Implementation of a Community-Partnered Research Suicide-Risk Management Protocol: Case Study From Community Partners in Care.

OBJECTIVE: Suicidality is common among participants in clinical trials and health services research, but approaches to suicide risk assessment and mitigation vary widely. Studies involving vulnerable populations with limited access to care raise additional ethical concerns. The authors applied a community-partnered approach to develop and implement a suicide-risk management protocol (SRMP) in a depression study in an underresourced setting in Los Angeles. METHODS: Using a community-partnered participatory research framework, the authors designed and adapted the SRMP. Qualitative data regarding SRMP implementation included notes from SRMP development meetings and from study clinicians conducting outreach calls to study participants. Analyses included baseline and 6- and 12-month telephone survey data from 1,018 enrolled adults with moderate to severe depressive symptoms (8-item Patient Health Questionnaire score ≥10), of whom 48% were Black and 40% Latino. RESULTS: Community stakeholders prioritized a robust SRMP to ensure participant safety. Features included rapid telephone outreach by study clinicians in all cases of reported recent suicidality and expedited treatment access. Using a suicidality timeframe prompt of "in the past 2 weeks," endorsement of suicidality was common (15% at baseline, 32% cumulative). Midway through the study, the SRMP was modified to assess for present suicidality, which reduced the frequency of clinician involvement. Overall, 318 outreach calls were placed, with none requiring an emergency response. Treatment referrals were provided in 157 calls, and outreach was well received. CONCLUSIONS: SRMP implementation in research involving underresourced and vulnerable communities merits additional considerations. Partnering with community stakeholders can facilitate the development of acceptable and feasible SRMP procedures.

Assessing care of vulnerable elders--Alzheimer's disease: a pilot study of a practice redesign intervention to improve the quality of dementia care.

OBJECTIVES: To determine whether a practice redesign intervention coupled with referral to local Alzheimer's Association chapters can improve the quality of dementia care. DESIGN: Pre-post intervention. SETTING: Two community-based physician practices. PARTICIPANTS: Five physicians in each practice and their patients aged 75 and older with dementia. INTERVENTION: Adaptation of the Assessing Care of Vulnerable Elders (ACOVE)-2 intervention (screening, efficient collection of clinical data, medical record prompts, patient education and empowerment materials, and physician decision support and education). In addition, physicians faxed referral forms to local Alzheimer's Association chapters, which assessed patients, provided counseling and education, and faxed information back to the physicians. MEASUREMENTS: Audits of pre- (5 per physician) and postintervention (10 per physician) medical records using ACOVE-3 quality indicators for dementia to measure the quality of care provided. RESULTS: Based on 47 pre- and 90 postintervention audits, the percentage of quality indicators satisfied rose from 38% to 46%, with significant differences on quality indicators measuring the assessment of functional status (20% vs 51%), discussion of risks and benefits of antipsychotics (32% vs 100%), and counseling caregivers (2% vs 30%). Referral of patients to Alzheimer's Association chapters increased from 0% to 17%. Referred patients had higher quality scores (65% vs 41%) and better counseling about driving (50% vs 14%), caregiver counseling (100% vs 15%), and surrogate decision-maker specification (75% vs 44%). Some quality indicators related to cognitive assessment and examination did not improve. CONCLUSION: This pilot study suggests that a practice-based intervention can increase referral to Alzheimer's Association chapters and improve quality of dementia care.

Closing the dementia care gap: Can referral to Alzheimer's Association chapters help?

The quality of care provided by primary-care physicians for patients with dementia remains poor, in part because physicians do not provide counseling and education. Local Alzheimer's Association chapters have the potential to improve the quality of care provided for dementia, but are hampered by a lack of referrals from primary-care physicians. Many physicians remain unaware of the services available through Alzheimer's Association chapters, but recognize the need to provide support to families, ensure patient safety, and manage behavioral problems. At present, systems to promote referrals and communication with local chapters are lacking. Practice redesign may facilitate linkages between practices and Alzheimer's Association chapters. However, if these linkages are to be adopted and sustained, they must demonstrate a relative advantage to physicians beyond the care they currently provide, and must be compatible with how care is currently delivered in their practices.

The relationship between expectations for aging and physical activity among older adults.

