Developing the Future End-of-Life Health Care Workforce: Lessons Learned From a Survey of Advanced Health Professions Students.

OBJECTIVE: To examine health professions trainees' end-of-life (EOL) care knowledge, attitudes, and intentions. METHODS: IRB-approved online survey of 346 students/5 universities in final training years-public health, pharmacy, physician, physician assistant, occupational therapy, and physical therapy (April-May 2016). Queried knowledge, attitudes, and intentions toward EOL care. RESULTS: Sufficient knowledge of palliative care was reported by 25% while sufficient knowledge of advance care planning (ACP) was 17%. Ninety-six percent thought it important to discuss EOL issues in training; 92% believed their professions played important roles in EOL care. Managing pain was chosen as the best example of palliative care by 93.6% and designating healthcare proxies was reported as the best example of ACP (5.8%). Pharmacy, public health, and rehabilitation therapy students were less likely than physician and physician assistant trainees to report intent to work in EOL care. Among those who want to work in EOL care, 65% reported having clinical experience with seriously ill or dying patients/clients. We discuss other findings related to perceptions of didactic preparation in palliative care, palliative care knowledge access/function, death/dying attitudes, and intentions toward seriously illness care. DISCUSSION: There is interest in and knowledge of palliative care, including EOL care, among multiple health professions. Provides guidance for how we train health professionals to improve population health by optimizing EOL care.

Documenting limited health literacy in a clinical setting.

Objective: Health literacy is important in lung cancer care, where treatments and symptoms are difficult to navigate. This study aims to describe how a single-item measure of health literacy can facilitate health literacy system capacity. Methods: Data include retrospective medical records from 456 patients with lung cancer. Limited or adequate health literacy was based on participant response to the Single Item Literacy Screener (SILS). Data were collected over a 12-month period following diagnosis for each patient. Results: One-third of patients had limited health literacy; they were more likely to have lung cancers of stage IIIB or higher and greater median levels of depression based on the PHQ-9 questionnaire. Patients with limited health literacy were also more likely to have at least one emergency department visit or unplanned hospitalization and had these visits sooner. Conclusion: These data document need for interventions to buffer the association between limited health literacy and poor health outcomes. Innovation: Routine intake screens should include the SILS to measure health literacy among lung cancer patients. New models that address health literacy at the organizational and patient levels can be implemented in health care settings using the SILS.

Population characteristics associated with pharmacy-based influenza vaccination in United States survey data.

OBJECTIVES: To examine the population characteristics associated with the health behavior of receiving an influenza vaccine from a pharmacy-based setting. DESIGN: Secondary analysis of data from states that participated in an optional influenza module in the 2014 Behavioral Risk Factor Surveillance System, a state-based observational survey of U.S. adults. SETTING AND PARTICIPANTS: Analytic sample of 28,954 respondents from 8 states and Puerto Rico who reported receiving an influenza vaccination in the past year. MAIN OUTCOME MEASURES: The main outcome was a self-reported categoric variable indicating the setting of the most recent seasonal influenza vaccination: doctor's office, pharmacy-based store, or other setting. RESULTS: Multinomial logistic regression results showed that environmental, predisposing, enabling, and need factors in the Andersen model were salient features associated with odds of using pharmacy-based influenza vaccination settings instead of a doctor's office. Residents of states that allowed pharmacists as immunizers before 1999 reported greater use of pharmacy-based store settings (odds ratio [OR] 1.31). Compared with young adults, individuals 65 years of age and older were more likely to choose a pharmacy-based store than a doctor's office (OR 1.41) and less likely to use other community settings (OR 0.45). Compared with non-Hispanic whites, black respondents were less likely to use pharmacy-based store vaccination (OR 0.51), and multiracial and Hispanic respondents were more likely to use other settings (ORs 1.47 and 1.60, respectively). Enabling and need factors were also associated with setting. CONCLUSION: Based on this dataset of selected states from 2014, almost one-fourth of U.S. adults who reported receiving an annual influenza vaccination did so from a pharmacy-based store; 35% reported using other community-based settings that may enlist pharmacists as immunizers. There were striking disparities in use of nontraditional vaccination settings by age and race or ethnicity. Pharmacists and pharmacies should address missed opportunities for vaccination by targeting outreach efforts based on environmental and predisposing characteristics.

