Biomedical subjects

Denise Orwig

Publications and source records attributed to Denise Orwig.

At least 19 recordsLinked to original sources

PubMed2006

Gender differences in functioning after hip fracture.

BACKGROUND: Hip fracture is a significant health problem for men and women; between 25 and 30 percent of all hip fractures are sustained by men. Relatively little is known about gender differences in functional outcomes after hip fracture. The purpose of the current study is to compare post-hip fracture functional recovery of men and women. METHODS: A sample of 674 patients age 65 or older were recruited as part of the Baltimore Hip Studies and were followed longitudinally for 1 year following fracture. Information on prefracture status and hospital course of treatment was collected as well as functional data at baseline, 2, 6, and 12 months postfracture. Data were analyzed longitudinally using Generalized Estimating Equations (GEEs). RESULTS: Men in the study were generally younger and suffered greater comorbidity at time of fracture. Men further suffered higher mortality in the year following fracture. Among survivors, little difference between men and women was seen in patterns of recovery of function following fracture. CONCLUSIONS: Hip fracture is not a problem affecting just women. Recovery following fracture for men is probably no better than that for women, even after mortality differentially eliminates the frailest male participants. However, psychosocial factors, greater comorbidity, and higher rates of certain complications among men may require adjustments to interventions designed to restore function. Further research into the consequences of hip fracture for men and women is needed.

Activities of Daily Living↗

PubMed2006

Medication management assessment for older adults in the community.

PURPOSE: The purpose of this study was to describe the Medication Management Instrument for Deficiencies in the Elderly (MedMaIDE) and to provide results of reliability and validity testing. DESIGN AND METHODS: Participants were 50 older adults, aged 65 and older, who lived in the community, took at least one prescription medication, and were then self-medicating. Nonmedical study staff assessed participants in their homes at baseline and 1 week, and a study pharmacist conducted pill counts at baseline and 30 days. The MedMaIDE covers three domains important for ensuring medication compliance (knowledge of medications, how to take medications, and procurement) and yields a total deficiency score. We assessed test-retest and interrater reliability. We assessed validity by comparing the MedMaIDE deficiency scores to 30-day pill count compliance. RESULTS: The sample was mostly female (72%) and White (56%), with a mean age of 78. Participants were taking an average of 7 prescription drugs, with an average pill count compliance of 70%. The MedMaIDE had very good test-retest reliability (intraclass correlation coefficient [ICC] = 0.93) and good interrater reliability (ICC = 0.74). Internal consistency was also strong (Cronbach's alpha = .71). Comparing the MedMaIDE to the pill count with those who were compliant (>80%) versus those that were not, the agreement was 75%. The MedMaIDE was more highly specific and predictive of compliance compared to the pill count. IMPLICATIONS: The MedMaIDE appears to be a reliable and valid instrument for determining if an older adult has deficiencies in managing medications.

Aged↗

PubMed2006

Inappropriate drug use and risk of transition to nursing homes among community-dwelling older adults.

BACKGROUND: Adverse events from inappropriate medications are preventable risk factors for nursing home admissions. OBJECTIVE: We sought to investigate the relationship between inappropriate medications in older adults and transitions to nursing home. METHODS: A retrospective cohort of Medicare beneficiaries with employer-sponsored supplemental health insurance was analyzed using a longitudinal data set of Medicare supplemental insurance claims. After a baseline year with no nursing home admissions, subjects were followed until the first month of transition to nursing home, loss to follow-up, or the end of the 24-month follow-up period. Survival analysis was used to compare the risk of nursing home transition among those with and without inappropriate drug use in the previous 3 months. RESULTS: Of the 487,383 subjects in the cohort, 22,042 (4.5%) had a nursing home admission. Use of inappropriate drugs was associated with a 31% increase in risk of nursing home admission, compared with no use of inappropriate drugs (adjusted relative risk 1.31, 99% confidence interval [CI] 1.26-1.36). Analyses of individual drug classes showed the risk of nursing home admission was similar, or lower, for inappropriate drugs versus other drugs of the same class. For example, the relative risk of nursing home admission was 2.34 (99% CI 2.20-2.47) for inappropriate narcotics and 2.68 (99% CI 2.55-2.82) for other narcotics, compared with no narcotic use. CONCLUSION: Inappropriate drug use was associated with increased risk of nursing home transition, but the increased risk may be explained by underlying patient conditions for which the drugs were prescribed rather than the inappropriate drug.

Aged↗

PubMed2006

Testing of the SEE and OEE post-hip fracture.