BACKGROUND: New strategies to increase physical activity among sedentary older adults are urgently needed. OBJECTIVE: To examine whether low expectations regarding aging (age-expectations) are associated with low physical activity levels among older adults. DESIGN: Cross-sectional survey. PARTICIPANTS: Six hundred and thirty-six English- and Spanish-speaking adults aged 65 years and above attending 14 community-based senior centers in the Los Angeles region. Over 44% were non-Latino whites, 15% were African American, and 36% were Latino. The mean age was 77 years (range 65 to 100). MEASUREMENTS: Self-administered written surveys including previously tested measures of age-expectations and physical activity level in the previous week. RESULTS: Over 38% of participants reported <30 minutes of moderate-vigorous physical activity in the previous week. Older adults with lower age-expectations were more likely to report this very low level of physical activity than those with high age-expectations, even after controlling for the independent effect of age, sex, ethnicity, level of education, physical and mental health-related quality of life, comorbidity, activities of daily living impairment, depressive symptoms, self-efficacy, survey language, and clustering at the senior center. Compared with the quintile of participants having the highest age-expectations, participants with the lowest quintile of age-expectations had an adjusted odds ratio of 2.6 (95% confidence intervals: 1.5, 4.5) of reporting <30 minutes of moderate-vigorous physical activity in the previous week. CONCLUSIONS: In this diverse sample of older adults recruited from senior centers, low age-expectations are independently associated with very low levels of physical activity. Harboring low age-expectations may act as a barrier to physical activity among sedentary older adults.

The effects of megestrol acetate suspension for elderly patients with reduced appetite after hospitalization: a phase II randomized clinical trial.

OBJECTIVES: To provide preliminary evidence on the effectiveness and optimal dosage of megestrol acetate for older persons with impaired appetite after hospitalization. DESIGN: Randomized clinical trial. SETTING: Acute care hospital. PARTICIPANTS: Forty-seven older persons (mean age 83) who were recently discharged from an acute care hospital and had fair or poor appetite. INTERVENTION: Participants were randomized to placebo or megestrol acetate suspension 200 mg, 400 mg, or 800 mg daily for 9 weeks. MEASUREMENTS: Appetite, health-related quality of life, and adverse effects were measured at baseline and 20, 42, and 63 days. Serum nutritional markers were measured at baseline and 20 and 63 days. RESULTS: During the course of the study, there were no significant differences between treatment groups on any of the appetite questions, although participants in the 400-mg and 800-mg groups demonstrated significant improvement from baseline on some questions. At 20 days, prealbumin increased in a dose-response relationship across the four groups (by 0.4, 5.1, 7.5, and 9.0 mg/dL, respectively). Participants in the 400-mg and 800-mg groups demonstrated greater improvement in prealbumin levels at 20 days than those receiving placebo (P=.009 and P=.004, respectively) and those in the 400-mg group also demonstrated improvement at 63 days (P=.02). At 20 days, no participant taking placebo had a morning serum cortisol level less than 8 ng/mL (the lower limit of normal). In contrast, 33%, 70%, and 78% of those taking 200 mg, 400 mg and 800 mg, respectively, had values below this level; by 63 days, these percentages were 11%, 30%, 56%, and 37%, respectively. No patient reported clinical symptoms of adrenal insufficiency. Diarrhea developed in three subjects, and thromboembolism occurred in two receiving active treatment. CONCLUSION: Megestrol acetate at doses of 400 mg and 800 mg increases prealbumin in recently hospitalized older persons. Cortisol suppression is common at higher doses and may be persistent. In this small study, the drug did not confer benefit on other nutritional or clinical outcomes.

Refining the categorization of physical functional status: the added value of combining self-reported and performance-based measures.

