@article {10954, title = {Impact of Instrumental Activities of Daily Living Limitations on Hospital Readmission: an Observational Study Using Machine Learning}, journal = {Journal of General internal Medicine}, year = {2020}, abstract = {Background Limitations in instrumental activities of daily living (IADL) hinder a person{\textquoteright}s ability to live independently in the community and self-manage their conditions, but its impact on hospital readmission has not been firmly established. Objective To test the importance of IADL dependency as a predictor of 30-day readmissions and quantify its impact relative to other morbidities. Design A retrospective cohort study of the population-based Health and Retirement Study linked to Medicare claims data. Random forest was used to rank each predictor variable in terms of its ability to predict readmission. Classification and regression tree (CART) was used to identify complex multimorbidity combinations associated with high or low risk of readmission. Generalized linear regression was used to estimate the adjusted relative risk of readmission for IADL limitations. Subjects Hospitalizations of adults age 65 and older (n = 20,007), from 6617 unique subjects. Main Measures The main outcome was 30-day all-cause unplanned readmission. The main predictor of interest was self-reported IADL limitation. Other key predictors were self-reported complex multimorbidity including chronic diseases, geriatric syndromes, and activities of daily living (ADL) limitations, along with demographic, socioeconomic, and behavioral factors. Key Results The overall 30-day readmission rate in the study was 16.4\%. Random forest analysis ranked ADLs and IADL limitations as the two most important predictors of 30-day readmission. CART identified hospitalizations of patients with IADL limitations and diabetes as a subgroup at the highest risk of readmission (26\% readmitted). Multivariable regression analyses showed that ADL limitations were associated with 1.17 (1.06{\textendash}1.29) times higher risk of readmission even after adjusting for other patient covariates. Risk prediction was modest though for even the best model (AUC = 0.612). Conclusions IADL limitations are key predictors of 30-day readmission as demonstrated using several machine learning methods. Routine assessment of functional abilities in hospital settings could help identify those most at risk.}, keywords = {Activities of Daily Living, Health Services Research, multimorbidity, Patient Readmission, supervised machine learning}, isbn = {1525-1497}, doi = {https://doi.org/10.1007/s11606-020-05982-0}, author = {Nicholas K Schiltz and Dolansky, Mary A. and David F Warner and Kurt C Stange and Gravenstein, Stefan and Siran M Koroukian} } @article {10092, title = {Complex multimorbidity and breast cancer screening among midlife and older women: The role of perceived need}, journal = {The Gerontologist}, volume = {59}, year = {2019}, pages = {S77 - S87}, abstract = {Background and Objectives There is minimal survival benefit to cancer screening for those with poor clinical presentation (complex multimorbidity) or at advanced ages. The current screening mammography guidelines consider these objective indicators. There has been less attention, however, to women{\textquoteright}s subjective assessment of screening need. This study examines the interplay between complex multimorbidity, age, and subjective assessments of health and longevity for screening mammography receipt. Research Design and Method This cross-sectional study uses self-reported data from 8,938 women over the age of 52 in the 2012 Health and Retirement Study. Logistic regression models estimated the association between women{\textquoteright}s complex multimorbidity (co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes), subjective health and longevity assessments, age, and screening mammography in the 2 years before the interview. These associations were evaluated adjusting for sociodemographic and behavioral factors. Results Both age and complex multimorbidity were negatively associated with screening mammography. However, women{\textquoteright}s perceived need for screening moderated these effects. Most significantly, women optimistic about their chances of living another 10{\textendash}15 years were more likely to have had screening mammography regardless of their health conditions or advanced age. Discussion and Implications Women with more favorable self-assessed health and perceived life expectancy were more likely to receive screening mammography even if they have poor clinical presentation or advanced age. This is contrary to current cancer screening guidelines and suggests an opportunity to engage women{\textquoteright}s subjective health and longevity assessments for cancer screening decision making in both for screening policy and in individual clinician recommendations.}, keywords = {Cancer screenings, Comorbidity, Decision making, Women and Minorities}, issn = {0016-9013}, doi = {10.1093/geront/gny180}, url = {https://academic.oup.com/gerontologist/article/59/Supplement_1/S77/5491135http://academic.oup.com/gerontologist/article-pdf/59/Supplement_1/S77/28667857/gny180.pdf}, author = {David F Warner and Siran M Koroukian and Nicholas K Schiltz and Kathleen A Smyth and Cooper, Gregory S and Owusu, Cynthia and Kurt C Stange and Nathan A. Berger} } @article {9518, title = {The Influence of Multimorbidity on Leading Causes of Death in Older Adults With Cognitive Impairment.}, journal = {Journal of Aging \& Health}, volume = {31}, year = {2019}, abstract = {

