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Biomedical subjects

L G Branch

Publications and source records attributed to L G Branch.

At least 37 records · Page 2Linked to original sources
PubMed1996

Analysis of change in self-reported physical function among older persons in four population studies.

Change in self-reported physical function was examined using baseline and 5 years of follow-up data between 1982 and 1991 from the four Established Populations for Epidemiologic Studies of the Elderly studies. In East Boston, Massachusetts (n = 3,809), Iowa and Washington Counties, Iowa (n = 3,673), New Haven, Connecticut (n = 2,812), and North Carolina (n = 4,163), noninstitutionalized persons aged 65 years and older were asked a series of questions to assess their physical function: a modified Katz Activities of Daily Living (ADL) scale, three items from the Rosow-Breslau Functional Health Scale, and questions on physical performance, adapted from Nagi, as well as information on demographic, social, and health characteristics. Longitudinal statistical analyses (random effects and Markov transition models) were used to evaluate improvement, stability, and deterioration in functional ability at both an individual and a population level over multiple years of data. The average decline in physical function associated with age was found to be greater than previous cross-sectional studies have suggested, and the rate of decline increased with increasing age. Considerable individual variation was evident. Although many people experienced declines, a smaller but substantial portion experienced recovery. Women reported a greater rate of decline in physical function and were less likely to recover from disability.

Activities of Daily Living↗
PubMed1996

A comparison by payor/provider type of the cost of dying among frail older adults.

OBJECTIVE: To compare expenditures and healthcare service use between decedents (in their last year of life) and survivors, all of whom were frail older people, under three payor/provider types. DESIGN: In-home interviews were conducted by home care nurses at baseline and at 6-month intervals for an 18-month period. Utilization and cost data were collected directly from providers and the Health Care Financing Administration for 12 months immediately before death for decedents and for the first 12 months of follow-up for survivors. SAMPLE: Five hundred seventy-seven frail older patients of an integrated healthcare system who were receiving physician prescribed home health services, under Medicare fee-for-service (FFS), Medicare HMO, or Medicare-Medicaid coverage. Frailty was defined as the receipt of physician-prescribed home healthcare services. OUTCOME MEASURES: Acute and long-term healthcare service utilization and expenditures; total healthcare expenditures. RESULTS: After controlling for baseline differences, significant differences in utilization and expenditures of survivors (n = 450) and decedents (n = 127) were demonstrated. Compared with survivors, frail older decedents were approximately: 7 times as likely to have had any hospital admissions 3 times as likely to have had one or more emergency room visits 8 times as likely to have 30 or more physician visits 4 times as likely to have been admitted to a skilled nursing facility and twice as likely to have used home health services after the baseline episode. On average, total expenditures for decedents were 276% higher than for survivors. Total expenditures for Medicaid-Medicare beneficiaries were 42% higher than expenditures for FFS participants, primarily because of higher hospitalization and emergency room expenditures. There were no differences in utilization and expenditures between HMO enrollees and FFS beneficiaries. Finally, interactions between decedent status and payor/provider were not statistically significant in multivariate analyses. CONCLUSION: During the last year of life, frail older people exhibit the same pattern of higher expenditures and service utilization as the general Medicare population. However, differences between decedents' and survivors' healthcare expenditures and resource use did not vary by payor/provider. Thus, cost-containment strategies should focus on new forms of managing healthcare services beyond those currently practiced within Medicare HMOs, traditional FFS, or Medicare-Medicaid in California.

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PubMed1995

A prospective study of consumption of carotenoids in fruits and vegetables and decreased cardiovascular mortality in the elderly.

