Identifying Older People at Risk of Abuse During Routine Screening Practices

To examine the association between various characteristics of community-based older people and a constructed measure of potential elder abuse. DESIGN: Cross-sectional design. SETTING: Public community-based long-term care programs in Michigan. PARTICIPANTS: Individuals aged 60 and older seeking home and community-based services in Michigan between November 1996 and October 1997 (N = 701). MEASUREMENTS: Data were collected using the Minimum Data Set for Home Care (MDS-HC) assessment. The dependent variable is a constructed measure of potential elder abuse reflecting physical and emotional abuse and neglect. Independent variables include demographic characteristics; diagnoses; behavioral measures; and cognitive, physical, and social functioning. RESULTS: Several measures of social support and social function were strongly associated with the signs of a potentially abusive environment: brittle support (odds ratio (OR) = 3.5, 90% confidence interval (CI) = 1.5–8.1), older person feels lonely (OR = 2.4, 90% CI = 1.3–4.5), and older person expresses conflict with family/friends (OR = 2.3, 90% CI = 1.2–4.3). Home care participants' alcohol abuse, psychiatric illness, lack of ease interacting with others, and short-term memory problems were also significantly associated with the signs of potential elder abuse. CONCLUSIONS: The results of this study suggest that the signs of potential elder abuse are associated with a diminishing social network and poor social functioning, although some characteristics of the older person's health are contributing factors. Improved understanding of the link between those characteristics and potential abuse will help healthcare providers, case managers, and others identify older people at high risk of abuse.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65922/1/j.1601-5215.2002.51005.x.pd

Caregiver Attitudes and Hospitalization Risk in Michigan Residents Receiving Home- and Community-Based Care

To study a cohort of participants in home- and community-based services (HCBS) in Michigan to evaluate the relationship between (1) caregiver attitudes and participant characteristics and (2) the risk of hospitalization. SETTING: HCBS programs funded by Medicaid or state/local funds in Michigan. PARTICIPANTS: Five hundred twenty-seven individuals eligible for HCBS in Michigan were studied. These HCBS participants were randomly selected clients of all agencies providing publicly funded HCBS in Michigan from November 1996 to October 1997. MEASUREMENTS: Data for this study were collected using the Minimum Data Set for Home Care. Assessments were collected longitudinally, and the baseline (initial admission assessment) and 90-day follow-up assessments were used. Key measures were caregiver attitudes (distress, dissatisfaction, and decreased caregiving ability) and HCBS participant characteristics (cognition, functioning, diseases, symptoms, nutritional status, medications, and disease stability). Multinomial logistic regression was used to evaluate how these characteristics were associated with the competing risks of hospitalization and death within 90 days of admission to HCBS. RESULTS: We found a strong association between caregiver dissatisfaction (caregiver dissatisfied with the level of care the home care participant was currently receiving) and an increased likelihood of hospitalization. HCBS participant cancer, chronic obstructive pulmonary disease, pain, and flare-up of a chronic condition were also associated with increased hospitalization. Poor food intake and prior hospitalization were associated with hospitalization and death. CONCLUSIONS: We conclude that, within a cohort of people receiving HCBS who are chronically ill, highly disabled, and at high risk for hospitalization and death, interventions addressing caregiver dissatisfaction, pain control, and medical monitoring should be evaluated for their potential to decrease hospitalization.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65947/1/j.1532-5415.2002.50264.x.pd

Does Screening for Pain Correspond to High Quality Care for Veterans?

Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. To assess adherence to measures of pain management quality and identify associated patient and provider factors. A cross-sectional visit-based study. One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that “patients want me to ask about pain” and “pain can have negative consequences on patient’s functioning”. Charts were more likely to document character of pain if providers agreed that “patients are able to rate their pain”. Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening

Trends in healthcare utilization among older Americans with colorectal cancer: A retrospective database analysis

<p>Abstract</p> <p>Background</p> <p>Analyses of utilization trends (cost drivers) allow us to understand changes in colorectal cancer (CRC) costs over time, better predict future costs, identify changes in the use of specific types of care (eg, hospice), and provide inputs for cost-effectiveness models. This retrospective cohort study evaluated healthcare resource use among US Medicare beneficiaries diagnosed with CRC between 1992 and 2002.</p> <p>Methods</p> <p>Cohorts included patients aged 66+ newly diagnosed with adenocarcinoma of the colon (n = 52,371) or rectum (n = 18,619) between 1992 and 2002 and matched patients from the general Medicare population, followed until death or December 31, 2005. Demographic and clinical characteristics were evaluated by cancer subsite. Resource use, including the percentage that used each type of resource, number of hospitalizations, and number of hospital and skilled nursing facility days, was evaluated by stage and subsite. The number of office, outpatient, and inpatient visits per person-year was calculated for each cohort, and was described by year of service, subsite, and treatment phase. Hospice use rates in the last year of life were calculated by year of service, stage, and subsite for CRC patients who died of CRC.</p> <p>Results</p> <p>CRC patients (mean age: 77.3 years; 44.9% male) used more resources than controls in every category (<it>P </it>< .001), with the largest differences seen in hospital days and home health use. Most resource use (except hospice) remained relatively steady over time. The initial phase was the most resource intense in terms of office and outpatient visits. Hospice use among patients who died of CRC increased from 20.0% in 1992 to 70.5% in 2004, and age-related differences appear to have evened out in later years.</p> <p>Conclusion</p> <p>Use of hospice care among CRC decedents increased substantially over the study period, while other resource use remained generally steady. Our findings may be useful for understanding CRC cost drivers, tracking trends, and forecasting resource needs for CRC patients in the future.</p

An Exploration of Urban and Rural Differences in Lung Cancer Survival Among Medicare Beneficiaries

Objectives. We tested the relationship between urban or rural residence as defined by rural–urban commuting area codes and risk of mortality in a sample of Medicare beneficiaries with lung cancer

Heart Failure, the Hidden Problem of Pain

Although dyspnea and fatigue are hallmark symptoms of heart failure (HF), the burden of pain may be underrecognized. This study assessed pain in HF and identified contributing factors. As part of a multicenter study, 96 veterans with HF (96% male, 67+/-11 years) completed measures of symptoms, pain (Brief Pain Inventory [BPI]), functional status (Functional Morbidity Index), and psychological state (Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Single items from the BPI interference and the quality of life-end of life measured social and spiritual well-being. Demographic and clinical variables were obtained by chart audit. Correlation and linear regression models evaluated physical, emotional, social, and spiritual factors associated with pain. Fifty-three (55.2%) HF patients reported pain, with a majority (36 [37.5%]) rating their pain as moderate to severe (pain&gt;or=4/10). The presence of pain was reported more frequently than dyspnea (67 [71.3%] vs. 58 [61.7%]). Age (P=0.02), psychological (depression: P=0.002; anxiety: P=0.001), social (P&lt;0.001), spiritual (P=0.010), and physical (health status: P=0.001; symptom frequency: P=0.000; functional status: P=0.002) well-being were correlated with pain severity. In the resulting model, 38% of the variance in pain severity was explained (P&lt;0.001); interference with relations (P&lt;0.001) and symptom number (P=0.007) contributed to pain severity. The association of physical, psychological, social, and spiritual domains with pain suggests that multidisciplinary interventions are needed to address the complex nature of pain in HF