@article {10278, title = {The comparative effect of episodes of chiropractic and medical treatment on the health of older adults.}, journal = {J Manipulative Physiol Ther}, volume = {37}, year = {2014}, month = {2014 Mar-Apr}, pages = {143-54}, abstract = {

OBJECTIVES: The comparative effect of chiropractic vs medical care on health, as used in everyday practice settings by older adults, is not well understood. The purpose of this study is to examine how chiropractic compares to medical treatment in episodes of care for uncomplicated back conditions. Episodes of care patterns between treatment groups are described, and effects on health outcomes among an older group of Medicare beneficiaries over a 2-year period are estimated.

METHODS: Survey data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old were linked to participants{\textquoteright} Medicare Part B claims under a restricted Data Use Agreement with the Centers for Medicare and Medicaid Services. Logistic regression was used to model the effect of chiropractic use in an episode of care relative to medical treatment on declines in function and well-being among a clinically homogenous older adult population. Two analytic approaches were used, the first assumed no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models.

RESULTS: Episodes of care between treatment groups varied in duration and provider visit pattern. Among the unadjusted models, there was no significant difference between chiropractic and medical episodes of care. The propensity score results indicate a significant protective effect of chiropractic against declines in activities of daily living (ADLs), instrumental ADLs, and self-rated health (adjusted odds ratio [AOR], 0.49; AOR, 0.62; and AOR, 0.59, respectively). There was no difference between treatment types on declines in lower body function or depressive symptoms.

CONCLUSION: The findings from this study suggest that chiropractic use in episodes of care for uncomplicated back conditions has protective effects against declines in ADLs, instrumental ADLs, and self-rated health for older Medicare beneficiaries over a 2-year period.

}, keywords = {Activities of Daily Living, Aged, 80 and over, Back Pain, Episode of Care, Female, Humans, Male, Manipulation, Chiropractic, Treatment Outcome}, issn = {1532-6586}, doi = {10.1016/j.jmpt.2013.12.009}, url = {https://www.ncbi.nlm.nih.gov/pubmed/24636108}, author = {Paula A Weigel and Jason Hockenberry and Suzanne E Bentler and Frederic D Wolinsky} } @article {10279, title = {Chiropractic use and changes in health among older medicare beneficiaries: a comparative effectiveness observational study.}, journal = {J Manipulative Physiol Ther}, volume = {36}, year = {2013}, month = {2013 Nov-Dec}, pages = {572-84}, abstract = {

OBJECTIVE: The purpose of this study was to investigate the effect of chiropractic on 5 outcomes among Medicare beneficiaries: increased difficulties performing activities of daily living (ADLs), instrumental ADLs (IADLs), and lower body functions, as well as lower self-rated health and increased depressive symptoms.

METHODS: Among all beneficiaries, we estimated the effect of chiropractic use on changes in health outcomes among those who used chiropractic compared with those who did not, and among beneficiaries with back conditions, we estimated the effect of chiropractic use relative to medical care, both during a 2- to 15-year period. Two analytic approaches were used--one assumed no selection bias, whereas the other adjusted for potential selection bias using propensity score methods.

RESULTS: Among all beneficiaries, propensity score analyses indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, and depressive symptoms, although there were increased risks associated with chiropractic for declines in lower body function and self-rated health. Propensity score analyses among beneficiaries with back conditions indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, lower body function, and depressive symptoms, although there was an increased risk associated with chiropractic use for declines in self-rated health.

CONCLUSION: The evidence in this study suggests that chiropractic treatment has comparable effects on functional outcomes when compared with medical treatment for all Medicare beneficiaries, but increased risk for declines in self-rated health among beneficiaries with back conditions.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Cohort Studies, Databases, Factual, Disability Evaluation, Female, Geriatric Assessment, Humans, Low Back Pain, Male, Manipulation, Chiropractic, Medicare, Mobility Limitation, Musculoskeletal Diseases, Patient Satisfaction, Quality of Life, Risk Assessment, Sex Factors, Treatment Outcome, United States}, issn = {1532-6586}, doi = {10.1016/j.jmpt.2013.08.008}, url = {https://www.ncbi.nlm.nih.gov/pubmed/24636108}, author = {Paula A Weigel and Jason Hockenberry and Suzanne E Bentler and Frederic D Wolinsky} } @article {10280, title = {Chiropractic episodes and the co-occurrence of chiropractic and health services use among older Medicare beneficiaries.}, journal = {Journal of Manipulative \& Physiological Therapeutics}, volume = {35}, year = {2012}, pages = {168-175}, abstract = {

OBJECTIVE: The purpose of this study was to define and characterize episodes of chiropractic care among older Medicare beneficiaries and to evaluate the extent to which chiropractic services were used in tandem with conventional medicine.