Recent evidence suggests that oxidative damage may be involved in atherogenesis, and thus dietary antioxidants, such as beta-carotene, may reduce the risks of cardiovascular disease (CVD). We examined the association between consumption of carotene-containing fruits and vegetables and CVD mortality among 1299 elderly Massachusetts residents who provided dietary information as a part of the Massachusetts Health Care Panel Study. During a mean follow-up of 4.75 years, there were 161 deaths attributable to CVD, 48 of which were due to myocardial infarction. For total CVD death and fatal myocardial infarction, risks were lower among those residents in the highest quartile for consumption of carotene-containing fruits and vegetables as compared with those in the lowest. For death due to CVD, the relative risk (RR) was 0.54 (95% confidence interval (CI), 0.34 to 0.86; P for trend across quartiles, 0.004). For myocardial infarction the RR was 0.25 (95% CI, 0.09 to 0.67; P for trend, 0.002). These observational data are compatible with the hypothesis that increased dietary intake of carotenoids decreases the risks of CVD mortality; however, confounding cannot be ruled out. This hypothesis requires rigorous evaluation in randomized trials of sufficient size to detect reliably whether carotenoids confer small-to-moderate but clinically important protection against CVD.

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PubMed1995

The PACE evaluation: initial findings.

As of mid-1994 there were nine replications of the On Lok model operating under dual capitation payments as sites in the Program of All-inclusive Care for the Elderly (PACE). A tenth site had begun operating under capitation, but was unable to remain viable. The present descriptive study documents the growth and development of the first seven of these sites, all that had been operating under capitation during 1992. Comparisons among these sites and with On Lok are presented in the areas of organizational structure, client characteristics, approaches to case management, service delivery options, and financing. There is considerable variability in the implementation of the PACE model. Combined Medicare and Medicaid capitation monthly payments range from $2,147 to $5,973. These seven PACE sites (excluding On Lok) served a total of 888 current clients at the end of 1992, after a cumulative 136 months of experience under capitation. The very slow enrollment rates may imply that the target clients are less enthusiastic about this model than are its architects. The client selection process may suggest niche-marketing or skimming, but not the full representation of the nursing home population in their states. Given both the slow enrollment and the niche-marketing (the benevolent term) or skimming (the pejorative term) that has occurred, caution about the long-term viability of the PACE model may be warranted.

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PubMed1995

Difficulty with holding urine among older persons in a geographically defined community: prevalence and correlates.

OBJECTIVE: The goal of this study was to estimate the prevalence and correlates of difficulty holding urine among a population of community-dwelling older people. DESIGN: Population-based cross-sectional study. SUBJECTS: A population census identified all residents aged 65 years and older residing in East Boston, Massachusetts, in 1982. MEASURES: Data collected via in-home interviews were used to estimate the prevalence of difficulty holding urine and to provide information regarding potential correlates of urinary difficulty. RESULTS: Of the 3809 study participants (85% response rate), 28% reported having "difficulty holding urine until they can get to a toilet" at least some of the time, and 8% reported difficulty "most" or "all of the time." Difficulty was associated with age and sex; 44% of women and 34% of men reported some difficulty (P < .001), and 9% of women and 6% of men (P < .001) reported difficulty most or all of the time. For respondents aged 65 to 74 years, 40% reported some difficulty, compared with 47% of those aged 85 and older (Ptrend < .001); difficulty most or all of the time was reported by 6% of those aged 65 to 74 and 12% of those aged 85 and older (Ptrend < .001). Difficulty holding urine was associated with important health and functional measures including depression, stroke, chronic cough, night awakening, fecal incontinence, problems with activities of daily living, decreased frequency and ease in getting out of the house, and poor self-perception of health. CONCLUSIONS: Difficulty holding urine is a prevalent condition among older people living in the community and is associated highly with a number of health conditions and functional problems.

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PubMed1995

Functional status and the use of formal home care in the year before death.

A national sample of persons who died in 1986 was analyzed to obtain a valid estimate of the relationship between functional status and the provision of formal home care during the last year of life. Community-based care has become increasingly important as the size of the elderly population increases and the cost for institutional care rises. When people need help in caring for themselves because of illness, frailty, or disability, community-based care may be more appropriate than acute or institutional care. The year before death is often a time of dependence and a high intensity of health service consumption. Although care at home is provided primarily by families, formal home care is also a critical component in any continuum of care.

