Biomedical subjects

F D Wolinsky

Publications and source records attributed to F D Wolinsky.

At least 19 recordsLinked to original sources

PubMed2001

The effect of discussions about advance directives on patients' satisfaction with primary care.

BACKGROUND: Discussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary care exist. These barriers include time constraints, communication difficulties, and perhaps physicians' anxiety that patients might react negatively to such discussions. OBJECTIVE: To assess the impact of discussions of advance directives on patients' satisfaction with their primary care physicians and outpatient visits. DESIGN: Prospective cohort study of patients enrolled in a randomized, controlled trial of the use of computers to remind primary care physicians to discuss advance directives with their elderly, chronically ill patients. SETTING: Academic primary care general internal medicine practice affiliated with an urban teaching hospital. PARTICIPANTS: Six hundred eighty-six patients who were at least 75 years old, or at least 50 years old with serious underlying disease, and their 87 primary care physicians (57 residents, 30 faculty general internists) participated in the study. MEASUREMENTS AND MAIN RESULTS: We assessed patients' satisfaction with their primary care physicians and visits via interviews held in the waiting room after completed visits. Controlling for satisfaction at enrollment and physician, patient, and visit factors, discussing advance directives was associated with greater satisfaction with the physician (P =.052). At follow-up, the strongest predictor of satisfaction with the primary care visit was having previously discussed advance directives with that physician (P =.004), with a trend towards greater visit satisfaction when discussions were held during that visit (P =.069). The percentage of patients scoring a visit as "excellent" increased from 34% for visits without prior advance directive discussions to 51% for visits with such discussions (P =.003). CONCLUSIONS: Elderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed. The improvement in visit satisfaction was substantial and persistent. This should encourage physicians to initiate such discussions to overcome communication barriers might result in reduced patient satisfaction levels.

Advance Directives↗

PubMed2000

Identifying meaningful intra-individual change standards for health-related quality of life measures.

Although numerous measures have been developed for the evaluation of health-related quality of life (HRQoL), strategies for identifying meaningful intra-individual change in these measures have not kept pace with instrument development. As a result, clinical trial researchers, quality assurance assessment teams and practising clinicians are without established standards to evaluate individual patient change in HRQoL measures as improved, stable or declined. This article reviews and critiques the methods that have been applied to establish intra-individual HRQoL change standards. These methods include within-person and between-persons anchor-based studies, as well as distribution-based techniques using the effect size, the standard error of measurement, the mean squared error or individual slope coefficients derived from hierarchical linear modelling. Practical approaches to improving and advancing HRQoL change evaluations that enhance the interpretation of intra-individual change are provided. Two future methodological challenges in this area of HRQoL research are examined: (1) the development of individual change standards for generic HRQoL measures; and (2) the incorporation of individual clinical assessments into the process for establishing significant intra-individual change standards.

Humans↗

PubMed2000

Physical activity, disability, and the risk of hospitalization for breast cancer among older women.

BACKGROUND: A recent investigation of physical activity, disability, and the risk of breast cancer among older women in the Iowa 65 + Rural Health Study reported a decreased risk of breast cancer among women with any disability compared with physically capable but inactive women (relative risk [RR] = 0.4. 95% confidence interval [CI] 0.2-0.9). Because of the intriguing nature of that association, those investigators urged replication before drawing any conclusions. METHODS: We replicated the Iowa approach using the Longitudinal Study on Aging (LSOA). a nationally representative, prospective cohort study. The 3131 community-dwelling women for whom we had complete data for these analyses ranged in age from 70 to 98 years old at baseline in 1984. Using ICD9-CM 174 codes, linked Medicare hospital claims identified 77 women with hospitalizations for breast cancer between 1984 and 1991. Multivariable proportional hazards regression was used to model the risk for this event among disabled, inactive, moderately active, and highly active women. RESULTS: No significant association between disability in older women and the risk of hospitalization for breast cancer relative to inactive older women was detected (adjusted hazard ratio [AHR]-0.78, 95% CI 0.41-1.5). Highly active older women had a significantly reduced risk of hospitalization for breast cancer (AHR-0.42, 95% CI 0.194).95). CONCLUSION: The intriguing finding from the Iowa 65+ Rural Health Study that disabled older women's risk for breast cancer was reduced could not be replicated in the LSOA, although power was limited. Highly active older women, however, had a significantly lower risk for breast cancer in both studies.

