TY - JOUR T1 - Identifying Specific Combinations of Multimorbidity that Contribute to Health Care Resource Utilization: An Analytic Approach. JF - Med Care Y1 - 2017 A1 - Nicholas K Schiltz A1 - David F Warner A1 - Jiayang Sun A1 - Paul M Bakaki A1 - Avi Dor A1 - Charles W Given A1 - Kurt C Stange A1 - Siran M Koroukian KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Comorbidity KW - Female KW - Health Behavior KW - Health Expenditures KW - Health Status KW - Humans KW - Machine learning KW - Male KW - Medicare KW - Retrospective Studies KW - Self Report KW - Socioeconomic factors KW - United States AB -

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.

VL - 55 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27753745?dopt=Abstract ER - TY - JOUR T1 - Combinations of Chronic Conditions, Functional Limitations, and Geriatric Syndromes that Predict Health Outcomes. JF - J Gen Intern Med Y1 - 2016 A1 - Siran M Koroukian A1 - Nicholas K Schiltz A1 - David F Warner A1 - Jiayang Sun A1 - Paul M Bakaki A1 - Kathleen A Smyth A1 - Kurt C Stange A1 - Charles W Given KW - Activities of Daily Living KW - Age Distribution KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Comorbidity KW - Female KW - Geriatric Assessment KW - Health Status KW - Health Status Indicators KW - Humans KW - Longitudinal Studies KW - Male KW - Middle Aged KW - Mobility Limitation KW - Prognosis KW - Risk Factors KW - Self Report KW - Sex Distribution KW - Socioeconomic factors KW - Syndrome KW - United States AB -

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.

VL - 31 UR - http://dx.doi.org/10.1007/s11606-016-3590-9 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26902246?dopt=Abstract ER - TY - JOUR T1 - Functional status in older women diagnosed with pelvic organ prolapse. JF - Am J Obstet Gynecol Y1 - 2016 A1 - Tatiana V D Sanses A1 - Nicholas K Schiltz A1 - Bruna M. Couri A1 - Sangeeta T Mahajan A1 - Holly E Richter A1 - David F Warner A1 - Jack M. Guralnik A1 - Siran M Koroukian KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Aging KW - Cross-Sectional Studies KW - Female KW - Health Status KW - Health Surveys KW - Humans KW - Medicare KW - Middle Aged KW - Mobility Limitation KW - Muscle Strength KW - Pelvic Organ Prolapse KW - United States KW - Upper Extremity AB -

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.

PB - 214 VL - 214 UR - http://www.sciencedirect.com/science/article/pii/S0002937815024783 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26704893?dopt=Abstract U2 - PMC4851569 U4 - activities of daily living/functional status/limitations/mobility/pelvic organ prolapse/strength ER -