Activities of Daily Living↗
PubMed1994

Short-term variability of self report of incontinence in older persons.

OBJECTIVE: Virtually all estimates of the prevalence and incidence of incontinence in the community rely on self-reported continence status. The goal of this study was to assess the reliability of this measure in older adults. DESIGN: Telephone interviews administered approximately 2 weeks apart. SETTING: Community-based congregate living facility. PARTICIPANTS: A convenience sample of approximately 100 residents was contacted by letter; 48 of 51 (94%) who indicated their willingness to participate were interviewed. They included eight men and 40 women > 70 years old (79% > 80 years old), virtually all of whom were independent in basic ADLs and 83% of whom reported their health as good or excellent. MEASUREMENT: Responses to a structured questionnaire. MAIN RESULTS: The prevalence of urinary incontinence was 40% at baseline and 44% on re-interview; the prevalence of fecal incontinence was 17% on both occasions. All Spearman correlations for items related to urinary incontinence characteristics were between .80 and .86, except for a question related to stress incontinence (r = .62); correlations for fecal incontinence were .67-.69. CONCLUSION: Prevalence estimates of incontinence are stable over a 2-week period. However, the variability of individual responses, while relatively low, was within the range previously reported for estimates of incidence and remission rates of incontinence in community-dwelling elderly. This, variability should be taken into consideration when interpreting previous studies and designing future ones.

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PubMed1994

Urinary incontinence knowledge among community-dwelling people 65 years of age and older.

OBJECTIVES: We determined elderly persons' knowledge about the epidemiology and treatment of urinary incontinence (UI) as part of a preintervention survey for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly (EDUCATE). DESIGN: An intact-group pretest-posttest design was employed to measure the effects of multimethod educational interventions on the knowledge, attitudes, and practices of physicians and older people concerning UI. PARTICIPANTS: A random sample of community-dwelling people aged 65 years and older from two counties in Massachusetts was selected (n = 1,140). MEASUREMENT: A 14-item urinary incontinence quiz was developed from information presented in the AHCPR UI Guideline Panel's recommendations. Participants answers to the quiz were part of a 20-minute telephone interview. RESULTS: For nine of the fact items, the elderly respondents were more likely to give the correct answer than the incorrect answer. However, for only four of those nine did the percentage of correct responses exceed 50% (there were substantial proportions of "don't know" responses). For several fact items, those who were younger, female, or had more formal education were more likely to provide correct responses. CONCLUSIONS: There are substantial gaps in the knowledge of older persons about urinary incontinence, especially among men, those age 85 and older, and those with lower levels of education. These knowledge gaps may contribute to misinterpretation of symptoms and underreporting of symptoms to health care professionals. This pattern of findings indicates a greater need for community education on urinary incontinence.

Age Factors↗
PubMed1994

The influence of the New York Quality Assurance System on casemix in nursing homes.

The New York Quality Assurance System (NYQAS) was designed to assure high-quality nursing home care in New York. Among its many incentives, NYQAS may change the likelihood that elderly with heavy-care needs will be admitted to nursing homes. This article addresses that hypothesis. Data for descriptive and multivariate analyses come from the RUGs-II Patient Review Instrument and the Medicare and Medicaid Automated Certification System files for 1986-1990. The descriptive analyses focus on functional ability in new nursing home residents before and after NYQAS. The multivariate analyses adjust for pre-NYQAS, RUGs-related trends in casemix, resident demographics, and nursing home characteristics that influence casemix. The results suggest a significant but small decrease in functional status at admission during the post-NYQAS era.

Data Collection↗
PubMed1994

Can a survey influence quality of care in nursing homes? The impact of the New York Quality Assurance System on resident deterioration and adverse outcomes.

