page 3Linked to original sources
PubMed1993

Change in self-reported functioning in older persons entering a residential care facility.

We evaluated the responsiveness of measures of function in admissions to a long-term care facility. Between baseline and follow-up assessment, one-fifth or more of the subjects either worsened or improved in most aspects of reported function. We compared two measures of self-reported function (COOP charts and a short-form survey). Convergent validity was observed for changes in pain, social health, and mental health (r = 0.39-0.74), but not for physical functioning. Although the short-form physical function measure discriminated worsening on several performance-based external criteria of physical functioning (area under ROC curves up to 0.82), the COOP and other measures of physical functioning were less likely to do so. All physical function measures were less responsive for detecting improvement. Clinicians and investigators intending to monitor change in function must consider the responsiveness of their measures.

Activities of Daily Living↗
PubMed1993

Measuring functioning and health in the very old.

To assess the validity of brief multidimensional measures of health, we studied 155 new residents of a long-term care institution. We collected self-reported measures of various aspects of health, as well as performance-based measures of physical and cognitive function. For six similar health dimensions measured using two self-reported methods, the average correlation between paired health dimensions was 0.64 (nonpaired correlation = 0.36). When we compared self-reports and performance on three closely paired health concepts, the average correlation of paired concepts was 0.49 (nonpaired correlation = 0.22). In a factor analysis, similar health dimensions measured using different methods tended to load on the same factor. Except for manual performance, performance-based and self-reported measures of physical and role function loaded on one factor. We conclude that brief measures of health and self-reported physical functioning in very old persons have acceptable validity.

Activities of Daily Living↗
PubMed1993

The geriatric "medical and public health" imperative revisited.

Attempts to reduce the future demand for institutional care through community services are likely to have limited success. For this reason, health professionals must focus on preventing or ameliorating functional decline in older persons. To focus attention on this aspect of the geriatric imperative, we use an epidemiologic model to estimate the potential impact of existing or potential medical and public health interventions that might decrease the incidence of functional decline. For at least three major causes (stroke, hip fracture, and incontinence) of disability, the potential exists for reducing the incidence and burden of functional disability by a number of mechanisms. For example, treating just half of adults age 65-74 with currently untreated diastolic or isolated systolic hypertension would reduce the incidence of stroke by 2.77% in this age group (or 1,500 fewer cases of stroke annually). The estimates presented indicate the need (1) to better implement those interventions that are known to be efficacious, and (2) to identify and to test new interventions for conditions contributing to functional impairment in the elderly.

Activities of Daily Living↗
PubMed1993

Follow-up after hospital discharge: does insurance make a difference?

As the length of hospital stays decreases, important medical problems are often deferred for follow-up after discharge. We investigated whether patients without regular physicians actually receive post-discharge care. Patients without regular physicians at the time of admission to a private nonprofit teaching hospital were surveyed by telephone one month after discharge. Forty-six percent were non-Caucasian and 53 percent had Medicaid or no insurance. Although discharge planning was documented for 97 percent of patients, only 54 percent of study participants had completed follow-up one month later and only 46 percent could identify a regular physician. Among all patients with a particular need for follow-up, Medicaid and uninsured patients were less likely to receive follow-up (p = 0.042), to identify a regular physician (p = 0.007), or to complete discharge instructions (p = 0.018). Cost of medical care was found to be a significant deterrent to obtaining follow-up for patients with Medicaid or with no insurance (p = 0.001). Expanded access to care, along with focused discharge planning, may improve completion of follow-up for Medicaid and uninsured patients.

Aftercare↗
PubMed1992

The predictive validity of self-report and performance-based measures of function and health.

To learn about the value of self-report and performance-based measures of function in predicting mortality and institutionalization, we conducted a longitudinal study of 149 elderly persons at four sites (a senior citizens housing unit, two ambulatory-based geriatrics practices, and a board-and-care facility). At baseline, all subjects were administered a questionnaire containing Katz, Spector, and Rosow-Breslau scale items as well as the Mini-Mental State Exam and two performance-based measures, the Tinetti gait score and Physical Performance Test. At follow-up (average 22 months; range 17-29 months), 17 subjects (11%) had died and seven (5%) had been institutionalized. Univariate analysis demonstrated significant associations between death and all functional status measures. In logistic regression models, Katz items, Tinetti gait score, and the seven-item Physical Performance Test were independent predictors of "death or nursing home placement"; Katz items and the seven-item Physical Performance Test were independent predictors of mortality. These findings support the use of performance-based as well as self-report measures for clinical and research purposes.

Activities of Daily Living↗
PubMed1992

HMO vs fee-for-service care of older persons with acute myocardial infarction.