Self-perceived uselessness and associated factors among older adults in China.

BACKGROUND: Self-perceived uselessness is associated with poor health and high mortality among older adults in China. However, it is unclear which demographic, psychosocial, behavioral and health factors are associated with self-perceived uselessness. METHODS: Data came from four waves (2005, 2008, 2011 and 2014) of the largest nationwide longitudinal survey of the population aged 65 and older in China (26,624 individuals contributed 48,476 observations). This study aimed to systematically investigate factors associated with self-perceived uselessness based on the proposed REHAB framework that includes resources (R), environments (E), health (H), fixed attributes (A) and behaviors (B). Self-perceived uselessness was measured by a single item: "with age, do you feel more useless?" and coded by frequency: high (always and often), moderate (sometimes) and low (seldom and never). Multinomial logistic regression models with low frequency as the reference category were employed to identify REHAB risk factors associated with self-perceived uselessness. RESULTS: Most factors in the REHAB framework were associated with self-perceived uselessness, although some social environmental factors in the full model were not significant. Specifically, more socioeconomic resources were associated with reduced relative risk ratio (RRR) of high or moderate frequency of self-perceived uselessness relative to low frequency. More environmental family/social support was associated with lower RRR of high frequency of self-perceived uselessness. Cultural factors such as coresidence with children and intergenerational transfer were associated with reduced RRR of high frequency of self-perceived uselessness. Indicators of poor health status such as disability and loneliness were associated with greater RRR of high or moderate frequency of self-perceived uselessness. Fixed attributes of older age and Han ethnicity were associated with increased RRR of high frequency of self-perceived uselessness; whereas optimism and self-control were associated with reduced RRR. Behaviors including regular consumption of alcohol, regular exercise, social participation and leisure activities were associated with reduced RRR of high frequency of self-perceived uselessness. CONCLUSIONS: Self-perceived uselessness was associated with a wide range of factors in the REHAB framework. The findings could have important implications for China to develop and target community health programs to improve self-perceived usefulness among older adults.

Concordance and Discordance of Self-Rated and Researcher-Measured Successful Aging: Subtypes and Associated Factors.

OBJECTIVES: To investigate subtypes of successful aging (SA) based on concordance and discordance between self-rated and researcher-defined measures and their associations with demographic, psychosocial, and life satisfaction factors. METHOD: We used multinomial logistic regression models to analyze 2013 cross-sectional survey data from 1,962 persons aged 65 and older in Shanghai that measured self-rated successful aging (SSA) with a single global assessment and researcher-defined successful aging (RSA) with a cumulative deficit index reflecting physical, physiological, cognitive, psychological, and social engagement domains. We generated four subtypes based on these two dichotomous variables: nonsuccessful aging (non-SA; meeting neither the criterion of RSA nor the criterion of SSA), RSA-only (meeting the criterion of RSA-only but not the criterion of SSA), SSA-only (meeting the criterion of SSA-only but not the criterion of RSA), and both-successful aging (both-SA; meeting both criteria of RSA and SSA). RESULTS: In the sample, 32% were nonsuccessful agers, 7% RSA-only, 34% SSA-only, and 27% successful agers. Female gender and older age were associated with lower likelihood of RSA-only and both-SA relative to non-SA, but with greater likelihood of SSA-only. Good socioeconomic conditions and social networks were associated with greater likelihood of SSA-only and both-SA relative to non-SA or RSA-only. Satisfaction with life domains was robustly and positively associated with good successful aging outcomes. DISCUSSION: Researcher-defined successful aging and self-rated successful aging are different measures with distinct social correlates. Subtypes of concordance and discordance provide a more holistic biopsychosocial conceptualization of successful aging.

Veteran Status, Sociodemographic Characteristics, and Healthcare Factors Associated with Visiting a Mental Health Professional.

Using data from a nationally representative study of the community-dwelling U.S. population, we estimated the percentage of male veterans who visited a mental health professional in the past year, compared it to an estimate from non-veteran males, and examined factors associated with visiting a mental health professional. We found that 10.5% of male veterans visited a mental health professional in the past year, compared to only 5.6% of male non-veterans. In the regression models, veteran status, sociodemographic factors, and healthcare utilization were independently associated with visiting a mental health professional. These findings demonstrate the importance of using nationally representative data to assess the mental healthcare needs of veterans.