Activities of Daily Living↗

PubMed2000

Rethinking functional limitation pathways.

Functional limitation has received considerable attention in gerontology and geriatrics. Much of this work has focused on single-wave transitions devoid of context rather than on the pattern of transitions over time that constitute trajectories. This Forum article suggests that it is time for a different way of looking at functional limitation pathways. It focuses on trajectories. Responses to three Rosow and Breslau (1966) and two Nagi (1976) items, asked of 12,998 older adults who participated in up to seven waves of data collection as part of the Established Populations for the Epidemiologic Study of the Elderly, are used to illustrate this approach, emphasizing both its conceptual and pragmatic advantages. The results provide greater clarity in terms of those who become functionally limited, take on more functional limitations, or recover as well as those who are likely to be lost to follow-up and in terms of the outcomes associated with those individuals over time.

Activities of Daily Living↗

PubMed2000

Restricting medicaid payments for transportation: effects on inner-city patients' health care.

BACKGROUND: Prior approval programs have been used to control spiraling costs of Medicaid, but they are rarely formally assessed. We evaluated the effect of a change in Indiana Medicaid's policy (effective October 1, 1993) requiring prior approval to pay transportation costs. METHODS: We performed a historical cohort study comparing the health care utilization of Medicaid patients during the first 6 months of 1993 versus the first 6 months of 1994. Subjects included all Medicaid patients who visited any inpatient or outpatient site affiliated with an inner-city public hospital in the first 6 months of 1993 (N = 23,015) and 1994 (N = 23,707). RESULTS: These Medicaid patients made 82,961 visits in the first 6 months of 1993 and 79,809 visits in the first 6 months of 1994. Visits to hospital-based primary care clinics declined 16% (P < 0.001), which was partially offset by a 7% increase in visits to neighborhood health centers (P < or = 0.001). Emergency and urgent visits fell by 8%; visits for medication refills fell by 18% (P < 0.001 for each). Hospitalizations increased slightly in 1994, with no change in the number of inpatient days. There was no change in inpatient or outpatient nontransportation charges. There were no systematic reductions in selected aspects of preventive care. However, there were fewer emergency and urgent visits among patients with reactive airway disease. CONCLUSIONS: Requiring prior approval for transportation was associated with reductions in visits for primary care visits and refilling prescriptions without measurable short-term effects on charges or selected clinical parameters. Neighborhood health centers partially ameliorated the decline in primary care visits.

Adolescent↗

PubMed1999

Further evidence supporting an SEM-based criterion for identifying meaningful intra-individual changes in health-related quality of life.

This study used the standard error of measurement (SEM) to evaluate intra-individual change on both the Chronic Respiratory Disease Questionnaire (CRQ) and the SF-36. After analyzing the reliability and validity of both instruments at baseline among 471 COPD outpatients, the SEM was compared to established minimal clinically important difference (MCID) standards for three CRQ dimensions. A value of one SEM closely approximated the MCID standards for all CRQ dimensions. This SEM-based criterion was then validated by cross-classifying the change status (improved, stable, or declined) of 393 follow-up outpatients using the one-SEM criterion and the MCID standard. Excellent agreement was achieved for all three CRQ dimensions. Although MCID standards have not been established for the SF-36, the one-SEM criterion was explored in these change scores. Among SF-36 scales demonstrating acceptable reliability and reasonable variance, the percent of individuals within each change category was consistent with those seen in the CRQ dimensions. These results replicate previous findings where a value of one SEM also closely approximated MCIDs for all dimensions of the Chronic Heart Disease Questionnaire among cardiovascular outpatients. The one-SEM criterion should be explored in other health-related quality of life instruments with established MCIDs.