BACKGROUND: When considered individually, self-reported functional status and performance-based functional status predict functional status decline and mortality. However, what additional prognostic information is gained by combining these approaches remains unknown. METHODS: The authors used three waves of three sites (5138 participants) of the Established Populations for Epidemiologic Studies of the Elderly to determine the prognostic value of individual and combined approaches. Baseline self-reported (mobility and activities of daily living [ADL] items) and performance-based (Physical Performance Score) functional status information was classified into three and four hierarchical categories, respectively. RESULTS: Based on self-reported information alone, at 1 year, 73% participants had not changed, 15% declined, 6% improved, and 6% died. At 4 years, 53% had not changed, 24% declined, 2% improved, and 22% died. Based on performance-based assessment alone, at 4 years, 33% of the sample remained stable, 37% declined, 6% improved, and 24% died. In the top two self-reported categories, functioning on the performance-based assessment varied widely. Among those who were independent in all self-reported functioning, approximately 40% scored in each of the top two performance-based categories. Among persons in the top two self-reported categories, poorer performance was associated with progressively higher 1-year and 4-year mortality rates. Among persons with impaired mobility and at least 1 ADL dependency, the mortality rate was high and was not influenced by performance-based score. CONCLUSIONS: Combining self-reported and performance-based measurements can refine prognostic information, particularly among older persons with high self-reported functioning. However, if ADL dependency is present, performance-based measures do not add prognostic value regarding mortality.

Cognitive decline in high-functioning older persons is associated with an increased risk of hospitalization.

OBJECTIVES: To examine hospital use for patients with evidence of cognitive decline indicative of early cognitive impairment. DESIGN: Medicare Part A hospital utilization data were linked to data from the MacArthur Research Network on Successful Aging Community Study to examine the association between baseline cognition and decline in cognitive function over a 3-year period and any hospitalization over that same period. SETTING: New Haven, Connecticut, and East Boston, Massachusetts. PARTICIPANTS: Subjects (N=598) were from two sites of the MacArthur Research Network on Successful Aging Community Study, a 7-year cohort study of community-dwelling older persons with high physical and cognitive functioning. MEASUREMENTS: Multivariate logistic regression was used to determine the association between any hospitalization over 3 years (1988-91) as the outcome variable and baseline cognitive function and decline in cognition over 3 years as primary predictor variables. Decline was based upon repeated (1988 and 1991) measures of delayed verbal recall and the Short Portable Mental Status Questionnaire (SPMSQ). RESULTS: Of 598 subjects, 48 died between 1988 and 1991. No baseline (1988) delayed recall scores or change in recall scores (1988-91) were associated with hospitalization. Although 48.2% declined on verbal memory scores, decline was not associated with risk of hospitalization. Of 494 subjects with complete 3-year data, 31.2% declined at least one point on the SPMSQ, and 4.7% declined more than two points. Among individuals aged 75 and older at baseline, the adjusted odds ratio for hospitalization for those who declined more than 2 points compared with those who declined less was 7.8 (95% confidence interval=2.0-30.8). CONCLUSION: Although specific memory tests were not associated with hospitalization, high-functioning older persons who experienced decline in overall cognitive function were more likely to be hospitalized. Variation in baseline cognitive function in this high-functioning cohort did not affect hospitalization, but additional research is needed to evaluate associations with other healthcare costs.

The effect of self-reported and performance-based functional impairment on future hospital costs of community-dwelling older persons.

PURPOSE: We determined the prognostic value of self-reported and performance-based measurement of function, including functional transitions and combining different measurement approaches, on utilization. DESIGN AND METHODS: Our cohort study used the 6th, 7th, and 10th waves of three sites of the Established Populations for Epidemiologic Studies of the Elderly, linked to 1- and 4-year Medicare Part A hospital costs. We examined mean hospital expenditures based on (a) 1- and 4-year transitions in self-reported functional status; (b) 4-year transitions in performance-based functional status; (c) combined baseline self-reported and performance-based functional status; and (d) poorest self-reported and performance-based functional status during a 4-year period. RESULTS: Even modest declines in self-reported or performance-based functional status were associated with increased expenditures. When baseline self-reported and performance-based assessments were combined, mean 1- and 4-year adjusted costs were higher with progressively worse performance-based scores, even among those who were independent in self-reported function. When the poorest 4-year self-reported and performance-based functions were examined, self-reported functioning was the most important determinant of hospital costs, but within each self-reported functional level, poorer performance-based function was associated with progressively higher costs. IMPLICATIONS: The costs associated with even modest functional decline are high. Combining self-reported and performance-based measurements can provide more precise estimates of future hospital costs.

Identification of risk for high hospital use: cost comparisons of four strategies and performance across subgroups.