Homeownership among Older Adults in Urban China: the Importance of Institutional Factors.

Homeownership is a key element to maintain social welfare and stability in an aging society. Yet, the existing literature on homeownership does not adequately address non-Western cultures and institutional factors. We used two nationwide surveys in 2006 and 2010 to investigate how institutional factors are associated with homeownership among older adults in China. Institutional factors were measured by proxy measures of job seniority, political status, type of work units, and hierarchy of cities. After controlling for demographics, resources, health needs, neighborhood characteristics, and cultural factors, we found that homeownership was strongly associated with these institutional factors among the current cohorts of older adults in China. Older adults who were more senior or who were from public sectors tended to have a higher odds of homeownership. Older adults in the top or bottom of the city hierarchy tended to have a lower odds of homeownership than those in other types of cities. Implications of these findings are discussed.

Socioeconomic status as a moderator between frailty and mortality at old ages.

BACKGROUND: Despite the well-established power of frailty to predict mortality, and the known associations of socioeconomic status (SES) with mortality, it is largely unknown whether the linkage between frailty and mortality varies across different SES groups. This study aims to investigate whether SES moderates the association between frailty and mortality. METHODS: We relied on the 2008/2009 and 2011/2012 waves of the Chinese Longitudinal Healthy Longevity Survey, a nationwide sample of 13,731 adults aged 65 or older in China. Frailty was constructed using a cumulative index of 38 items (with 39 deficits) reflecting different dimensions of health; the index or the proportion of deficits ranges from 0 to 1, with greater scores indicating poorer health condition. SES was measured by a socioeconomic vulnerability index (SEVI) also from a similar cumulative approach consisting of 6 deficits; the proportion of deficits ranges from 0 to 1 with higher scores indicating lower SES. Eight Weibull hazard regression models were performed to examine how SES moderates the linkage between frailty and mortality. RESULTS: We found that a one percentage point increase in the frailty index was associated with an increased hazard ratio (HR) by 2.7 % (HR = 1.027, 95 % CI: 1.025-1.027); a one percentage point increase in SEVI score was associated with an increased hazard ratio by 0.6 % (HR = 1.006, 95 % CI: 1.004-1.008) controlling for demographics. When interactions between SEVI and frailty index were modeled, the increased mortality risk associated with frailty was weaker among people with lower SES than among people with higher SES (HR = 0.983, 95 % CI: 0.967-0.992). However, the moderating role of SES was diminished when interactions between SES and age and between frailty and age were modeled. With increasing age, the increased mortality risks associated with frailty and socioeconomic vulnerability weakened. CONCLUSIONS: Frailty was a stronger predictor of mortality among individuals with higher SES than those with lower SES. The increased mortality risks associated with socioeconomic vulnerability and frailty weakened with age. Public health programs aimed at improving SES and promoting healthy longevity should start early in old age, or even earlier, and target poor and frail older adults for maximum impact.

Diffusion of Pharmacy-Based Influenza Vaccination Over Time in the United States.

OBJECTIVES: To examine pharmacy-based influenza vaccination using diffusion of innovation theory. METHODS: We used 1993 to 2013 Behavioral Risk Factor Surveillance System data to generate weighted prevalence rates of influenza vaccination, stratified by age (18-64 years vs ≥ 65 years) and state of residence. The diffusion of innovation theory adopter categories were residents of states allowing pharmacist vaccination before 1996 ("innovator/early adopters"), between 1996 and 1998 ("early majority"), between 1999 and 2004 ("late majority"), and in 2007 or later ("laggards"). RESULTS: For adults aged 18 to 64 years, vaccination rates were similar before the innovation (1993), diverged as the innovation reached the majority (2003), and were significantly lower for laggard states by 2013. Younger adults' vaccination rates steadily increased from 12% to 16% in 1993 to 29% to 36% in 2013. For older adults, there was no significant difference in vaccination rates between adopter categories in any year and no advantage associated with adoption category. CONCLUSIONS: Key features of pharmacy-based vaccination, including relative advantage and compatibility, are most relevant to younger adults; different interventions are warranted for older adults.