OBJECTIVE: The aim of this study is to evaluate the relationship of leading causes of death with gradients of cognitive impairment and multimorbidity.

METHOD: This is a population-based study using data from the linked 1992-2010 Health and Retirement Study and National Death Index ( n = 9,691). Multimorbidity is defined as a combination of chronic conditions, functional limitations, and geriatric syndromes. Regression trees and Random Forest identified which combinations of multimorbidity associated with causes of death.

RESULTS: Multimorbidity is common in the study population. Heart disease is the leading cause in all groups, but with a larger percentage of deaths in the mild and moderate/severe cognitively impaired groups than among the noncognitively impaired. The different "paths" down the regression trees show that the distribution of causes of death changes with different combinations of multimorbidity.

DISCUSSION: Understanding the considerable heterogeneity in chronic conditions, functional limitations, geriatric syndromes, and causes of death among people with cognitive impairment can target care management and resource allocation.

}, keywords = {Cognitive Ability, Comorbidity, Mortality, NDI}, issn = {1552-6887}, doi = {10.1177/0898264317751946}, author = {Nicholas K Schiltz and David F Warner and Kathleen A Smyth and Gravenstein, Stefan and Kurt C Stange and Siran M Koroukian} } @article {9470, title = {Changes in Case-Mix and Health Outcomes of Medicare Fee-for-Service Beneficiaries and Managed Care Enrollees During the Years 1992-2011.}, journal = {Medical Care}, volume = {56}, year = {2018}, pages = {39-46}, abstract = {

BACKGROUND: Recent studies suggest that managed care enrollees (MCEs) and fee-for-service beneficiaries (FFSBs) have become similar in case-mix over time; but comparisons of health outcomes have yielded mixed results.

OBJECTIVE: To examine changes in differentials between MCEs and FFSBs both in case-mix and health outcomes over time.

DESIGN: Temporal study of the linked Health and Retirement Study (HRS) and Medicare data, comparing case-mix and health outcomes between MCEs and FFSBs across 3 time periods: 1992-1998, 1999-2004, and 2005-2011. We used multivariable analysis, stratified by, and pooled across the study periods. The unit of analysis was the person-wave (n=167,204).

SUBJECTS: HRS participants who were also enrolled in Medicare.

MEASURES: Outcome measures included self-reported fair/poor health, 2-year self-rated worse health, and 2-year mortality. Our main covariate was a composite measure of multimorbidity (MM), MM0-MM3, defined as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes.

RESULTS: The case-mix differential between MCEs and FFSBs persisted over time. Results from multivariable models on the pooled data and incorporating interaction terms between managed care status and study period indicated that MCEs and FFSBs were as likely to die within 2 years from the HRS interview (P=0.073). This likelihood remained unchanged across the study periods. However, MCEs were more likely than FFSBs to report fair/poor health in the third study period (change in probability for the interaction term: 0.024, P=0.008), but less likely to rate their health worse in the last 2 years, albeit at borderline significance (change in probability: -0.021, P=0.059).

CONCLUSIONS: Despite the persistence of selection bias, the differential in self-reported fair/poor status between MCEs and FFSBs seems to be closing over time.

