Prevalence, risk factors, and burden of disease for falls and balance or walking problems among older adults in the U.S.

This study assesses the prevalence of falls, factors predicting future falls, and health impacts of falls and balance or walking problems for U.S. older adults. Data were from participants ≥65 years in the Medicare Health Outcomes Survey Cohort 15 (baseline survey in 2012; follow-up survey in 2014; n = 164,597). We examined baseline factors predicting falls at follow-up and estimated the impact of falls and balance/walking problems on health-related quality of life (HRQOL), mortality, and quality-adjusted life years (QALYs). About 23% reported falls and 34% reported balance/walking problems in the past 12 months. The strongest predictors of falls were previous falls [adjusted odds ratio (OR) = 2.9] and balance/walking problems (OR = 1.7). Many self-reported chronic conditions (e.g., depression, stroke, and diabetes), geriatric symptoms (e.g., urine leakage), and limitations of activities of daily living (e.g., transferring and walking) also predicted falls, but at a smaller magnitude (ORs = 1.1-1.3). Having balance/walking problems was associated with a greater decrease in HRQOL scores (0.195 points) than falls (0.077 points), while falls were associated with a greater increase in mortality [adjusted hazard ratio (HR) = 1.5] than balance/walking problems (HR = 1.1). Falls were associated with a 4.6-year (48%) decrease in QALYs, while balance/walking problems was associated with a 7.3-year (62%) decrease in QALYs. Falls are a major problem for U.S. elderly and will continue to have an even greater impact as the population ages. The nearly 50% decrease in QALYs for falls and >60% decrease for balance or walking problems demonstrates the substantial burden associated with these problems among older Americans.

Quality-adjusted life years (QALYs) associated with limitations in activities of daily living (ADL) in a large longitudinal sample of the U.S. community-dwelling older population.

BACKGROUND: The staging method for activities of daily living (ADLs) limitations developed by Stineman and colleagues that classifies people into five stages can reflect severity of activity limitations. OBJECTIVE: To assess the impact of stages of limitations in ADLs on quality-adjusted life years (QALYs) and the relative severity of each ADL limitation for a large, nationally-representative sample of the U.S. community-dwelling older population. METHODS: Data were obtained from the Limited Dataset of the Medicare Health Outcomes Survey Cohort 15 (2012 baseline survey, 2014 follow-up survey). We included respondents aged ≥65 years (n = 105,473). We estimated expected QALYs throughout the remaining lifetime of participants stratified by the ADL limitation status and stages of ADL limitations. RESULTS: Overall, the expected QALYs was 5.6 years. QALYs decreased with increasing stages of ADL limitations. The adjusted QALYs for Stage 0 (no limitation) participants were 6.8; for Stage I (mild) participants, 3.9; for Stage II (moderate) participants, 2.2; for Stage III (severe) participants, 1.8; and for Stage IV (complete limitations) participants, 1.5. Differences in QALYs occurred between individual ADL items within an ADL stage. In Stage I, for example, participants who reported only problems with getting in or out of chairs had 6.7 QALYs which was markedly higher than participants who reported only problems with walking (3.8 QALYs). CONCLUSIONS: Our findings provide additional evidence that Stineman's ADL stages serve as valid estimates of the overall health of elderly Americans. Self-reported ADL status should be routinely collected as a patient-reported outcome in the elderly population.

Comparing the Performance of 2 Health Utility Measures in the Medicare Health Outcome Survey (HOS).

BACKGROUND: The Medicare Health Outcomes Survey (HOS), a nationwide annual survey of Medicare beneficiaries, includes the Centers for Disease Control and Prevention's HRQOL-4 questionnaire and Veterans RAND 12-item Health Survey (VR-12). This study compared EQ-5D scores derived from the HRQOL-4 (dEQ-5D) to SF-6D scores derived from VR-12. METHODS: Data were from Medicare HOS Cohort 15 (2012 baseline; 2014 follow-up). We included participants aged 65+ ( n = 105,473). We compared score distributions, evaluated known-groups validity, assessed each index as a predictor for mortality, and estimated quality-adjusted life years (QALYs) using the dEQ-5D and SF-6D. RESULTS: Compared to the SF-6D, the dEQ-5D had a higher mean score (0.787 v. 0.691) and larger standard deviation (0.310 v. 0.101). The decreases in estimated scores associated with chronic conditions were greater for the dEQ-5D than for the SF-6D. For example, dEQ-5D scores for persons with depression decreased 0.456 points compared to 0.141 points for the SF-6D. The dEQ-5D strongly predicted mortality, as adjusted hazard ratios for the first to fourth quintiles, relative to the fifth quintile, were 2.2, 1.7, 1.8, and 1.5, respectively, while the association between SF-6D and mortality was weaker or nonexistent (adjusted hazard ratios were 1.3, 1.1, 1.0, and 0.6, respectively). Compared to the SF-6D, QALYs estimated using the dEQ-5D were higher overall (5.6 v. 4.9 years), higher for persons with less debilitating conditions (e.g., hypertension, 5.0 v. 4.4 years), and lower for more debilitating conditions (e.g. depression, 2.5 v. 2.8 years). CONCLUSIONS: Compared to the SF-6D, the dEQ-5D was better able to measure individuals' overall health; detect the differential impact of chronic conditions, particularly among persons in poorer health; and predict mortality. The HRQOL-4 questionnaire may be valuable for monitoring and improving health outcomes for the Medical HOS data set.