Prevalence and trends in psychotropic medication use among US male veterans, 1999-2010.

PURPOSE: Prior studies of psychotropic medication use among US veterans are limited in their ability to generalize estimates to the full veteran population and make comparisons with non-veterans. This study estimated the prevalence of psychotropic medication use and trends over time among male US veterans, compared their use of psychotropic medications with non-veteran males, and examined differences among veteran subpopulations. METHODS: The data for our analysis came from the National Health and Nutrition Examination Survey (1999-2010), a cross-sectional, nationally representative study of the civilian, non-institutionalized US population. RESULTS: The percentage of male veterans who used any psychotropic medication increased from 10.4% in 1999-2002 to 14.3% in 2003-2006, then remained stable in 2007-2010 (14.0%). During the same time period, the percentage of non-veteran males who used psychotropic medications remained relatively stable (7.0%, 8.3%, and 9.2%, respectively). Veterans were more likely to use psychotropic medication, specifically antidepressants, than non-veterans. The percentage of non-Hispanic white veterans and veterans aged 60 years and over who used psychotropic medications increased between 1999-2002 and 2003-2006, but the percentages remained stable between 2003-2006 and 2007-2010. In 2003-2006 and 2007-2010, a higher percentage of non-Hispanic white veterans used psychotropic medications than non-Hispanic black veterans. CONCLUSIONS: This study found that the use of psychotropic medications and antidepressants was higher among male veterans than male non-veterans, and that prevalence of use increased between 1999-2002 and 2007-2010 for male veterans but remained relatively stable for non-veterans. There were significant variations in the use of psychotropic medications among veteran subpopulations.

A randomized clinical trial of an integrated behavioral self-management intervention Simultaneously Targeting Obesity and Pain: the STOP trial.

BACKGROUND: Obesity often occurs co-morbid with chronic, non-cancer pain. While behavioral treatments have proved effective for pain management and weight loss independently, integrated interventions are lacking. The study Simultaneously Targeting Obesity and Pain (STOP) is a prospective, pragmatic, randomized controlled trial that aims to determine whether overweight/obese individuals with chronic pain who are randomized to receive an integrated treatment Simultaneously Targeting Obesity and Pain (STOP) will show more weight loss and greater reduction in pain intensity over a 6-month period and greater maintenance at 12 months than those who receive standard care behavioral weight loss or standard care behavioral pain management. We hypothesize that individuals randomized to receive the STOP treatment will demonstrate improved weight loss, pain reduction, and maintenance compared to standard care treatment approaches. METHODS/DESIGN: Adults aged ≥ 18 with a body mass index ≥ 25 and who report persistent pain (≥4 out of 0-10 for > 6 months) will be recruited for treatment at the Health Behavior Research Lab at the University of the Sciences. After baseline assessments and goal setting, participants will be randomized to receive one of three treatments. Participants will receive eleven treatment sessions delivered during 1 hour, weekly individual meetings with a clinic therapist. Follow-up will occur at 3, 6 and 12-month time points; assessments will include measures of weight and pain intensity (primary outcomes). A mixed-method approach to evaluating study outcomes will include individual interviews with participants about their treatment experience. These interviews will be led by a research staffer who was not involved in study intervention or assessment using a semi-structured discussion guide. DISCUSSION: This study fills an important gap in intervention research, evaluating best-practices for behavioral management of a highly prevalent co-morbidity that has sub-optimal outcomes with currently-implemented approaches. STOP's pragmatic focus builds upon treatments already in use in clinical practice. Should STOP be found efficacious in achieving the dual outcomes of pain management and weight loss, such an approach could be integrated into practice with minimal additional cost or training. TRIAL REGISTRATION: Clinical Trials.gov NCT02100995 Date of Registration: March 2014.

Caregiver experience during advanced chronic illness and last year of life.