}, keywords = {Medicare linkage, Medicare/Medicaid/Health Insurance, Mortality}, issn = {1537-1948}, doi = {10.1097/MLR.0000000000000847}, author = {Siran M Koroukian and Basu, Jayasree and Nicholas K Schiltz and Navale, Suparna and Paul M Bakaki and David F Warner and Avi Dor and Charles W Given and Kurt C Stange} } @article {9464, title = {Older Adults Undergoing Total Hip or Knee Arthroplasty: Chronicling Changes in Their Multimorbidity Profile in the Last Two Decades.}, journal = {Journal of Arthroplasty}, volume = {33}, year = {2018}, pages = {976-982}, abstract = {

BACKGROUND: Despite the ubiquitous use of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in older adults, little is known about the multimorbidity (MM) profile of this patient population. This study evaluates the temporal trends of MM, hypothesizing that patients with MM have had an increasingly greater representation in THA and TKA patients over time.

METHODS: Data on a US representative sample of older adults from the linked Health and Retirement Study and Medicare data from 1993 to 2012 were used. The Health and Retirement Study is a biennial survey that collects data on a broad array of measures, including self-reported chronic conditions and geriatric syndromes, which were used to account for MM. Medicare data were used to identify fee-for-service Medicare beneficiaries who underwent THA (n~= 479) or TKA (n~= 998) during the study years, which were grouped into 3 periods: 1993-1999, 2000-2006, and 2007-2012. Multivariable logistic regression analysis was conducted to obtain age-, gender-, and race-adjusted time trends for MM.

RESULTS: Compared to the earliest study period, and for both THA and TKA patients, there were significantly fewer patients with stroke and/or poor cognitive performance in the most recent study period. In addition, more TKA than THA patients presented with 2+ chronic conditions. Nearly 70\% presented with co-occurring chronic conditions and geriatric syndromes, and this percentage did not change significantly over time.

CONCLUSION: The high representation of THA and TKA patients presenting with co-occurring chronic conditions and geriatric syndromes in this patient population warrants detailed exploration of the effects of geriatric syndromes on postoperative outcomes.

}, keywords = {Chronic conditions, Comorbidity, Functional limitations, Joint replacement}, issn = {1532-8406}, doi = {10.1016/j.arth.2017.11.014}, author = {Siran M Koroukian and Nicholas K Schiltz and David F Warner and Alison K Klika and Carlos A. Higuera-Rueda and Wael K. Barsoum} } @article {9336, title = {Complex multimorbidity and health outcomes in older adult cancer survivors }, journal = {Family Medicine and Community Health}, volume = {5}, year = {2017}, pages = {129-138}, abstract = {Objective: To characterize complex multimorbidity among cancer survivors and evaluate the association between cancer survivorship, time since cancer diagnosis, and self-reported fair/poor health, self-rated worse health in 2 years, and 2-year mortality. Methods: We used the 2010-2012 Health and Retirement Study. Cancer survivors were individuals who reported a (nonskin) cancer diagnosis 2 years or more before the interview. We defined complex multimorbidity as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. In addition to descriptive analyses, we used logistic regression to evaluate the independent association between cancer survivor status and health outcomes. We also examined whether cancer survivorship differed by the number of years since diagnosis. Results: Among 15,808 older adults (age >=50 years), 11.8\% were cancer survivors. Compared with cancer-free individuals, a greater percentage of cancer survivors had complex multimorbidity: co-occurring chronic conditions, functional limitations, and geriatric syndromes. Cancer survivorship was significantly associated with self-reported fair/poor health, self-rated worse health in 2 years, and 2-year mortality. These effects declined with the number of years since diagnosis for fair/ poor health and mortality but not for self-rated worse health. Conclusion: Cancer survivor status is independently associated with more complex multimorbidity, and with worse health outcomes. These effects attenuate with time, except for patient perception of being in worse health. }, keywords = {Cancer screenings, Comorbidity, Health Care Outcomes}, issn = {2305-6983}, doi = {10.15212/FMCH.2017.0127}, url = {http://www.ingentaconnect.com/content/10.15212/FMCH.2017.0127http://www.ingentaconnect.com/content/cscript/fmch/2017/00000005/00000002/art00005http://www.ingentaconnect.com/content/cscript/fmch/2017/00000005/00000002/art00005}, author = {David F Warner and Nicholas K Schiltz and Kurt C Stange and Charles W Given and Owusu, Cynthia and Nathan A. Berger and Siran M Koroukian} } @article {8697, title = {Identifying Specific Combinations of Multimorbidity that Contribute to Health Care Resource Utilization: An Analytic Approach.}, journal = {Med Care}, volume = {55}, year = {2017}, month = {2017 03}, pages = {276-284}, abstract = {

BACKGROUND: Multimorbidity affects the majority of elderly adults and is associated with higher health costs and utilization, but how specific patterns of morbidity influence resource use is less understood.