METHODS: Medicare Part B claims histories for 1991 to 2007 were linked to the nationally representative survey on Assets and Health Dynamics among the Oldest Old baseline interviews (1993-1994) to define episodes of chiropractic sensitive care using 4 approaches. Chiropractic and nonchiropractic patterns of service use were examined within these episodes of care. Of the 7447 Assets and Health Dynamics among the Oldest Old participants, 971 used chiropractic services and constituted the analytic sample.

RESULTS: There were substantial variations in the number and duration of episodes and the type and volume of services used across the 4 definitions. Depending on how the episode was constructed, the mean number of episodes per chiropractic user ranged from 3.74 to 23.12, the mean episode duration ranged from 4.7 to 28.8 days, the mean number of chiropractic visits per episode ranged from 0.88 to 2.8, and the percentage of episodes with co-occurrent use of chiropractic and nonchiropractic providers ranged from 4.9\% to 10.9\% over the 17-year period.

CONCLUSION: Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Chiropractic, Combined Modality Therapy, Episode of Care, Female, Geriatric Assessment, Health Care Surveys, Health Services, Humans, Incidence, Insurance Claim Reporting, Low Back Pain, Medicare Part B, Musculoskeletal Diseases, Primary Health Care, Retrospective Studies, Sex Factors, Treatment Outcome, United States}, issn = {1532-6586}, doi = {10.1016/j.jmpt.2012.01.011}, author = {Paula A Weigel and Jason Hockenberry and Suzanne E Bentler and Kaskie, Brian and Frederic D Wolinsky} } @article {7579, title = {Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries.}, journal = {BMC Geriatr}, volume = {11}, year = {2011}, month = {2011 Aug 16}, pages = {43}, publisher = {11}, abstract = {

BACKGROUND: Most prior studies have focused on short-term (<= 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines.

METHODS: The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop.

RESULTS: The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6\% on ADL abilities, 32.3\% on IADL abilities, and 30.9\% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline.

CONCLUSIONS: Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Cohort Studies, Disabled Persons, Female, Follow-Up Studies, Geriatric Assessment, Health Surveys, Humans, Insurance Benefits, Longitudinal Studies, Male, Medicare, Mobility Limitation, Prospective Studies, Time Factors, United States}, issn = {1471-2318}, doi = {10.1186/1471-2318-11-43}, author = {Frederic D Wolinsky and Suzanne E Bentler and Jason Hockenberry and Michael P Jones and Maksym Obrizan and Paula A Weigel and Kaskie, Brian and Robert B Wallace} } @article {8939, title = {Older adults who persistently present to the emergency department with severe, non-severe, and indeterminate episode patterns.}, journal = {BMC Geriatrrics}, volume = {11}, year = {2011}, pages = {65}, abstract = {

BACKGROUND: It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates.

METHODS: Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen{\textquoteright}s behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects.

RESULTS: We identified 948 individuals (17.2\% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5\%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58).

CONCLUSIONS: We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.

}, keywords = {Emergency services, Health Shocks, Medicare/Medicaid/Health Insurance, Older Adults}, issn = {1471-2318}, doi = {10.1186/1471-2318-11-65}, author = {Kaskie, Brian and Maksym Obrizan and Michael P Jones and Suzanne E Bentler and Paula A Weigel and Jason Hockenberry and Robert B Wallace and Robert L. Ohsfeldt and Gary E Rosenthal and Frederic D Wolinsky} } @article {7580, title = {A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries.}, journal = {BMC Public Health}, volume = {11}, year = {2011}, month = {2011 Sep 20}, pages = {710}, publisher = {11}, abstract = {

BACKGROUND: Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function.

METHODS: We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were >= 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests.

RESULTS: Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6\%, 54.9\%, and 52.3\% declining and 25.4\%, 20.8\%, and 22.9\% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status.