OBJECTIVES: To compare the prevalence and predictors of caregiver esteem and burden during two different stages of care recipients' illnesses-advanced chronic illness and the last year of life. DESIGN: Longitudinal, observational cohort study. SETTING: Community sample recruited from outpatient clinics at Duke University and Durham Veterans Affairs Medical Centers. PARTICIPANTS: Individuals with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease and their primary caregiver, retrospectively coded as chronic-illness (n = 62) or end-of-life (EOL; n = 62) care recipient-caregiver dyads. MEASUREMENTS: Caregiver experience was measured monthly using the Caregiver Reaction Assessment, which includes caregiver esteem and four domains of burden: schedule, health, family, and finances. RESULTS: During chronic illness and at the end of life, high caregiver esteem was almost universal (95%); more than 25% of the sample reported health, family, and financial burden. Schedule burden was the most prevalent form of burden; EOL caregivers (58%) experienced it more frequently than chronic-illness caregivers (32%). Caregiver esteem and all dimensions of burden were relatively stable over 1 year. Few factors were associated with burden. CONCLUSION: Caregiver experience is relatively stable over 1 year and similar in caregivers of individuals in the last year of life and those earlier in the course of chronic illness. Schedule burden stands out as most prevalent and variable among dimensions of experience. Because prevalence of burden is not specific to stage of illness and is relatively stable over time, multidisciplinary healthcare teams should assess caregiver burden and refer burdened caregivers to supportive resources early in the course of chronic illness.

Age differential effects of severity of visual impairment on mortality among older adults in China.

We use a population-based longitudinal survey in China from 2002 to 2005 to examine age differentials in the association between severity of visual impairment and mortality risk in older adults. Controlling for numerous factors and baseline health, a substantial age difference is found. Young-old women and men aged 65 to 79 with severe visual impairments have 161% (hazard ratio = 2.61) and 52% (hazard ratio = 1.52) higher risk of death respectively as compared to their unimpaired counterparts. Mild impairment does not increase mortality risk among young-old adults, while both mild and severe impairment increase mortality risk by 33% and 32% for women and 24% and 34% for men among the oldest-old as a whole when all factors are controlled for. We conclude that visual impairment is an independent predictor of mortality and severe visual impairment likely plays a stronger role in determining mortality risk among young-old adults than among the oldest-old.

Socioeconomic status and the Black-White mortality crossover.

OBJECTIVES: We investigated associations among age, race, socioeconomic status (SES), and mortality in older persons and whether low SES contributes to the Black-White mortality crossover (when elevated age-specific mortality rates invert). METHODS: We used panel data from the North Carolina Established Populations for Epidemiologic Studies of the Elderly to test the main and interactive effects of SES on mortality. RESULTS: Discrete-time hazard models showed that the association between low education and mortality did not vary by race or age and was only significant for men. For women, the effect of low income diminished with age and had little impact on the crossover. For men, low income varied by race and age, altering the Black-White crossover and producing low-high income crossovers at advanced ages. CONCLUSIONS: Low education and income were associated with increased mortality risk for older adults, but only low income had a differential impact on the Black-White mortality crossover. A primary route to reducing mortality differentials in later life is to prevent the disproportionate selective mortality of Blacks and the poor earlier in the life course.

Burden and well-being among a diverse sample of cancer, congestive heart failure, and chronic obstructive pulmonary disease caregivers.

CONTEXT: Three important causes of death in the U.S. (cancer, congestive heart failure, and chronic obstructive pulmonary disease) are preceded by long periods of declining health; often, family members provide most care for individuals who are living with serious illnesses and are at risk for impaired well-being. OBJECTIVES: To expand understanding of caregiver burden and psychosocial-spiritual outcomes among understudied groups of caregivers-cancer, congestive heart failure, and chronic obstructive pulmonary disease caregivers-by including differences by disease in a diverse population. METHODS: The present study included 139 caregiver/patient dyads. Independent variables included patient diagnosis and function; and caregiver demographics, and social and coping resources. Cross-sectional analyses examined distributions of these independent variables between diagnoses, and logistic regression examined correlates of caregiver burden, anxiety, depressive symptoms, and spiritual well-being. RESULTS: There were significant differences in patient functioning and caregiver demographics and socioeconomic status between diagnosis groups but few differences in caregiver burden or psychosocial-spiritual outcomes by diagnosis. The most robust social resources indicator of caregiver burden was desire for more help from friends and family. Anxious preoccupation coping style was robustly associated with caregiver psychosocial-spiritual outcomes. CONCLUSION: Caregiver resources, not patient diagnosis or illness severity, are the primary correlates associated with caregiver burden. Additionally, caregiver burden is not disease specific to those examined here, but it is rather a relatively universal experience that may be buffered by social resources and successful coping styles.