OBJECTIVES: Health maintenance organizations (HMOs) continue to grow in number and in their enrollment of Medicare recipients. They are also increasingly viewed as organizational structures that might contribute to control of health care costs. Yet little is known about the quality of care that elderly HMO enrollees receive. METHODS: We compared patients from three HMOs to a fee-for-service (FFS) sample that was national in scope. Sickness at admission, the quality of process of care, and mortality were assessed for patients aged 65 years and older who had been hospitalized with a diagnosis of acute myocardial infarction. RESULTS: After adjustment for sickness at admission, there were no significant mortality differences between the HMO and FFS groups at either 30 (23.2% vs 23.5%) or 180 days (34.4% vs 34.5%) after admission. Compliance with process criteria was higher for the HMO group as a whole (P < .05). The HMOs had greater compliance with three of five scales measuring different aspects of care for patients with acute myocardial infarction. CONCLUSIONS: We conclude that older patients from our participating HMOs who were hospitalized for acute myocardial infarction received hospital care that was generally better in terms of process than that received by patients in a national FFS sample.

Age Factors↗
PubMed1992

Choosing quality of care measures based on the expected impact of improved care on health.

Consumers, payers, and policymakers are demanding to know more about the quality of the services they are purchasing or might purchase. The information provided, however, is often driven by data availability rather than by epidemiologic and clinical considerations. In this article, we present an approach for selecting topics for measuring technical quality of care, based on the expected impact on health of improved quality. This approach employs data or estimates on disease burden, efficacy of available treatments, and the current quality of care being provided. We use this model to select measures that could be used to measure the quality of care in health plans, but the proposed framework could also be used to select quality of care measures for other purposes or in other contexts (for example, to select measures for hospitals). Given the limited resources available for quality assessment and the policy consequences of better information on provider quality, priorities for assessment efforts should focus on those areas where better quality translates into improved health.

Breast Neoplasms↗
PubMed1991

Screening for dementia and investigating its causes.

OBJECTIVE: To examine, from the perspective of primary care physicians, the value of mental status findings and ancillary tests in diagnosing dementia or its causes. DATA SOURCES: Studies identified using MEDLINE and bibliographies of pertinent articles. STUDY SELECTION: Selection based on availability of information on specific findings or tests, the criterion standard used to confirm diagnoses, the disease spectrum, and the richness of the reported data. DATA EXTRACTION: Data collected on sensitivity and specificity. In many cases, the originally reported data are re-analyzed to illustrate the usefulness of alternative cut-off values or to answer specific clinical questions. Likelihood ratios estimated to summarize test results. DATA SYNTHESIS: Probability of dementia is greatly reduced (likelihood ratio, 0.06 to 0.2) when either normal serial 7s, 7-digit span, 3-item recall, or clock drawing test results are obtained; abnormal results only moderately increase the odds of disease. Low (less than or equal to 20), intermediate (21 to 25), or high (greater than or equal to 26) scores on the Mini-Mental State Examination (MMSE) increase (likelihood ratio greater than or equal to 8.2), have little effect (likelihood ratio, 1.3 to 2.4), or decrease (likelihood ratio, 0.06 to 0.1) the odds of disease. The usefulness of tests to investigate the cause of dementia varies depending on the pretest probability of the specific condition. CONCLUSIONS: Several useful methods exist to screen for cognitive impairment, and clinicians need to be familiar with the strengths and limitations of their preferred screening methods. In investigating the cause of dementia, routinely obtaining a VDRL test, cerebral imaging studies, serum cobalamin level, or folate level is unwarranted.

Aged↗
PubMed1991

Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence.

Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations. In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta-analysis. In this initial meta-analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta-analysis of 6-month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46-0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42-0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55-0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61-1.49).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Physician satisfaction with career choices in geriatrics.

In a national survey of fellows who had trained in geriatric medicine and psychiatry, the vast majority of former fellows expressed satisfaction with their current work. Satisfaction with a career choice in geriatrics was significantly greater among those physicians who had practices with large numbers of patients over 75, accepted Medicare assignment, spent their time as clinician-researchers, and had a medical school appointment. Physician job satisfaction may have important consequences, and attention to maximizing satisfaction is warranted.

Career Choice↗
PubMed1990

An objective measure of physical function of elderly outpatients. The Physical Performance Test.

Direct observation of physical function has the advantage of providing an objective, quantifiable measure of functional capabilities. We have developed the Physical Performance Test (PPT), which assesses multiple domains of physical function using observed performance of tasks that simulate activities of daily living of various degrees of difficulty. Two versions are presented: a nine-item scale that includes writing a sentence, simulated eating, turning 360 degrees, putting on and removing a jacket, lifting a book and putting it on a shelf, picking up a penny from the floor, a 50-foot walk test, and climbing stairs (scored as two items); and a seven-item scale that does not include stairs. The PPT can be completed in less than 10 minutes and requires only a few simple props. We then tested the validity of PPT using 183 subjects (mean age, 79 years) in six settings including four clinical practices (one of Parkinson's disease patients), a board-and-care home, and a senior citizens' apartment. The PPT was reliable (Cronbach's alpha = 0.87 and 0.79, interrater reliability = 0.99 and 0.93 for the nine-item and seven-item tests, respectively) and demonstrated concurrent validity with self-reported measures of physical function. Scores on the PPT for both scales were highly correlated (.50 to .80) with modified Rosow-Breslau, Instrumental and Basic Activities of Daily Living scales, and Tinetti gait score. Scores on the PPT were more moderately correlated with self-reported health status, cognitive status, and mental health (.24 to .47), and negatively with age (-.24 and -.18). Thus, the PPT also demonstrated construct validity. The PPT is a promising objective measurement of physical function, but its clinical and research value for screening, monitoring, and prediction will have to be determined.