Adult↗

PubMed1999

The risk of hospitalization for acute myocardial infarction among older adults.

BACKGROUND: The purpose of this study was to prospectively examine the risk of hospitalization for acute myocardial infarction (AMI) in a large, nationally representative sample of very old men and women. METHODS: We utilized secondary analysis of the Longitudinal Study of Aging. Baseline (1984) in-person interview data were linked to Medicare hospitalization records for 1984-1991. Subjects were 6,071 noninstitutionalized adults 70 years old or older at baseline. Hospitalization for AMI was defined as having primary discharge diagnoses containing ICD9-CM 410 codes. Multivariable proportional hazards regression was used to evaluate the epidemiologic risks for all persons, and separately for women, men, self-respondents, those with no previous AMIs, and those with no history of coronary heart disease. RESULTS: Of the sample, 357 persons (5.9%; 172 women and 185 men) had at least one primary discharge diagnosis of AMI. Significant (p<.05) risk factors for being hospitalized with an AMI (adjusted hazards ratios in parentheses) from the pooled analysis were male gender (1.86), having no more than a grade school education (1.35), atherosclerosis (1.43), hypertension (1.29), coronary heart disease (1.63), angina (1.60), previous AMI (1.52), diabetes (1.89), and four or more lower body limitations (1.43). The gender-specific analyses, however, revealed that hypertension, angina, diabetes, and lower body limitations were risk factors only for women, and that having no more than a grade school education was a risk factor only for men. CONCLUSION: Men, especially those with low education, women with diabetes, angina, hypertension, or lower body limitations, and either men or women with previous AMIs, coronary heart disease, or atherosclerosis have elevated risks for AMI resulting in hospitalization, and they should be considered for evaluation and monitoring. Current protocols for therapeutic management should be adopted, and compliance should be encouraged.

Activities of Daily Living↗

PubMed1999

Linking clinical relevance and statistical significance in evaluating intra-individual changes in health-related quality of life.

OBJECTIVE: To compare the standard error of measurement (SEM) with established standards for clinically relevant intra-individual change in an evaluation of health-related quality of life. DESIGN: Secondary analysis of data from a randomized controlled trial. SUBJECTS: Six hundred and five outpatients with a history of cardiac problems attending the general medicine clinics of a major academic medical center. MEASURES: Baseline and follow-up interviews included a modified version of the Chronic Heart Failure Questionnaire (CHQ) and the SF-36. The SEM values corresponding to established standards for minimal clinically important differences (MCIDs) on the CHQ were determined. Individual change on the SF-36 was explored using the same SEM criterion. RESULTS: One-SEM changes in this population corresponded well to the patient-driven MCID standards on all CHQ dimensions (weighted kappas (0.87; P < 0.001). The distributions of outpatients who improved, remained stable, or declined (defined by the one-SEM criterion) were generally consistent between CHQ dimensions and SF-36 subscales. CONCLUSIONS: The use of the SEM to evaluate individual patient change should be explored among other health-related quality of life instruments with established standards for clinically relevant differences. Only then can it be determined whether the one-SEM criterion can be consistently applied as a proxy for clinically meaningful change.

Adult↗

PubMed1999

Gender differences in the sequelae of hospitalization for acute myocardial infarction among older adults.