CONCLUSIONS: In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

}, keywords = {Aged, Aged, 80 and over, Aging, Cognition, Cognition Disorders, Cohort Studies, Female, Humans, Interviews as Topic, Male, Medicare, Mental Health, Outcome Assessment, Health Care, Prospective Studies, Regression Analysis, Risk Factors, United States}, issn = {1471-2458}, doi = {10.1186/1471-2458-11-710}, author = {Frederic D Wolinsky and Suzanne E Bentler and Jason Hockenberry and Michael P Jones and Paula A Weigel and Kaskie, Brian and Robert B Wallace} } @article {7443, title = {Continuity of care with a primary care physician and mortality in older adults.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {65}, year = {2010}, month = {2010 Apr}, pages = {421-8}, publisher = {65A}, abstract = {

BACKGROUND: We examined whether older adults who had continuity of care with a primary care physician (PCP) had lower mortality.

METHODS: Secondary analyses were conducted using baseline interview data (1993-1994) from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The analytic sample included 5,457 self-respondents 70 years old or more who were not enrolled in managed care plans. AHEAD data were linked to Medicare claims for 1991-2005, providing up to 12 years of follow-up. Two time-dependent measures of continuity addressed whether there was more than an 8-month interval between any two visits to the same PCP during the prior 2-year period. The "present exposure" measure calculated this criterion on a daily basis and could switch "on" or "off" daily, whereas the "cumulative exposure" measure reflected the percentage of follow-up days, also on a daily basis allowing it to switch on or off daily, for which the criterion was met.

RESULTS: Two thousand nine hundred and fifty-four (54\%) participants died during the follow-up period. Using the cumulative exposure measure, 27\% never had continuity of care, whereas 31\%, 20\%, 14\%, and 8\%, respectively, had continuity for 1\%-33\%, 34\%-67\%, 68\%-99\%, and 100\% of their follow-up days. Adjusted for demographics, socioeconomic status, social support, health lifestyle, and morbidity, both measures of continuity were associated (p < .001) with lower mortality (adjusted hazard ratios of 0.84 for the present exposure measure and 0.31, 0.39, 0.46, and 0.62, respectively, for the 1\%-33\%, 34\%-67\%, 68\%-99\%, and 100\% categories of the cumulative exposure measure).

CONCLUSION: Continuity of care with a PCP, as assessed by two distinct measures, was associated with substantial reductions in long-term mortality.

}, keywords = {Aged, Continuity of Patient Care, Female, Health Services for the Aged, Humans, Male, Mortality, Physicians, Family}, issn = {1758-535X}, doi = {10.1093/gerona/glp188}, author = {Frederic D Wolinsky and Suzanne E Bentler and Li Liu and John F Geweke and Elizabeth A Cook and Maksym Obrizan and Elizabeth A Chrischilles and Kara B Wright and Michael P Jones and Gary E Rosenthal and Robert L. Ohsfeldt and Robert B Wallace} } @article {7526, title = {Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries.}, journal = {BMC Health Serv Res}, volume = {10}, year = {2010}, month = {2010 Jun 21}, pages = {173}, publisher = {8}, abstract = {

BACKGROUND: Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization.

METHODS: We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents >or=70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity.

RESULTS: Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001).

CONCLUSIONS: We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.

}, keywords = {Aged, Aged, 80 and over, Cohort Studies, Emergency Service, Hospital, Humans, Insurance Claim Review, Medicare, Prospective Studies, Severity of Illness Index, United States}, issn = {1472-6963}, doi = {10.1186/1472-6963-10-173}, author = {Kaskie, Brian and Maksym Obrizan and Elizabeth A Cook and Michael P Jones and Li Liu and Suzanne E Bentler and Robert B Wallace and John F Geweke and Kara B Wright and Elizabeth A Chrischilles and Claire E Pavlik and Robert L. Ohsfeldt and Gary E Rosenthal and Frederic D Wolinsky} } @article {7527, title = {A longitudinal study of chiropractic use among older adults in the United States.}, journal = {Chiropr Osteopat}, volume = {18}, year = {2010}, month = {2010 Dec 21}, pages = {34}, publisher = {18}, abstract = {

BACKGROUND: Longitudinal patterns of chiropractic use in the United States, particularly among Medicare beneficiaries, are not well documented. Using a nationally representative sample of older Medicare beneficiaries we describe the use of chiropractic over fifteen years, and classify chiropractic users by annual visit volume. We assess the characteristics that are associated with chiropractic use versus nonuse, as well as between different levels of use.

METHODS: We analyzed data from two linked sources: the baseline (1993-1994) interview responses of 5,510 self-respondents in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD), and their Medicare claims from 1993 to 2007. Binomial logistic regression was used to identify factors associated with chiropractic use versus nonuse, and conditional upon use, to identify factors associated with high volume relative to lower volume use.