Associations between frequency of tea consumption and health and mortality: evidence from old Chinese.

Tea consumption may be associated with reduced risk of morbidity and mortality; however, this association is not conclusive and has rarely been investigated among very old adults. The present study examines how self-reported frequency of tea consumption in daily life is associated with health and mortality among very old adults in China. The data are from a national longitudinal data set that included 32 606 individuals (13 429 men and 19 177 women) aged 65 years and older: 11 807 respondents aged 65 to 84 years and 20 799 respondents aged 85 years and older. A total of four measurements between 1998 and 2005 resulted in 51 668 observations. Hazard regressions showed that men who drink tea almost every day have a 10-20 % lower risk of death compared to their counterparts who seldom drink tea, after adjusting for numerous confounders including baseline health. This relationship was stronger in younger male elders aged 65 to 84 years than in the oldest-old men aged 85 years and older. However, frequency of tea consumption was not significantly associated with mortality in women. Our analyses further show that high frequency of tea consumption is significantly associated with reduced OR of disability in activities of daily living, cognitive impairment, self-rated poor health, cumulative health deficits and CVD in both young elders and the oldest-old, and in both men and women. These results suggest that the health benefit of drinking tea is universal. We conclude that frequent tea consumption probably helps one achieve healthy longevity and that men benefit more from such lifestyles.

Age and gender differences in linkages of sleep with subsequent mortality and health among very old Chinese.

BACKGROUND: Studies suggest that sleep quality and duration are significantly associated with mortality risk and health conditions, yet such studies are seldom conducted among very old adults. The objective of this study was to examine associations between self-reported sleep quality/duration and subsequent mortality/health among very old adults in China. A second objective determines whether these associations vary by age and gender. METHODS: This study used data of the 2005 and 2008 waves from a large, representative survey with a total of 12,671 individuals in 22 provinces in mainland China, in which 3158 respondents were aged 90-99 and 2293 were centenarians. Two self-reported questions about sleep quality and duration were examined while adjusting for numerous socio-demographic, family/social support, health practices, and baseline health factors. RESULTS: Hazard regressions showed that, when demographic factors are controlled for, Chinese elders who report poor and fair quality of sleep have 26% and 10% higher risk of death over the next three years compared to those with good sleep quality; those who sleep either 6h or less or 10h or more per day have an 18-22% higher mortality risk as compared to those who sleep 8h per day. The increased mortality risks of poorer sleep and too short or too long sleep duration are larger in men than in women and more robust in the oldest-old than in young elders. Logistic regressions show that poor sleep and daily sleep durations of 5h or less or 10h or more are also associated with worse health three years later. CONCLUSIONS: Poorer sleep quality and too short or too long sleep duration are associated with higher subsequent mortality risk and lower odds of being in a healthy state among very old Chinese.

Health inputs and cumulative health deficits among the older Chinese.

Using a health economics framework, we examined how both individual level investments at different life stages and current community-level environmental factors affect individual health stock and flows at old ages. We used a nationwide dataset from the 2002 and 2005 waves of the Chinese Longitudinal Healthy Longevity Survey, which included more than 15,000 adults aged 65 and older from 22 provinces in mainland China. We measured health stock with a cumulative health deficit index, a measure developed in geriatrics and gerontology that reflects deficits, illnesses, and functional impairment in numerous domains of health. The cumulative health deficit index has not been used in health economics before, but is a significant contribution because it captures the health stock concept very well and overcomes the problems of inconsistency resulting from the use of different measures of health stock in research. Our results show that several proxy measures for individual health investments in both childhood (nutritional status and parental survival status) and adulthood (family financial condition and access to healthcare) yielded positive returns to health stock measured by the cumulative health deficit index. Investments in social connections and healthy behaviors (religious involvement, alcohol use, and exercise) also produced positive returns in health stock. Current community-level factors such as air quality and labor force participation rate were significantly associated with levels of health deficits in old age as well. Yet, most of these individual investment and community environment variables did not significantly affect short-term health flows (improvement or deterioration in health status over three years). Our findings have important implications for developing preventive health programs in the context of population aging by focusing on policy-relevant predictors and a comprehensive indicator of health status in later life.