Data from a standardized administrative form, the Patient Review Instrument, were used to evaluate whether the New York Quality Assurance System (NYQAS) had an impact on deterioration in functional status or on the incidence of adverse outcomes among residents in New York's nursing homes. The NYQUAS approach evaluated nursing homes by using "triggers" suggestive of deficient quality of care. A random sample of nursing home facilities was selected from data encompassing 2 years before and 2 years after the implementation of NYQAS in 1988. Growth curve analysis and logistic regression were used to assess the influence of NYQAS on deterioration and on the probability of developing decubitus ulcers or contractures, or of being mechanically restrained. The functional status of most residents did not change significantly over time. After allowing statistically for differences in the resource needs of residents within the facilities, the implementation of NYQAS was associated with decreased deterioration in toileting and/or transferring, depending on the site of care. NYQAS was not associated with changes in incidence rates of decubitus, contractures, or the use of mechanical restraints.

Activities of Daily Living↗
PubMed1994

Elders' out-of-pocket payment for community-based long-term care.

This research describes characteristics of community living elders aged 71 and older with long-term care (LTC) needs who pay out-of-pocket for community-based LTC. Community living elders with higher incomes, more friends and non-child relatives outside the home, and greater ADL or IADL needs are more likely to purchase LTC than those without these characteristics. Also the lack of sufficient numbers of children outside the home to provide assistance tended to result in the use of out-of-pocket paid services. Paying for LTC is not associated with the extent of disability experienced. This study clarifies the characteristics of those in need who currently pay out-of-pocket for community LTC as a basis for examining the inadequacies of current LTC financing.

Activities of Daily Living↗
PubMed1994

Mortality and physical functioning in epidemiologic studies of three older populations.

Mortality experienced in the first three years of follow-up for three Established Populations for Epidemiologic Studies of the Elderly (EPESE) is examined in relation to the participants' self-reported functional ability. In East Boston, Massachusetts (N = 3,812), Iowa and Washington Counties, Iowa (N = 3,673), and New Haven, Connecticut (N = 2,812), noninstitutionalized persons aged 65 and older were asked a series of questions to determine their functional status. These measures, used in logistic regression analyses of the mortality data, showed that an increased number of reported disabilities significantly increased the risk of mortality over and above the effects of the age and sex of the participant, or the methodological differences among the sites. Disabilities in gross mobility (e.g., ability to walk a half mile, climb stairs, or perform heavy work around the house) were more strongly related to mortality than were measures of activities of daily living.

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PubMed1993

Educational status and active life expectancy among older blacks and whites.

BACKGROUND AND METHODS: Persons of low socioeconomic status are known to have reduced life expectancy. In a study of the relation of socioeconomic status to disability-free or active life expectancy among older persons, we analyzed prospectively gathered data on 2219 blacks and 1838 whites who were 65 years of age or older in the Piedmont region of North Carolina. We defined disability as the inability to perform independently one or more basic functional activities such as walking, bathing, dressing, eating, and using the toilet. For subgroups defined by sex, race, and education, statistical models were used to estimate, for persons at each year of age, the probability of transition from not being disabled or being disabled at base line to not being disabled, being disabled, or having died one year later. These transition probabilities were then entered into increment-decrement life tables to generate estimates of total, active, and disabled life expectancy (with total life expectancy equal to active life expectancy plus disabled life expectancy). RESULTS: Sixty-five-year-old black men had a lower total life expectancy (11.4 years) and active life expectancy (10 years) than white men (total life expectancy, 12.6 years; active life expectancy, 11.2 years), although the differences were reduced after we controlled for education. The estimates for 65-year-old black women (total life expectancy, 18.7 years; active life expectancy, 15.9 years) were similar to those for white women. Black men and women 75 years old and older had higher values for total life expectancy and active life expectancy than whites, and the differences were larger after stratification for education. Education had a substantially stronger relation to total life expectancy and active life expectancy than did race. At the age of 65, those with 12 or more years of education had an active life expectancy that was 2.4 to 3.9 years longer than the values for those with less education in all the four subgroups defined by sex and race. Overall, the subgroups with longer total life expectancy and active life expectancy also lived more years with a disability. CONCLUSIONS: Among older blacks and whites, the level of education, a measure of socioeconomic status, has a greater effect than race on total life expectancy and active life expectancy.