OBJECTIVES: To determine the relative costs of four risk-identification strategies and compare their performance in predicting hospital use by different subgroups of older persons based on age, sex, and prior hospital use. DESIGN: Prospective validation study and cost-comparison analysis. SETTING: Community-based. PARTICIPANTS: Five thousand one hundred thirty-eight participants of the sixth wave of three sites of the Established Populations for Epidemiologic Studies of the Elderly. MEASUREMENTS: Four strategies (prior hospitalization data only, a 10-item self-report screen alone, self-report combined with two laboratory tests, and sequential self-report plus as-needed use of laboratory tests when the self-report screen is inconclusive) and 3-year Medicare Part A hospital cost data. RESULTS: Assuming that interventions based on screening would yield a total benefit of $1,000 per true-positive case and a cost of $400 for each false-positive case, the sequential strategy was slightly less expensive than the self-report only strategy; both were considerably less expensive than the combined or hospitalization-only strategies. Accuracy as measured by the area under the receiver operating characteristic curve for the sequential strategy was comparable for all subgroups (between 0.62 and 0.70) but was least accurate for those who had high prior use and for those aged 85 and older. CONCLUSION: A sequential screening strategy that administers laboratory tests selectively is slightly less expensive than one that uses only self-report items. This strategy is also accurate in both sexes, in those with various degrees of prior use, and in the oldest old.

A randomized clinical trial to assess the benefit of offering on-site mobile mammography in addition to health education for older women.

OBJECTIVE: We conducted a cluster randomized clinical trial to compare the benefit of offering on-site mobile mammography in addition to an outreach program designed to increase mammography use by educating patients. SUBJECTS AND METHODS: We recruited a consecutive volunteer sample of 499 women ranging in age from 60 to 84 years who had not undergone mammography in the previous year to participate in a cluster randomized clinical trial about the benefit of on-site mobile mammography. Subjects were recruited from 60 community-based sites where seniors gather. The intervention included a structured on-site multicomponent educational program with or without available on-site mobile mammography. The primary outcome measure was self-reported receipt of mammography within 3 months of the intervention. RESULTS: Women in the group offered access to on-site mammography and health education were significantly more likely than those in the group offered health education only to undergo mammography within 3 months (55% vs 40%, p = 0.001; adjusted [for clustering] odds ratio, 1.83; 95% confidence interval, 1.22-2.74). Gains from offering on-site mammography were shown for several ethnic and sociodemographic subgroups and were especially large for Asian American women. CONCLUSION: Offering on-site mammography at community-based sites where older women gather is an effective method for increasing breast cancer screening rates among older women and may be particularly effective for some subgroups of women who traditionally have had low screening rates.

Development of a method to identify seniors at high risk for high hospital utilization.

BACKGROUND: A small percentage of older persons account for most Medicare costs. If persons at high risk for high health care utilization can be identified, resources can be directed to improve their health care and reduce utilization. OBJECTIVE: To develop an efficient and economical approach to identifying older persons at risk for high future health care utilization. DESIGN: Validation cohort. SETTING: Three communities. SUBJECTS: Five thousand one hundred thirty-eight community-dwelling persons aged 71 years or older. MAIN OUTCOME MEASURES: High utilization (defined as >or=11 hospital days during 3 years) and overall Part A Medicare hospital costs during 3 years. RESULTS: Predictive multivariable models were created that relied on prior hospitalization only, self-report only, and combined self-report and physical examination/lab data. Ten self-report items (hospitalizations in prior year and year before that, male gender, fair/poor health, not working, infrequent religious participation, needing help bathing, unable to walk 1/2 mile, diabetes, and taking loop diuretics) and two lab tests (low serum albumin and iron) remained as independent predictors of high utilization. Based upon these variables, approximately 1/4 of the population was identified as being at high risk (>or=0.28 probability) for high health care utilization and those identified accounted for approximately half of all Medicare Part A costs for the entire population. Finally, a two-phase strategy was developed in which tests are only administered to individuals whose risk cannot be adequately determined by self-report variables (approximately 1/4 of subjects). CONCLUSIONS: Simple questions and laboratory tests can accurately and efficiently identify seniors at high risk for high health care utilization.