Activities of Daily Living↗
PubMed1990

Hierarchical measures of physical function in ambulatory geriatrics.

Brief and uncomplicated methods for obtaining information on functional status would facilitate the assessment of older patients. We evaluated the potential usefulness, reliability, and validity of four hierarchical measures of physical function in 123 elderly subjects seen in four ambulatory geriatrics settings. Although the vast majority (83.2%) of subjects were fully independent on the Katz Activities of Daily Living Scale, a broader scope of functional difficulty was reported on the Spector-Katz, five-item OARS, and Rosow-Breslau scales. The three scales all had either borderline or more acceptable coefficients of scalability (0.57-0.77); the hierarchical order of items was not observed in 5.3% to 13.6% of subjects. Combining items from these established measures resulted in two new scales with acceptable scalability and construct validity; however, some errors in item order persisted. Although their ease of administration is clearly advantageous, clinicians using short hierarchical scales to assess functional status of older patients should be aware of their limitations.

Activities of Daily Living↗
PubMed1990

Patient, provider and hospital characteristics associated with inappropriate hospitalization.

To determine the relation between patient and provider characteristics and inappropriate hospital use, we examined adult nonpregnancy hospitalizations from a randomized trial of health insurance conducted in six sites in the United States. Appropriateness of inpatient treatment was based on medical record review; patient characteristics on sociodemographic, economic, and health status; and provider characteristics on descriptors of physician practice and hospital facilities. Twenty-seven percent of admissions attended by physicians licensed for more than 15 years were judged inappropriate, compared to 20 percent for younger physicians. Admissions were more likely to be inappropriate if the patient was female (27 percent compared with 18 percent). Controlling for patient and provider characteristics reduces but does not eliminate the differences in the appropriateness of inpatient care across the study's six sites. Differences in available provider and patient characteristics do not account for geographic differences in inappropriate hospitalization in this study.

Cost Control↗
PubMed1989

Comprehensive geriatric assessment: toward understanding its efficacy.

Comprehensive geriatric assessment (CGA) offers health care professionals a technique for multidimensional diagnosis of frail elderly people to plan medical, psychosocial, and rehabilitative care. In the present paper, we provide a brief history of geriatric assessment, a description of the varied organization of geriatric assessment programs (GAPs), and a review of published effectiveness studies of programs worldwide performing comprehensive geriatric assessment. Program diversity has complicated drawing conclusions about the efficacy of CGA from a literature reporting generally positive, but not uniformly significant, results. We suggest that sample size limitations explain much of the variability in findings. Using the techniques of meta-analysis, we evaluate the effect of GAPs on mortality when all controlled trials are considered cumulatively. Meta-analysis of six-month mortality demonstrates a statistically significant 36% reduction of mortality for inpatient CGA programs (odds ratio = 0.64; 95% confidence interval = 0.50 to 0.83), and a 32% mortality reduction for all CGA programs (odds ratio = 0.68; 95% confidence interval = 0.57 to 0.80). Further use of meta-analytic techniques can be employed to clarify the effect of GAPs on other important outcomes (e.g., reduced hospital and nursing home use, improved functional status), and to identify program characteristics best promoting these benefits.

Aged↗
PubMed1989

Comprehensive geriatric care in a day hospital: a demonstration of the British model in the United States.

A geriatric day hospital (GDH) was developed in a community hospital to meet the complex medical and social needs of the frail elderly. A review of medical records (n = 273) and interviews with referring physicians (n = 42 on 96 patients) revealed that the GDH provided intensive outpatient care, geriatric assessment, rehabilitation, and an alternative to hospitalization. In all, 21% of physician-referred patients would have been hospitalized without the GDH, 7% would have had longer hospital stays, and care would have been deferred for 18%.

Aged↗
PubMed1989

Geriatric medicine in the United States. The current activities of former trainees.

To improve the health care received by frail older persons, an effort has been made in the United States to increase the number of physicians trained in geriatric medicine and geropsychiatry. The goal of training has been to create leaders in education, research, and patient care. To assess the progress of this effort, we surveyed physicians (284 in geriatric medicine and 91 in geropsychiatry) who graduated from U.S. geriatrics fellowship programs. Responses were obtained from 224 medicine (79% response) and 59 psychiatry fellows (65% response). Sixty-five percent of former geriatric medicine fellows report spending 10% or less time on teaching; 44% report doing no research, and 44% report spending more than half their time in patient care. Compared to other primary care specialties, the geriatricians reported caring for larger proportions of older patients and spending more time per patient visit. However, their role in teaching, research, and long-term care is minimal.

Data Collection↗