The purpose of this study was to test the reliability and validity of the Self-Efficacy for Exercise (SEE) and the Outcome Expectations for Exercise (OEE) scales in a sample of 166 older women post-hip fracture. There was some evidence of validity of the SEE and OEE based on confirmatory factor analysis and Rasch model testing, criterion based and convergent validity, and evidence of internal consistency based on alpha coefficients and separation indices and reliability based on R2 estimates. Rasch model testing demonstrated that some items had high variability. Based on these findings suggestions are made for how items could be revised and the scales improved for future use.

Activities of Daily Living↗

PubMed2006

The inpatient consultation approach to osteoporosis treatment in patients with a fracture. Is automatic consultation needed?

BACKGROUND: Osteoporosis has been described as a "silent epidemic." We describe an osteoporosis consultation program to facilitate the evaluation and treatment of inpatients with fragility fractures. METHODS: The inpatient orthopaedic team voluntarily requested an osteoporosis consultation on all patients with a fragility fracture. The osteoporosis consultant evaluated patients for secondary causes and started treatment with calcium, vitamin D, and bisphosphonates unless contraindicated. From November 2001 to December 2003, fifty-three osteoporosis consultations were performed. A retrospective review of the charts of all patients with a hip fracture treated during this twenty-six-month period revealed that only 47% were actually seen by the osteoporosis consultants, creating an unintentional "nonintervention" cohort of thirty-one patients with a hip fracture. Treatment for osteoporosis was assessed by a review of the inpatient charts and by a telephone interview after discharge. RESULTS: The study group consisted of eighty-four patients, which included fifty-three in the intervention cohort (twenty-eight hip and twenty-five other fractures) and thirty-one in the nonintervention cohort (all patients with a hip fracture). In the intervention cohort, most patients were vitamin-D deficient. Calcium and vitamin-D treatment was recommended for all fifty-three patients, and bisphosphonates were recommended for forty-one of the fifty-three patients in the intervention cohort. In the nonintervention cohort, two patients received calcium and vitamin D and one received a bisphosphonate; the difference between the cohorts was significant (p < 0.0001). In the intervention cohort, twenty-seven of the thirty-four patients who were available for a telephone interview after discharge (at a mean of eighteen months) remained on calcium and vitamin D; twenty-two of the thirty-four patients remained on bisphosphonates. In the nonintervention cohort, only one of the twelve patients who were available for follow-up (at a mean of thirty-nine months) was receiving calcium and vitamin D and none were on bisphosphonate treatment. CONCLUSIONS: This consultation program cannot be considered an outright success since only half of all patients with a hip fracture actually received a consultation. However, osteoporosis consultation, when provided, facilitated the recognition of secondary causes and the generic treatment of osteoporosis, and inpatients started on treatment generally continued the medication after discharge. The results of this study strongly support the need for a mechanism of automatic osteoporosis consultation for inpatients with a fragility fracture and suggest that, if consultation is reliably obtained, this approach can be effective in improving patient care. LEVEL OF EVIDENCE: Therapeutic Level III.

Aged↗

PubMed2005

Medical care costs of Paget's disease of bone in a privately insured population.

INTRODUCTION: Medical care costs are difficult to calculate in diseases such as Paget's disease because they have low detection rates and a wide range of clinical manifestations that commonly occur in aging patient populations. MATERIALS AND METHODS: Using 2001-2002 MarketScan Research databases, this study linked medical claims, prescription records, and encounter data on 2.8 million active and retired employees to create a longitudinal panel with 24 months of observation. Patients with Paget's disease were identified by ICD-9 code 731.0. Matched controls (MC) were identified through an exact match procedure using gender, age, and predicted Medicare costs estimated with a risk adjuster. Diagnostic and expenditure records were extracted for the sample and prevalence rates calculated for 20 conditions with well-documented associations to Paget's disease. Comorbidities and health care costs of Paget's disease patients were compared to those of the MCs, and the differences tested using Chi-square and t tests. RESULTS: Our study identified 244 matched pairs. The average age was 72.7 years; 50.8% were female. Significantly higher comorbidities (P < 0.05) were detected in Paget's disease patients relative to MCs for: pathological fractures (4.9% vs. 0.4%), heart murmurs (3.3% vs. 0.4%), low back pain (19.7% vs. 8.6%), spinal stenosis (16.4% vs. 9.8%), and hearing loss (13.5% vs. 5.7%), respectively. Biannual per patient outpatient costs were significantly higher in Paget's disease patients (Paget's disease $9301 vs. MC $6339, P < 0.05), especially for services associated with physician visits and diagnostic tests. Prescription costs for antiresportive agents and analgesics were also higher (Paget's disease $1115 vs. MC $507, P < 0.05). Inpatient costs (Paget's disease $16,144 vs. MC $21,480) were comparable. CONCLUSION: This study is the first to describe the excessive costs of Paget's disease, based on known patterns of disease expression, evaluation, and treatment.