RESULTS: There were 806 users of chiropractic in the AHEAD sample yielding a full period prevalence for 1993-2007 of 14.6\%. Average annual prevalence between 1993 and 2007 was 4.8\% with a range from 4.1\% to 5.4\%. Approximately 42\% of the users consumed chiropractic services only in a single calendar year while 38\% used chiropractic in three or more calendar years. Chiropractic users were more likely to be women, white, overweight, have pain, have multiple comorbid conditions, better self-rated health, access to transportation, higher physician utilization levels, live in the Midwest, and live in an area with fewer physicians per capita. Among chiropractic users, 16\% had at least one year in which they exceeded Medicare{\textquoteright}s "soft cap" of 12 visits per calendar year. These over-the-cap users were more likely to have arthritis and mobility limitations, but were less likely to have a high school education. Additionally, these over-the-cap individuals accounted for 58\% of total chiropractic claim volume. High volume users saw chiropractors the most among all types of providers, even more than family practice and internal medicine combined.

CONCLUSION: There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".

}, issn = {1746-1340}, doi = {10.1186/1746-1340-18-34}, author = {Paula A Weigel and Jason Hockenberry and Suzanne E Bentler and Maksym Obrizan and Kaskie, Brian and Michael P Jones and Robert L. Ohsfeldt and Gary E Rosenthal and Robert B Wallace and Frederic D Wolinsky} } @article {7484, title = {Prior hospitalization and the risk of heart attack in older adults: a 12-year prospective study of Medicare beneficiaries.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {65}, year = {2010}, month = {2010 Jul}, pages = {769-77}, publisher = {65}, abstract = {

BACKGROUND: We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old.

METHODS: Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect.

RESULTS: The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8\%) suffered postbaseline heart attacks, with 423 participants (7.7\%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366\% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3\%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.

}, keywords = {Aged, Educational Status, Female, Hospitalization, Humans, Male, Marital Status, Medicare, Myocardial Infarction, Patient Discharge, Proportional Hazards Models, Prospective Studies, Risk Factors, Sex Factors, United States}, issn = {1758-535X}, doi = {10.1093/gerona/glq003}, author = {Frederic D Wolinsky and Suzanne E Bentler and Li Liu and Michael P Jones and Kaskie, Brian and Jason Hockenberry and Elizabeth A Chrischilles and Kara B Wright and John F Geweke and Maksym Obrizan and Robert L. Ohsfeldt and Gary E Rosenthal and Robert B Wallace} } @article {7326, title = {A 12-year prospective study of stroke risk in older Medicare beneficiaries.}, journal = {BMC Geriatr}, volume = {9}, year = {2009}, month = {2009 May 09}, pages = {17}, publisher = {9}, abstract = {

BACKGROUND: 5.8 M living Americans have experienced a stroke at some time in their lives, 780K had either their first or a recurrent stroke this year, and 150K died from strokes this year. Stroke costs about $66B annually in the US, and also results in serious, long-term disability. Therefore, it is prudent to identify all possible risk factors and their effects so that appropriate intervention points may be targeted.

METHODS: Baseline (1993-1994) interview data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to 1993-2005 Medicare claims. Participants were 5,511 self-respondents >or= 70 years old. Two ICD9-CM case-identification approaches were used. Two approaches to stroke case-identification based on ICD9-CM codes were used, one emphasized sensitivity and the other emphasized specificity. Participants were censored at death or enrollment into managed Medicare. Baseline risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting post-baseline non-stroke hospitalizations was included to reflect health shocks, and sensitivity analyses were conducted to identify its peak effect. Competing risk, proportional hazards regression was used.

RESULTS: Post-baseline strokes occurred for 545 (9.9\%; high sensitivity approach) and 374 (6.8\%; high specificity approach) participants. The greatest static risks involved increased age, being widowed or never married, living in multi-story buildings, reporting a baseline history of diabetes, hypertension, or stroke, and reporting difficulty picking up a dime, refusing to answer the delayed word recall test, or having poor cognition. Risks were similar for both case-identification approaches and for recurrent and first-ever vs. only first-ever strokes. The time-dependent health shock (recent hospitalization) marker did not alter the static model effect estimates, but increased stroke risk by 200\% or more.

CONCLUSION: The effect of our health shock marker (a time-dependent recent hospitalization indicator) was large and did not mediate the effects of the traditional risk factors. This suggests an especially vulnerable post-hospital transition period from adverse effects associated with both their underlying health shock (the reasons for the recent hospital admission) and the consequences of their treatments.