Activities of Daily Living↗
PubMed1993

Local variations in old age care in the welfare state: the case of Sweden.

Swedish local municipalities are responsible for the provision of social welfare, including old age care. Local autonomy is far-reaching, and local inequities are indeed great for all kinds of domestic and institutional care for the elderly. Not only coverage rates differ widely but also costs per citizen and spending per elderly person vary vastly. Numerous parameters of the political, economic and geo-social structure of the municipalities explain only very little of these local variations. It seems that local differences are often of long standing: this may explain why 'rational' indicators of needs and local capacity fail to explain much of the inequities. Yet, one factor of socio-political importance emerges as significant: the system of tax redistribution enforced on largely autonomous municipalities.

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PubMed1993

Dental care use by U.S. veterans eligible for VA care.

Military veterans eligible for dental care in U.S. Department of Veterans Affairs (VA) facilities cooperated for a mailed survey about their dental care utilization. Subjects were selected because of their eligibility for continuing dental care in VA facilities at no monetary cost. However, only 48% reported the VA as their only or primary source of dental care; this allowed us the opportunity to compare dental care frequency by those who received dental care at no monetary cost with those who did not, as well as measure delivery system effects on dental care use. Consequently, we tested respondent-level and delivery system-level hypotheses regarding determinants of veterans' dental care use. Predisposing characteristics (dentate status, usual reason for dental visits, and the importance placed on dental care and oral health) were the strongest determinants of interval since last dental visit. Enabling determinants (current source of dental care, and having a regular source of care) were also significant, but measures of need for dental care (perceived oral health and perceived need for treatment) were not. More recent dental care use by veterans who used the VA delivery system as their source of dental care, even with dental care payment source and other determinants accounted for, suggests that the VA delivery system may have promoted more regular use compared to other systems.

Adult↗
PubMed1993

The Goldilocks dilemma in survey design and its solution.

A dilemma appears in the design of any survey with followups intended to detect the occurrence of an event. Suppose that, at followup, the event of interest can only be determined to have occurred since the previous interview (such is often the case, for example, with onset of dependent behavior in the aged). Then a followup which takes place too soon runs the risk of observing no or very few events, while a followup which is conducted after too long a wait might observe events in nearly every subject, and so be equally uninformative. Thus we would have what one investigator compares to Goldilocks dilemma: is the interval before followup too short, too long, or just right? The problem is multiplied when more than one followup is intended. As a partial solution, a technique is described here which provides guidance on the spacing of followup waves in a multiwave study, preventing possibly serious inefficiencies in study design. Data from the Massachusetts Health Care Panel Study (MHCPS) on functional dependence in the elderly are used for a demonstration.

Data Collection↗
PubMed1993

A preliminary case-mix classification system for Medicare home health clients.

In this study, a hierarchical case-mix model was developed for grouping Medicare home health beneficiaries homogeneously, based on the allowed charges for their home care. Based on information from a two-page form from 2,830 clients from ten states and using the classification and regression trees method, a four-component model was developed that yielded 11 case-mix groups and explained 22% of the variance for the test sample of 1,929 clients. The four components are rehabilitation, special care, skilled-nurse monitoring, and paralysis; each are categorized as present or absent. The range of mean-allowed charges for the 11 groups in the total sample was $473 to $2,562 with a mean of $847. Of the six groups with mean charges above $1,000, none exceeded 5.2% of clients; thus, the high-cost groups are relatively rare.

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