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PubMed2005

A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research.

A. Bellg, B. Borrelli, et al. (2004) previously developed a framework that consisted of strategies to enhance treatment fidelity of health behavior interventions. The present study used this framework to (a) develop a measure of treatment fidelity and (b) use the measure to evaluate treatment fidelity in articles published in 5 journals over 10 years. Three hundred forty-two articles met inclusion criteria; 22% reported strategies to maintain provider skills, 27% reported checking adherence to protocol, 35% reported using a treatment manual, 54% reported using none of these strategies, and 12% reported using all 3 strategies. The mean proportion adherence to treatment fidelity strategies was .55; 15.5% of articles achieved greater than or equal to .80. This tool may be useful for researchers, grant reviewers, and editors planning and evaluating trials.

Behavioral Research↗

PubMed2005

The Exercise Plus Program for older women post hip fracture: participant perspectives.

PURPOSE: The purpose of this study was to explore the experiences of older women post hip fracture who were exposed to a motivational intervention, the Exercise Plus Program, intended to increase adherence to exercise. DESIGN AND METHODS: This study used a naturalistic inquiry. We interviewed a total of 70 older women, 12 months post hip fracture, using an interview guide asking about issues related to willingness to exercise. All interviews were tape recorded and transcribed verbatim. RESULTS: Analysis of the semi-structured interviews revealed 44 codes that were categorized and reduced to 14 major themes. Eleven of these themes focused on components that facilitated participation in exercise and included: (a) real and expected benefits; (b) visual cues and knowing what to do; (c) simplicity; (d) individualized care; (e) verbal encouragement to exercise; (f) regular schedule; (g) confidence (i.e., self-efficacy); (h) determination; (i) social support; (j) reciprocity; and (k) goal identification. The remaining three themes reflected what decreased the participants' willingness to exercise: (a) unpleasant sensations; (b) constraints to exercise; and (c) getting back to baseline. IMPLICATIONS: The findings provide some support for the benefit of the Exercise Plus Program. Lessons learned in the Exercise Plus Program can be translated to the development of other motivational interventions to help engage older adults in exercise, particularly those individuals who recently experienced an acute event, such as a hip fracture.

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PubMed2005

Examples of implementation and evaluation of treatment fidelity in the BCC studies: where we are and where we need to go.

Treatment fidelity plays an important role in the research team's ability to ensure that a treatment has been implemented as intended and that the treatment has been accurately tested. Developing, implementing, and evaluating a treatment fidelity plan can be challenging. The treatment fidelity workgroup within the Behavior Change Consortium (BCC) developed guidelines to comprehensively evaluate treatment fidelity in behavior change research. The guidelines include evaluation of treatment fidelity with regard to study design, training of interventionists, delivery and receipt of the intervention, and enactment of the intervention in real-life settings. This article describes these guidelines and provides examples from four BCC studies as to how these recommended guidelines for fidelity were considered. Future work needs to focus not only on implementing treatment fidelity plans but also on quantifying the evaluations performed, developing specific criteria for interpretation of the findings, and establishing best practices of treatment fidelity.

Behavioral Research↗

PubMed2004

Prescription psychotropic medication use among the U.S. adult population: results from the third National Health and Nutrition Examination Survey, 1988-1994.

OBJECTIVE: We estimated prescription psychotropic medication use among US adults. METHODS: We examined household interview data from the third National Health and Nutrition Examination Survey (1988-1994) for persons 17 years and older (n=20,050). STUDY DESIGN AND SETTING: An estimated 10 million adults (5.5%) reported psychotropic medication use during a 1-month period. The use of anxiolytics, sedatives, and hypnotics (ASH) was most common (3.2%), followed by antidepressants (2.3%), antipsychotics (0.7%), and antimanics (0.1%). Psychotropic medication use was more prevalent among women than men (P<.001), non-Hispanic whites than non-Hispanic blacks (P<.001) and Mexican Americans (P<.001), and older rather than younger age groups (P<.001). Psychotropic medication use was also most common among those below the federal poverty level, those with no high school education, and among insured persons. Only 1% of adults used two or more psychotropic medications monthly. CONCLUSION: Many adults use psychotropic medications on a monthly basis. ASH users comprised the largest proportion of psychotropic medication users. Patterns of use varied by several socio-demographic factors.

Adolescent↗

PubMed2004

Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium.