OBJECTIVE: The objective was to identify specific combinations of chronic conditions, functional limitations, and geriatric syndromes associated with direct medical costs and inpatient utilization.

DESIGN: Retrospective cohort study using the Health and Retirement Study (2008-2010) linked to Medicare claims. Analysis used machine-learning techniques: classification and regression trees and random forest.

SUBJECTS: A population-based sample of 5771 Medicare-enrolled adults aged 65 and older in the United States.

MEASURES: Main covariates: self-reported chronic conditions (measured as none, mild, or severe), geriatric syndromes, and functional limitations. Secondary covariates: demographic, social, economic, behavioral, and health status measures.

OUTCOMES: Medicare expenditures in the top quartile and inpatient utilization.

RESULTS: Median annual expenditures were $4354, and 41\% were hospitalized within 2 years. The tree model shows some notable combinations: 64\% of those with self-rated poor health plus activities of daily living and instrumental activities of daily living disabilities had expenditures in the top quartile. Inpatient utilization was highest (70\%) in those aged 77-83 with mild to severe heart disease plus mild to severe diabetes. Functional limitations were more important than many chronic diseases in explaining resource use.

CONCLUSIONS: The multimorbid population is heterogeneous and there is considerable variation in how specific combinations of morbidity influence resource use. Modeling the conjoint effects of chronic conditions, functional limitations, and geriatric syndromes can advance understanding of groups at greatest risk and inform targeted tailored interventions aimed at cost containment.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Comorbidity, Female, Health Behavior, Health Expenditures, Health Status, Humans, Machine learning, Male, Medicare, Retrospective Studies, Self Report, Socioeconomic factors, United States}, issn = {1537-1948}, doi = {10.1097/MLR.0000000000000660}, author = {Nicholas K Schiltz and David F Warner and Jiayang Sun and Paul M Bakaki and Avi Dor and Charles W Given and Kurt C Stange and Siran M Koroukian} } @article {9294, title = {Increasing Burden of Complex Multimorbidity Across Gradients of Cognitive Impairment.}, journal = {American Journal of Alzheimer{\textquoteright}s Disease and Other Dementias}, year = {2017}, abstract = {

INTRODUCTION: This study evaluates the burden of multimorbidity (MM) across gradients of cognitive impairment (CI).

METHODS: Using data from the 2010 Health and Retirement Study, we identified individuals with no CI, mild CI, and moderate/severe CI. In addition, we adopted an expansive definition of complex MM by accounting for the occurrence and co-occurrence of chronic conditions, functional limitations, and geriatric syndromes.

RESULTS: In a sample of 18 913 participants (weighted n = 87.5 million), 1.93\% and 1.84\% presented with mild and moderate/severe CI, respectively. The prevalence of most conditions constituting complex MM increased markedly across the spectrum of CI. Further, the percentage of individuals presenting with 10 or more conditions was 19.9\%, 39.3\%, and 71.3\% among those with no CI, mild CI, and moderate/severe CI, respectively.

DISCUSSION: Greater CI is strongly associated with increased burden of complex MM. Detailed characterization of MM across CI gradients will help identify opportunities for health care improvement.

}, keywords = {Cognitive Ability, Comorbidity, Functional limitations}, issn = {1938-2731}, doi = {10.1177/1533317517726388}, author = {Siran M Koroukian and Nicholas K Schiltz and David F Warner and Kurt C Stange and Kathleen A Smyth} } @article {10893, title = {Multimorbidity: constellations of conditions across subgroups of midlife and older individuals, and related Medicare expenditures.}, journal = {J Comorbidity}, volume = {7}, year = {2017}, month = {2017}, pages = {33-43}, abstract = {

INTRODUCTION: The Department of Health and Human Services{\textquoteright} 2010 Strategic Framework on Multiple Chronic Conditions called for the identification of common constellations of conditions in older adults.