OBJECTIVE: To examine the effect of gender differences among older adults hospitalized for an acute myocardial infarction (AMI) on subsequent health outcomes. DESIGN: Secondary analysis of the Longitudinal Study on Aging. Data from baseline interviews (1984) and three biennial (1986, 1988, and 1990) re-interviews were linked to Medicare hospitalization and National Death Index records for 1984-1991. PARTICIPANTS: A total of 6071 community-dwelling adults aged 70 years or older at baseline. METHODS: Pooled and stratified multivariable models were used to examine gender differences in the independent effects of being hospitalized for an AMI on all-cause mortality, the risk and volume of subsequent hospitalization, and increases in the number of functional limitations. Two comparison groups were used. RESULTS: Three hundred fifty-seven AMI cases (6%; 172 women and 185 men) were compared with 3976 hospitalized controls and 1738 nonhospitalized controls. The risk of all-cause mortality for AMI cases was greater than that for either hospitalized controls or nonhospitalized controls (referent), and this increased risk was significantly (P < .001) stronger for women (adjusted hazards ratio (AHR) = 14.24, 95%CI = 10.99, 18.46) than for men (AHR = 9.91, 95%CI = 7.75, 12.67). Overall, AMI cases were also more likely to be hospitalized subsequently than the hospitalized controls (referent; adjusted odds ratio (AOR) = 1.47, 95%CI = 1.17, 1.85), although in the stratified analysis this association held for men (AOR = 1.73, 95%CI = 1.25, 2.41) but not for women (AOR = 1.25, 95%CI = .90, 1.73). Among those subsequently hospitalized, both women and men AMI cases consumed more hospital resources than the hospitalized controls, and there were gender differences suggesting that the effects on total charges and length of stay were greater for women than for men with AMI. Finally, although the AMI cases had greater adjusted mean increases in the number of instrumental activities of daily living limitations and lower body limitations than the nonhospitalized controls, they were no worse off than the hospitalized controls, and there were no gender differences in those effects. CONCLUSION: Relative to the appropriate comparison groups, hospitalization for an AMI increases the risk of death and the total costs and lengths of stay of subsequent hospitalizations for women more than for men. Therefore, increased primary prevention, diagnosis, and treatment efforts should be directed toward women.

Aged↗

PubMed1998

Predictors of onset of and recovery from mobility difficulty among adults aged 51-61 years.

Relative to information on activities of daily living, information regarding the onset of and recovery from mobility difficulty has been limited. Drawing upon data gathered from 6,376 self-respondents aged 51-61 years at baseline (1992) who were successfully reinterviewed in 1994 as part of the Health and Retirement Survey, the authors were able to build upon and add to knowledge gained from previous studies of the onset of and recovery from mobility difficulty. Hierarchical logistic regression was used to separate the direct and indirect effects of predictors of mobility difficulty onset and recovery at 2-year follow-up. To separate direct and indirect effects, the authors categorized various predictors as being related to sociodemographic factors, economic factors, health behavior, chronic disease, or physical impairment, and the categories were sequentially incorporated into a series of equations. The order in which the predictors were incorporated into the equations followed from a theoretical model of the disability process. In this study of mobility difficulty, the strongest direct predictors of recovery were having little baseline difficulty and the absence of diabetes mellitus, lung disease, and frequent pain. The strongest direct predictors of onset were female sex, less education, low net worth, lack of private health insurance, obesity, and frequent pain. Few indirect predictors for either onset or recovery were identified. Predictors of recovery were few and differed from predictors of onset. Further efforts are needed to identify modifiable predictors among females, persons with few economic resources, and those with frequent pain.

Activities of Daily Living↗

PubMed1998

Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms. A randomized, controlled trial.

BACKGROUND: Physicians can increase the rate of completion of advance directive forms by discussing directives with their patients, but the means by which physicians can be induced to initiate these discussions are unclear. Computer-generated reminders have been shown to increase physician compliance with practice guidelines. OBJECTIVE: To determine the effects of computer-generated reminders to physicians on the frequency of advance directive discussions between patients and their primary caregivers and the frequency of consequent establishment of advance directives. DESIGN: Randomized, controlled trial with a 2 x 2 factorial design. SETTING: An outpatient general medicine practice associated with an urban public hospital. PARTICIPANTS: Participants were 1) 1009 patients who were at least 75 years of age or were at least 50 years of age with serious underlying disease and 2) 147 primary care physicians (108 housestaff and 39 faculty). INTERVENTION: Computer-generated reminders that recommended discussion of one or both of two types of advance directives compared with no reminders. MEASUREMENTS: Discussions about advance directives, determined by patient interviews after all scheduled patient-physician outpatient encounters, and completed advance directive forms. The study period was approximately 1 year. RESULTS: Physicians who did not receive reminders (controls) discussed advance directives with 4% of the study patients compared with 24% for physicians who received both types of reminders (adjusted odds ratio, 7.7 [95% CI, 3.4 to 18]; P < 0.001). Physicians who did not receive reminders completed advance directive forms with only 4% of their study patients compared with 15% for physicians who received both types of reminders (adjusted odds ratio, 7.0 [CI, 2.9 to 17]; P < 0.001). Overall, 45% of patients with whom advance directives were discussed completed at least one type of advance directive. CONCLUSIONS: Simple computer-generated reminders aimed at primary caregivers can increase the rates of discussion of advance directives and completion of advance directive forms among elderly outpatients with serious illnesses.