Treatment fidelity refers to the methodological strategies used to monitor and enhance the reliability and validity of behavioral interventions. This article describes a multisite effort by the Treatment Fidelity Workgroup of the National Institutes of Health Behavior Change Consortium (BCC) to identify treatment fidelity concepts and strategies in health behavior intervention research. The work group reviewed treatment fidelity practices in the research literature, identified techniques used within the BCC, and developed recommendations for incorporating these practices more consistently. The recommendations cover study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. Funding agencies, reviewers, and journal editors are encouraged to make treatment fidelity a standard part of the conduct and evaluation of health behavior intervention research.

Benchmarking↗

PubMed2003

Predictors of bone loss after hip fracture.

Although accelerated bone mineral density (BMD) loss follows hip fracture, little is known about factors associated with this loss. We examined potential predictors of BMD loss in a cohort of community-dwelling women who had sustained hip fracture and who were followed for 1 year after fracture. BMD was measured at the femoral neck, intertrochanteric region, and total body, during hospitalization and 2, 6, and 12 months later. Demographic, health, lifestyle, clinical, surgical, and functional characteristics at baseline, and postfracture activity were evaluated for associations with baseline BMD and BMD 1 year later. To examine possible BMD-dependent effects, high and low baseline BMD groups were defined. None of the studied factors consistently predicted either baseline BMD or BMD at 1 year after fracture, among women with either high or low baseline BMD. Baseline BMD was the only factor that substantially and consistently predicted change, explaining 70% to 90% of variation. These results suggest that BMD will not be preserved by general rehabilitative measures and that prompt, specific intervention to minimize bone loss after hip fracture is an essential element of clinical management of the hip fracture patient.

Absorptiometry, Photon↗

PubMed2002

Evaluating the components of the Exercise Plus Program: rationale, theory and implementation.

Recovery following a hip fracture is facilitated by participation in regular exercise. Despite the benefits of exercise, it is difficult to get older adults to initiate and adhere to regular exercise programs. The Attribution Theory of Achievement Motivation suggests that an individual's future involvement in an activity is based on assessments of prior experience with the activity. Conversely, the Theory of Self-efficacy states that self-efficacy expectations and outcome expectations are not only influenced by behavior, but also by verbal encouragement, physiological sensations and exposure to role models or self-modeling. These expectations then determine the individual's willingness to initiate and engage in a given activity. Using a 2x2 factorial design, the primary aim of this study is to compare these two theories. The effectiveness of the Exercise Plus Program will be compared to the individual components of the program (Exercise Training and Plus components) on both self-efficacy and outcome expectations, exercise behavior, activity, and specific physical and psychological outcomes. A total of 240 older women post hip fracture will be recruited from five different acute care facilities. This study will add to current knowledge by examining the impact of a combined exercise training/social learning intervention approach versus either alone.

Exercise Therapy↗

PubMed2002

The effect of social support on exercise behavior in older adults.

The purpose of this study was to test the relationship among social supports related to exercise (family, friends, and expert support), self-efficacy expectations, outcome expectations, and exercise behavior in a sample of older adults living in a continuing care retirement community. The sample included 74 older adults with a mean age of 85.6 +/- 5.5. Path analysis using Amos 4.0 was done. The model fit the data (chi-square = 4.6, df = 3, p = .21, normed fit index of .99, relative fit index of .98, and root mean square error of approximation of .08) and explained 53% of the variance in exercise behavior. Five of the seven hypothesized paths in the model were statistically significant. Friend support indirectly influenced exercise through self-efficacy and outcome expectations. This suggests interventions to improve exercise behavior in older adults should incorporate social supports to strengthen self-efficacy and outcome expectations related to exercise.

Aged↗

PubMedDate not supplied

Three-tiered-copayment drug coverage and use of nonsteroidal anti-inflammatory drugs.

BACKGROUND: Previous studies of 3-tier formularies are rare, although the evidence suggests that their cost-sharing structure reduces overall drug spending. However, it is unclear how incentive-based formularies affect the selection of medications with safety advantages, or restrict the access that high-risk populations have to recommended therapies in the higher tiers. This study was designed to determine whether 3-tier formularies influence the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in a population of patients with arthritis. METHODS: This retrospective study used the 2000 MarketScan Research Database, which contains person-level claims data for employer-sponsored health plans. The sample for this study consisted of 20 868 individuals treated for osteoarthritis or rheumatoid arthritis and using NSAIDs while enrolled in tiered drug plans (n = 32). The likelihood of any use of cyclo-oxygenase (COX-2)-selective inhibitors was determined as a function of tiered drug plan coverage, adjusting for other person-level and plan-level covariates. RESULTS: Use of COX-2-selective inhibitors decreased (63.0% vs 53.6% vs 41.6%, respectively) and use of generic NSAIDs increased (37.7% vs 40.7% vs 55.7%, respectively) as formularies incorporated 1, 2, and 3 tiers. Enrollees in 3-tier plans with arthritis and serious gastrointestinal comorbidities (odds ratio, 0.51; 95% confidence interval, 0.40-0.66) were significantly less likely to use COX-2-selective inhibitors compared with patients in 1-tier plans. CONCLUSIONS: Three-tier formularies appear to reduce the use of COX-2-selective inhibitors among all patients with arthritis, even those at risk of experiencing gastrointestinal complications from using nonselective NSAIDs. These findings are among the first to suggest that tiered-copayment drug plans may be influencing the selection of medications beyond generic and branded products.