OBJECTIVES: To analyze patterns of conditions constituting multimorbidity (CCMM) and expenditures in a US representative sample of midlife and older adults (50-64 and >=65 years of age, respectively).

DESIGN: A cross-sectional study of the 2010 Health and Retirement Study (HRS; =17,912). The following measures were used: (1) count and combinations of CCMM, including (i) chronic conditions (hypertension, arthritis, heart disease, lung disease, stroke, diabetes, cancer, and psychiatric conditions), (ii) functional limitations (upper body limitations, lower body limitations, strength limitations, limitations in activities of daily living, and limitations in instrumental activities of daily living), and (iii) geriatric syndromes (cognitive impairment, depressive symptoms, incontinence, visual impairment, hearing impairment, severe pain, and dizziness); and (2) annualized 2011 Medicare expenditures for HRS participants who were Medicare fee-for-service beneficiaries (=5,677). Medicaid beneficiaries were also identified based on their self-reported insurance status.

RESULTS: No large representations of participants within specific CCMM categories were observed; however, functional limitations and geriatric syndromes were prominently present with higher CCMM counts. Among fee-for-service Medicare beneficiaries aged 50-64 years, 26.7\% of the participants presented with >=10 CCMM, but incurred 48\% of the expenditure. In those aged >=65 years, these percentages were 16.9\% and 34.4\%, respectively.

CONCLUSION: Functional limitations and geriatric syndromes considerably add to the MM burden in midlife and older adults. This burden is much higher than previously reported.

}, keywords = {Death, Medicare, Medicare claims data, multimorbidity}, issn = {2235-042X}, doi = {10.15256/joc.2017.7.91}, author = {Siran M Koroukian and Nicholas K Schiltz and David F Warner and Jiayang Sun and Kurt C Stange and Charles W Given and Avi Dor} } @article {8750, title = {Social determinants, multimorbidity, and patterns of end-of-life care in older adults dying from cancer.}, journal = {J Geriatr Oncol}, volume = {8}, year = {2017}, month = {2017 03}, pages = {117-124}, abstract = {

OBJECTIVE: Most prior studies on aggressive end-of-life care in older patients with cancer have accounted for social determinants of health (e.g., race, income, and education), but rarely for multimoribidity (MM). In this study, we examine the association between end-of-life care and each of the social determinants of health and MM, hypothesizing that higher MM is associated with less aggressive care.

METHODS: From the linked 1991-2008 Health and Retirement Study, Medicare data, and the National Death Index, we identified fee-for-service patients age >=66years who died from cancer (n=835). MM was defined as the occurrence or co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. Aggressive care was based on claims-derived measures of receipt of cancer-directed treatment in the last two weeks of life; admission to the hospital and/or emergency department (ED) within the last month; and in-hospital death. We also identified patients enrolled in hospice. In multivariable logistic regression models, we analyzed the associations of interest, adjusting for potential confounders.

RESULTS: While 61.2\% of the patients enrolled in hospice, 24.6\% underwent cancer-directed treatment; 55.1\% were admitted to the hospital and/or ED; and 21.7\% died in the hospital. We observed a U-shaped distribution between income and in-hospital death. Chronic conditions and geriatric syndromes were associated with some outcomes, but not with others.

CONCLUSIONS: To improve quality end-of-life care and curtail costs incurred by dying patients, relevant interventions need to account for social determinants of health and MM in a nuanced fashion.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Emergency Service, Hospital, Female, Health Surveys, Hospices, Hospital Mortality, Humans, Logistic Models, Male, multimorbidity, Neoplasms, Population Surveillance, Quality of Health Care, Risk Factors, Socioeconomic factors, Terminal Care}, issn = {1879-4076}, doi = {10.1016/j.jgo.2016.10.001}, url = {http://linkinghub.elsevier.com/retrieve/pii/S1879406816301229http://api.elsevier.com/content/article/PII:S1879406816301229?httpAccept=text/xmlhttp://api.elsevier.com/content/article/PII:S1879406816301229?httpAccept=text/plain}, author = {Siran M Koroukian and Nicholas K Schiltz and David F Warner and Charles W Given and Mark Schluchter and Owusu, Cynthia and Nathan A. Berger} } @article {6495, title = {Combinations of Chronic Conditions, Functional Limitations, and Geriatric Syndromes that Predict Health Outcomes.}, journal = {J Gen Intern Med}, volume = {31}, year = {2016}, month = {2016 Jun}, pages = {630-7}, chapter = {630}, abstract = {