Advance Care Planning↗

PubMed1998

Mortality, symptoms, and functional impairment in late-life depression.

OBJECTIVE: To determine whether depressive symptoms measured at baseline are associated with mortality and to describe the course of depressive symptoms and their relation to physical decline in patients over a 6-year period. DESIGN: Prospective cohort study conducted from 1990 through 1996. SETTING: Urban academic primary care group practice. PATIENTS: A cohort of 3,767 patients aged 60 years and older screened for depressive symptoms during routine office visits using the Centers for Epidemiologic Studies Depression Scale (CES-D) participated in the mortality study. A subsample of 300 patients with CES-D scores 16 or above and a subsample of 100 patients with CES-D scores less than 16 participated in the study of the course of depressive symptoms and physical decline. MEASUREMENTS AND MAIN RESULTS: Mortality by December 1995 was measured for all screened patients; reinterviewed patients completed the CES-D and the Sickness Impact Profile (SIP). The mean follow-up period was 45 months (+/- SD 12.2 months); 561 (14.9%) of the patients died by December 1995. In proportional hazards models, age, gender, race, history of smoking, serum albumin value, and an ideal body weight in the lowest 10% were significant correlates of time to death, but the baseline CES-D was not. Patients with depressive symptoms had significantly worse physical and psychosocial functioning scores on the SIP than did patients without depressive symptoms. Using the generalized estimating equation method, the strongest predictor of the current CES-D score was the patient's prior CES-D score. However, worsening physical functioning score on the SIP was also independently correlated with worse CES-D scores p < or = .001). CONCLUSIONS: Symptoms of depression were not associated with mortality in this cohort of older adults. However, patients with depressive symptoms reported greater functional impairment than did those without depressive symptoms. Moreover, decline in physical functioning was independently correlated with a concurrent increase in depressive symptoms.

Activities of Daily Living↗

PubMed1998

Self-rated health and adverse health outcomes: an exploration and refinement of the trajectory hypothesis.

OBJECTIVES: To examine the hypothesis that the relationship between poor self-rated health and adverse health outcomes simply reflects self-assessments of declining health trajectories rather than current health status. METHODS: A 12-month follow-up of 786 disadvantaged adults aged 50-99 years old was conducted. Baseline markers of poor self-rated health and declining health trajectory were used to predict 12-month follow-up reports of the expectations of being hospitalized within one year, being placed in a nursing home within five years, and dying within ten years. Hierarchical multivariable logistic regression was used with poor self-rated health entered first, standard epidemiologic covariates entered next, and declining health trajectory entered last. RESULTS: Poor self-rated health was not independently associated with expectations for being hospitalized, but declining health trajectory independently increased the risk of such expectations by 65-88%. Neither poor self-rated health nor declining health trajectory were independently associated with expectations for being placed in a nursing home, but both were independently associated with expectations for dying, increasing such expectations by 70-105%. DISCUSSION: The relationship between poor self-rated health and adverse outcomes is not a simple reflection of unmeasured self-assessments of impending decline or doom. Rather, the effects of poor self-rated health and declining health trajectory appear to be independent and complementary.

Aged↗

PubMed1998

The risk of hospitalization for ischemic stroke among older adults.