Aged↗

PubMedDate not supplied

Health-related quality of life: is it a good indicator of function post THR?

The purpose of this study was to explore the impact of health-related quality of life (HRQOL) measured with the Short Form Health Survey (SF-36) on Functional Recovery Status (physical and psychosocial recovery status) at base-line, 2 months, 6 months, and 12 months following total hip replacement (THR). A secondary analysis was performed using data gathered from a sample of 271 older adults post THR. Four empirically based hypothesized models were tested. None of the models fit the data, with each having significant chi2 values and chi2 /df ratios greater than 3. Different dimensions of HRQOL at baseline, 2, 6, and 12 months were related to physical recovery status, and none of the 8 dimensions of the SF-36 was significantly related to psychosocial recovery status. Overall, the results of this study do not support the hypothesis that HRQOL, as measured by the SF-36, comprehensively explains functional recovery status following THR. Clinically, these findings may be applicable to individuals at risk for poor recovery. They also may prompt practitioners to consider alternative factors that influence psychosocial recovery.

Age Distribution↗

PubMedDate not supplied

Recruitment of older women: lessons learned from the Baltimore Hip Studies.

OBJECTIVES: This study used a qualitative approach in which participants were asked to write about their experiences in recruiting older women into either one of two exercise intervention studies that are part of the Baltimore Hip Studies. The sample included 8 researcher nurses all women, White, and 42-53 years of age. BACKGROUND: Older adults, particularly older women, are less likely to participate in research studies when compared to their younger counterparts. The purpose of this study was to explore the techniques successfully used by research nurses in the Baltimore Hip Studies to recruit older women after hip fracture into exercise intervention studies. METHOD: Data analysis was performed using basic content analysis (Crabtree & Miller, 1992; Miles & Huberman, 1984) "in vivo" coding (Dowd, 1991), or "grounded" coding (Glaser & Strauss, 1967), which involves using the informants' own words to capture a particular idea. RESULTS: A total of 16 codes were identified and reduced to nine themes. Seven themes focused on techniques that facilitated recruitment: (a) caring for individuals; (b) emphasizing benefits; (c) eliciting support from others; (d) being an expert; (e) using role models; (f) using good timing; and (g) giving good first impressions. The remaining two themes identified barriers to recruitment: (a) time commitment and (b) lack of support. DISCUSSION: Based on these themes, specific recruitment techniques are recommended. Ongoing research, however, is needed to establish the most effective recruitment procedures with older women.

Adult↗

PubMedDate not supplied

Treatment fidelity in behavior change research: a case example.

BACKGROUND: Treatment fidelity refers to the methodological strategies used to monitor and enhance the reliability and validity of behavioral interventions. Assuring optimal treatment fidelity also may decrease the costs of a study and help the research team explain findings. APPROACH: The Behavioral Change Consortium developed a comprehensive model of treatment fidelity that incorporates 5 areas: (a) study design, (b) training providers, (c) delivery of treatment, (d) receipt of treatment, and (e) enactment of treatment skills. The definitions of these areas and a case example (Testing the Effectiveness of the Exercise Plus Program) are provided. RESULTS: There was evidence of treatment fidelity related to delivery based on careful monitoring of the study implementation. A comprehensive plan for training of the interventionists was provided, although evidence of treatment fidelity to training was not quantified. There were evidence based on observations of treatment sessions of delivery and receipt of the intervention and evidence of enactments based on evaluation of exercise calendars. DISCUSSION: The development and implementation of a treatment fidelity plan requires a careful conceptualization of what is relevant to treatment fidelity in any given study. Monitoring of treatment fidelity ideally requires direct or indirect observations of sessions, which can be built into the study design so that costs are minimal in terms of time and resources. Monitoring treatment fidelity allows research teams to truly test interventions and to develop and implement interventions that ultimately improve the overall health and well-being of individuals.

Models, Nursing↗