BACKGROUND: The strategic framework on multiple chronic conditions released by the US Department of Health and Human Services calls for identifying homogeneous subgroups of older adults to effectively target interventions aimed at improving their health.

OBJECTIVE: We aimed to identify combinations of chronic conditions, functional limitations, and geriatric syndromes that predict poor health outcomes. DESIGN, SETTING AND PARTICIPANTS Data from the 2010-2012 Health and Retirement Study provided a representative sample of U.S. adults 50~years of age or older (n = 16,640).

MAIN MEASURES: Outcomes were: Self-reported fair/poor health, self-rated worse health at 2~years, and 2-year mortality. The main independent variables included self-reported chronic conditions, functional limitations, and geriatric syndromes. We conducted tree-based classification and regression analysis to identify the most salient combinations of variables to predict outcomes.

KEY RESULTS: Twenty-nine percent and 23~\% of respondents reported fair/poor health and self-rated worse health at 2~years, respectively, and 5~\% died in 2~years. The top combinations of conditions identified through our tree analysis for the three different outcome measures (and percent respondents with the outcome) were: a) for fair/poor health status: difficulty walking several blocks, depressive symptoms, and severe pain (> 80~\%); b) for self-rated worse health at 2~years: 68.5~years of age or older, difficulty walking several blocks and being in fair/poor health (60~\%); and c) for 2-year mortality: 80.5~years of age or older, and presenting with limitations in both ADLs and IADLs (> 40~\%).

CONCLUSIONS: Rather than chronic conditions, functional limitations and/or geriatric syndromes were the most prominent conditions in predicting health outcomes. These findings imply that accounting for chronic conditions alone may be less informative than also accounting for the co-occurrence of functional limitations and geriatric syndromes, as the latter conditions appear to drive health outcomes in older individuals.

}, keywords = {Activities of Daily Living, Age Distribution, Aged, Aged, 80 and over, Chronic disease, Comorbidity, Female, Geriatric Assessment, Health Status, Health Status Indicators, Humans, Longitudinal Studies, Male, Middle Aged, Mobility Limitation, Prognosis, Risk Factors, Self Report, Sex Distribution, Socioeconomic factors, Syndrome, United States}, issn = {1525-1497}, doi = {10.1007/s11606-016-3590-9}, url = {http://dx.doi.org/10.1007/s11606-016-3590-9}, author = {Siran M Koroukian and Nicholas K Schiltz and David F Warner and Jiayang Sun and Paul M Bakaki and Kathleen A Smyth and Kurt C Stange and Charles W Given} } @article {8397, title = {Functional status in older women diagnosed with pelvic organ prolapse.}, journal = {Am J Obstet Gynecol}, volume = {214}, year = {2016}, month = {2016 May}, pages = {613.e1-7}, publisher = {214}, abstract = {

BACKGROUND: Functional status plays an important role in the comprehensive characterization of older adults. Functional limitations are associated with an increased risk of adverse treatment outcomes, but there are limited data on the prevalence of functional limitations in older women with pelvic floor disorders.

OBJECTIVE: The aim of the study was to describe the prevalence of functional limitations based on health status in older women with pelvic organ prolapse (POP).

STUDY DESIGN: This pooled, cross-sectional study utilized data from the linked Health and Retirement Study and Medicare files from 1992 through 2008. The analysis included 890 women age >=65 years with POP. We assessed self-reported functional status, categorized in strength, upper and lower body mobility, activities of daily living (ADL), and instrumental ADL (IADL) domains. Functional limitations were evaluated and stratified by respondents self-reported general health status. Descriptive statistics were used to compare categorical and continuous variables, and logistic regression was used to measure differences in the odds of functional limitation by increasing age.