OBJECTIVES: The purpose of this study was to identify risk factors for stroke and to estimate their relative importance in a large, nationally representative sample of very old men and women. METHODS: The study was designed as a secondary analysis of the Longitudinal Study on Aging. Baseline (1984) in-person interview data were linked to Medicare hospitalization records for 1984 to 1991. Participants were 6,071 noninstitutionalized adults 70 years old or older at baseline. Hospitalization for ischemic stroke was defined as having one or more episodes with a primary discharge diagnosis containing ICD-9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Multivariable proportional hazards regression was used to estimate the risks associated with previously identified epidemiologic factors. RESULTS: Five hundred and three persons (8.3%) had at least one primary discharge diagnosis of ischemic stroke. In descending order of importance-based on the partial r statistics associated with their adjusted hazards ratios (AHRs), the salient risk factors were having a previous history of stroke (AHR = 2.86), age (AHR = 1.04 per year), diabetes (AHR = 1.78), male gender (AHR = 1.42), lower body limitations (AHR = 1.09 per limitation), arthritis (AHR = 0.74), hypertension (AHR = 1.29), and poverty (AHR = 1.33). CONCLUSION: Patients presenting with the high risk factors identified in this study should be considered for further evaluation and monitoring. Current protocols for the therapeutic management of these higher risk patients should be considered, and compliance should be encouraged.

Aged↗

PubMed1998

Dimensions and correlates of physician work satisfaction in a midwestern city.

OBJECTIVES: The purpose of this study was to examine the dimensions of physician work satisfaction across a variety of medical specialties and practice settings. METHODS: A modified version of the Scheckler et al survey instrument was mailed to all physicians in Marion County, Indiana. Forty-two percent (777) of the eligible physicians responded. Exploratory factor analysis and internal consistency measures were used to assess the instrument's validity and reliability. Multivariable linear regression was used to predict global and summary scale scores. RESULTS: Four dimensions of physician work satisfaction were identified: relationships with patients (k = 6, alpha = 0.81), autonomy in clinical decision-making (k = 8, alpha = 0.81), office resources (k = 7, alpha = 0.87), and professional relationships (k = 5, alpha = 0.82). Most (73%) of the physicians were satisfied with their overall practice, and the majority were also satisfied with their income. Significant differences were observed in the sources and magnitude of physician work satisfaction across medical specialty, practice setting, and financial arrangement. Physicians in private practice were most satisfied with their overall practice and office resources, whereas physicians in health maintenance organizations (HMOs) were most satisfied with their autonomy in clinical decision-making. Physicians not working in HMOs but having a large percentage of patients with capitated reimbursement were not enthusiastic about the effect of managed care on their medical practice. Among primary care physicians, family practitioners and general internists were generally less satisfied, and general pediatricians were generally more satisfied with most aspects of their medical practices. CONCLUSIONS: The modified version of the Scheckler et al instrument is a reliable and valid measure of physician work satisfaction. Increases in the market share of managed care have differentially affected the work satisfaction of physicians based on their medical specialty, practice setting, and financial arrangements.

Adult↗

PubMed1998

Impact of an all-inclusive diagnosis-related group payment system on inpatient utilization.

OBJECTIVES: Although case-based payment is one of the main reimbursement mechanisms for hospitals, little is known about its effects in the general population. Prior studies have focused on Medicare or on all-payer systems in particular states. This study estimates the effect of a prospective payment system based on diagnosis-related groups (DRGs) nationwide in the Department of Veterans Affairs. METHODS: Multiple regression analysis was used to estimate the effect of Department of Veterans Affairs's diagnosis-related group system separately for 22 diagnoses. The dependent variables were length of stay, inpatient days per patient, and discharges per patient. Covariates included patient, hospital, and area characteristics. RESULTS: Department of Veterans Affairs's diagnosis-related group system reduced lengths of stay and inpatient days per patient. The largest impacts were for the psychiatric diagnoses and several surgical procedures. The magnitudes of the effects were generally moderate. Department of Veterans Affairs's case-based system had a negligible effect on discharges per patient. CONCLUSIONS: Per case reimbursement is a potentially useful tool for improving the efficiency of inpatient care for all types of diagnoses and age groups. The effect may be larger than estimated here because of institutional barriers and caps on financial impact.