}, keywords = {Aged, Aged, 80 and over, Female, Humans, Insurance Benefits, Male, Medicare, Prospective Studies, Risk Factors, Socioeconomic factors, Stroke, United States}, issn = {1471-2318}, doi = {10.1186/1471-2318-9-17}, author = {Frederic D Wolinsky and Suzanne E Bentler and Elizabeth A Cook and Elizabeth A Chrischilles and Li Liu and Kara B Wright and John F Geweke and Maksym Obrizan and Claire E Pavlik and Robert L. Ohsfeldt and Michael P Jones and Robert B Wallace and Gary E Rosenthal} } @article {7379, title = {The aftermath of hip fracture: discharge placement, functional status change, and mortality.}, journal = {Am J Epidemiol}, volume = {170}, year = {2009}, month = {2009 Nov 15}, pages = {1290-9}, publisher = {170}, abstract = {

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73\% of fracture patients were white women, 45\% had pertrochanteric fractures, and 55\% underwent surgical pinning. Most patients (58\%) were discharged to a nursing facility, with 14\% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7\%, 19\%, and 26\%, respectively. Declines in functional-status-scale scores ranged from 29\% on the fine motor skills scale to 56\% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, depression, Female, Health Status, Health Status Indicators, Hip Fractures, Humans, Interviews as Topic, Iowa, Length of Stay, Logistic Models, Medicare, Patient Discharge, Prospective Studies, Psychometrics, Socioeconomic factors, Time Factors, Treatment Outcome, United States}, issn = {1476-6256}, doi = {10.1093/aje/kwp266}, author = {Suzanne E Bentler and Li Liu and Maksym Obrizan and Elizabeth A Cook and Kara B Wright and John F Geweke and Elizabeth A Chrischilles and Claire E Pavlik and Robert B Wallace and Robert L. Ohsfeldt and Michael P Jones and Gary E Rosenthal and Frederic D Wolinsky} } @article {7405, title = {Recent hospitalization and the risk of hip fracture among older Americans.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {64}, year = {2009}, month = {2009 Feb}, pages = {249-55}, publisher = {64}, abstract = {

BACKGROUND: We identified hip fracture risks in a prospective national study.

METHODS: Baseline (1993-1994) interview data were linked to Medicare claims for 1993-2005. Participants were 5,511 self-respondents aged 70 years and older and not in managed Medicare. ICD9-CM 820.xx (International Classification of Diseases, 9th Edition, Clinical Modification) codes identified hip fracture. Participants were censored at death or enrollment into managed Medicare. Static risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting postbaseline hospitalizations was included.

RESULTS: A total of 495 (8.9\%) participants suffered a postbaseline hip fracture. In the static proportional hazards model, the greatest risks involved age (adjusted hazard ratios [AHRs] of 2.01, 2.82, and 4.91 for 75-79, 80-84, and > or =85 year age groups vs those aged 70-74 years; p values <.001), sex (AHR = 0.45 for men vs women; p < .001), race (AHRs of 0.37 and 0.46 for African Americans and Hispanics vs whites; p values <.001 and <.01), body mass (AHRs of 0.40, 0.77, and 1.73 for obese, overweight, and underweight vs normal weight; p values <.001, <.05, and <.01), smoking status (AHRs = 1.49 and 1.52 for current and former smokers vs nonsmokers; p values <.05 and <.001), and diabetes (AHR = 1.99; p < .001). The time-dependent recent hospitalization marker did not alter the static model effect estimates, but it did substantially increase the risk of hip fracture (AHR = 2.51; p < .001).

CONCLUSIONS: Enhanced discharge planning and home care for non-hip fracture hospitalizations could reduce subsequent hip fracture rates.

}, keywords = {Accidental Falls, Age Distribution, Aged, Aged, 80 and over, Aging, Cohort Studies, Female, Follow-Up Studies, Geriatric Assessment, Hip Fractures, Hospitalization, Humans, Logistic Models, Male, Multivariate Analysis, Probability, Proportional Hazards Models, Prospective Studies, Risk Factors, Sex Distribution, Survival Analysis, United States}, issn = {1758-535X}, doi = {10.1093/gerona/gln027}, author = {Frederic D Wolinsky and Suzanne E Bentler and Li Liu and Maksym Obrizan and Elizabeth A Cook and Kara B Wright and John F Geweke and Elizabeth A Chrischilles and Claire E Pavlik and Robert L. Ohsfeldt and Michael P Jones and Kelly K Richardson and Gary E Rosenthal and Robert B Wallace} }