RESULTS: The prevalence of functional limitations was 76.2\% in strength, 44.9\% in upper and 65.8\% in lower body mobility, 4.5\% in ADL, and 13.6\% in IADL. Limitations were more prevalent in women with poor or fair health status than in women with good health status, including 91.5\% vs 69.9\% in strength, 72.9\% vs 33.5\% in upper and 88.0\% vs 56.8\% in lower body mobility, 11.6\% vs 0.9\% in ADL, and 30.6\% vs 6.7\% in IADL; all P < .01. The odds of all functional limitations also increased significantly with advancing age.

CONCLUSION: Functional limitations, especially in strength and body mobility domains, are highly prevalent in older women with POP, particularly in those with poor or fair self-reported health status. Future research is necessary to evaluate if functional status affects clinical outcomes in pelvic reconstructive and gynecologic surgery and whether it should be routinely assessed in clinical decision-making when treating older women with POP.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Aging, Cross-Sectional Studies, Female, Health Status, Health Surveys, Humans, Medicare, Middle Aged, Mobility Limitation, Muscle Strength, Pelvic Organ Prolapse, United States, Upper Extremity}, issn = {1097-6868}, doi = {10.1016/j.ajog.2015.11.038}, url = {http://www.sciencedirect.com/science/article/pii/S0002937815024783}, author = {Tatiana V D Sanses and Nicholas K Schiltz and Bruna M. Couri and Sangeeta T Mahajan and Holly E Richter and David F Warner and Jack M. Guralnik and Siran M Koroukian} } @article {doi:10.1200/jco.2014.32.15_suppl.9542, title = {Multimorbidity and racial disparities in use of hospice by older patients dying from cancer.}, journal = {Journal of Clinical Oncology}, volume = {32}, year = {2014}, pages = {9542-9542}, abstract = {9542 Background: While previous studies have documented lower use of hospice by Non-Hispanic Blacks (NHBs) than by Non-Hispanic Whites (NHWs), racial variations have not been examined in the context of multimorbidity (MM), which affects minority patients disproportionately. We sought to determine the impact of MM severity on NHBs{\textquoteright} use of hospice in a U.S. representative sample of older adults. Methods: We used data from the linked 1991-2008 Health and Retirement Study (HRS), Medicare data, and the National Death Index (NDI). From the NDI, we identified fee-for-service patients >=65 years of age who died from cancer (n=812), and retrieved their demographic data, presence of comorbidities (COM), functional limitations (FL), and geriatric syndromes (GS) from their last HRS interview. We characterized severity of MM by 3 levels: none or only one of COM, FL, or GS (MM0/1); presence of two of COM, FL, or GS (MM2); or presence of all three of COM, FL, and GS (MM3). Hospice use was identified from Medicare claims data. We developed multivariable logistic regression models to analyze the association between race and hospice use, adjusting for MM and other patient covariates. Results: Nearly 12\% of the study population was NHB; 61.3\% of NHBs and 53.0\% of NHWs were identified in MM3 (p=0.057). Overall, 61\% of the patients received hospice care (63.7\% in NHWs, and 43.0\% in NHBs, p < 0.001). The distribution NHBs and NHWs by MM was similar across hospice users and non-users. Adjusting for MM and other confounders, NHBs were significantly less likely than NHWs to utilize hospice (Adjusted odds ratio: 0.42, 95\% Confidence Interval: 0.27-0.66, p < 0.001). Conclusions: Despite the greater representation of NHBs in the highest severity of MM category, NHBs remain significantly less likely than NHWs to use hospice, even after adjusting for MM. The findings carry important implications with regard to disparities in providing optimal, and cost effective quality of end-of-life care.}, keywords = {Cancer, Death, multimorbidity, National Death Index, race, race difference, race-ethnicity}, doi = {10.1200/jco.2014.32.15_suppl.9542}, author = {Siran M Koroukian and Nicholas K Schiltz and Warner, David and Charles W Given and Owusu, Cynthia and Mark Schluchter and Nathan A. Berger} }