Aged↗

PubMed1998

Changes in the SF-36 in 12 months in a clinical sample of disadvantaged older adults.

OBJECTIVES: The present study assessed changes in the Medical Outcomes Study 36-item short-form health survey (SF-36) during a 12-month period and examined the relation of those changes to selected baseline characteristics. METHODS: The study was a 12-month follow-up evaluation of 786 disadvantaged adults aged 50 to 99 years old who had participated in a randomized controlled clinical trial in the general medicine outpatient clinics of a major academic medical center. Descriptive and psychometric analyses of changes in the SF-36 scale scores during a 12-month period were performed, and two series of multivariable logistic regressions of increases or decreases greater than one standard error of measurement (SEM) versus stability on selected baseline characteristics were done. Measures were the eight SF-36 scales. RESULTS: Mean baseline scores on the SF-36 scales were substantially below age-specific national norms. Problematic floor and/or ceiling effects were found for the bodily pain, social function, role--physical, and role--emotional scales, consistent with age-specific national norms. Internal consistency was unacceptable for the general health perceptions scale, adequate for the social function scale, and good for all the other SF-36 scales. Improvements greater than one standard error of measurement were found for between one fifth and one third of the patients, and declines greater than one standard error of measurement were found for between one fifth and one third of the patients. Selected baseline characteristics generally were unrelated to either improvements or declines on the SF-36 scales. CONCLUSIONS: The SF-36 scales appear to be sufficiently sensitive for measuring changes in health outcomes during a 1-year period in older patients with debilitating disease. Little of the measured change, however, was predictable.

Adult↗

PubMed1998

The sequelae of hospitalization for ischemic stroke among older adults.

OBJECTIVES: To estimate the independent effect of hospitalization for ischemic stroke on change in functional status, subsequent hospitalization, and mortality. DESIGN: Secondary analysis of the nationally representative Longitudinal Study on Aging. Baseline (1984) interview data were linked to Medicare hospitalization and death records for 1984-1991 and to functional status reports at three biennial follow-ups. SETTING: In-person and telephone interviews were conducted. PARTICIPANTS: A total of 6071 noninstitutionalized respondents 70 years old or older at baseline. MEASUREMENTS: Hospitalization for ischemic stroke was defined as having one or more episodes with primary discharge ICD9-CM codes of 433.0-434.9, 436, and 437.0-437.1. Two reference groups were used: those who were hospitalized for something other than stroke, and those who were not hospitalized at all. The statistical methods employed were multivariable proportional hazards, logistic, and linear regression. RESULTS: The adjusted hazards ratio for having a primary hospital discharge diagnosis of ischemic stroke on mortality was 7.57 (CI95% = 6.47 to 8.85) versus 3.67 (CI95% = 3.28 to 4.10) for having been hospitalized for something other than stroke (both compared with the reference category of those not hospitalized at all). The adjusted odds ratio for having any subsequent hospitalization associated with having a primary hospital discharge diagnosis of ischemic stroke (compared with having been hospitalized for something other than stroke) was not significantly elevated (AOR = 1.16; CI95% = .94 to 1.42). However, the percent increases in the subsequent number of hospital episodes, total charges, and total length of stay for those who were hospitalized for ischemic stroke relative to those hospitalized for something other than stroke were significant (P < .001), and ranged from 16.3 to 39.0%. Hospitalization for ischemic stroke was also related significantly to greater increases in the regression-adjusted mean number of instrumental activities of daily living and lower body function limitations at follow-up. CONCLUSION: Hospitalization for ischemic stroke among older adults substantially increases the risk of subsequent mortality, the volume of hospital resource consumption, and greater functional decline, even when compared with hospitalization for something other than stroke. Therefore, greater attention to the prevention and management of ischemic stroke is needed.

Activities of Daily Living↗