Quality-adjusted Life Years (QALY) for 15 Chronic Conditions and Combinations of Conditions Among US Adults Aged 65 and Older.

BACKGROUND: Although the life expectancy for the US population has increased, a high proportion of this population has lived with ≥1 chronic conditions. We have quantified the burden of disease associated with 15 chronic conditions and combinations of conditions by estimating quality-adjusted life years (QALYs) for older US adults. RESEARCH DESIGN: Data were from the Medicare Health Outcomes Survey Cohort 15 (baseline survey in 2012, follow-up survey 2014, with mortality follow-up through January 31, 2015). We included individuals aged 65 years and older (n=96,481). We estimated mean QALY throughout the remainder of the lifetime according to the occurrence of these conditions. RESULTS: The age-adjusted QALY was 5.8 years for men and 7.8 years for women. Over 90% respondents reported at least 1 condition and 72% reported multiple conditions. Respondents with depression and congestive heart failure had the lowest age-adjusted QALY (1.1-1.5 y for men and 1.5-2.2 y for women), whereas those with hypertension, arthritis, and sciatica had higher QALY (4.2-5.4 and 6.4-7.2 y, respectively). Having either depression or congestive heart failure and any 1 or 2 of the other 13 conditions was associated with the lowest QALY among the possible dyads and triads of chronic conditions. Dyads and triads with hypertension or arthritis were more prevalent, but had higher QALY. CONCLUSIONS: Understanding the burden of disease for common chronic conditions and for combinations of these conditions is useful for delivering high-quality primary care that could be tailored for individuals with combinations of chronic conditions.

Measurement characteristics for two health-related quality of life measures in older adults: The SF-36 and the CDC Healthy Days items.

BACKGROUND: The Short Form Health Survey (SF-36) and the Centers for Disease Control and Prevention (CDC) Healthy Days items are well known measures of health-related quality of life. The validity of the SF-36 for older adults and those with disabilities has been questioned. OBJECTIVE: Assess the extent to which the SF-36 and the Centers for Disease Control and Prevention (CDC) Healthy Days items measure the same aspects of health; whether the SF-36 and the CDC unhealthy days items are invariant across gender, functional status, or the presence of chronic health conditions of older adults; and whether each of the SF-36's eight subscales is independently associated with the CDC Healthy Days items. METHODS: We analyzed data from 66,269 adult Medicare advantage members age 65 and older. We used confirmatory factor analyses and regression modeling to test associations between the CDC Healthy Days items and subscales of the SF-36. RESULTS: The CDC Healthy Days items were associated with the SF-36 global measures of physical and mental health. The CDC physically unhealthy days item was associated with the SF-36 subscales for bodily pain, physical role limitations, and general health, while the CDC mentally unhealthy days item was associated with the SF-36 subscales for mental health, emotional role limitations, vitality and social functioning. The SF-36 physical functioning subscale was not independently associated with either of the CDC Healthy Days items. CONCLUSIONS: The CDC Healthy Days items measure similar domains as the SF-36 but appear to assess HRQOL without regard to limitations in functioning.

Revisiting the Surveillance Epidemiology and End Results Cancer Registry and Medicare Health Outcomes Survey (SEER-MHOS) Linked Data Resource for Patient-Reported Outcomes Research in Older Adults with Cancer.

Researchers and clinicians are increasingly recognizing the value of patient-reported outcome (PRO) data to better characterize people's health and experiences with illness and care. Considering the rising prevalence of cancer in adults aged 65 and older, PRO data are particularly relevant for older adults with cancer, who often require complex cancer care and have additional comorbid conditions. A data linkage between the Surveillance Epidemiology and End Results (SEER) cancer registry and the Medicare Health Outcomes Survey (MHOS) was created through a partnership between the National Cancer Institute and the Centers for Medicare and Medicaid Services that created the opportunity to examine PROs in Medicare Advantage enrollees with and without cancer. The December 2013 linkage of SEER-MHOS data included the linked data for 12 cohorts, bringing the number of individuals in the linked data set to 95,723 with cancer and 1,510,127 without. This article reviews the features of the resource and provides information on some descriptive characteristics of the individuals in the data set (health-related quality of life, body mass index, fall risk management, number of unhealthy days in the past month). Individuals without (n=258,108) and with (n=3,440) cancer (1,311 men with prostate cancer, 982 women with breast cancer, 689 with colorectal cancer, 458 with lung cancer) were included in the current descriptive analysis. Given increasing longevity, advances in effective therapies and earlier detection, and population growth, the number of individuals aged 65 and older with cancer is expected to reach more than 12 million by 2020. SEER-MHOS provides population-level, self-reported, cancer registry-linked data for person-centered surveillance research on this growing population.