Qualitative research for the study of cancer and age.

Qualitiative research emphasizes identification, illumination, and understanding of phenomena, the meaning and theory behind which are unpresumed by the investigator. Although quantitative techniques are used to test predetermined hypotheses, qualitative techniques are used to generate hypotheses. Qualitative techniques have only begun to be used in medical research in the past decade but are especially useful in exploring content areas about which little is known and in eliciting and understanding the patient's perspective. Despite the aging of the United States population, the cancer illness experience has not been well studied in older patients. Because communication preferences, treatment decision-making styles, psychosocial issues, and the illness experience itself may be significantly different for older persons diagnosed with cancer than for younger persons, qualitative research techniques can be used to identify those differences critical to the effective health care of this burgeoning population.

Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence.

BACKGROUND: Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option. OBJECTIVES: To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence. SUBJECTS: Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions. MEASURES: In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention. RESULTS: The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600. CONCLUSIONS: The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.

Coping with breast cancer in later life: the role of religious faith.

PURPOSE: To identify and examine religious and spiritual coping strategies among elderly women with newly diagnosed breast cancer. METHODS: A convenience sample of 33 women age 65 years was recruited within 6 months of diagnosis. Respondents participated in a structured interview with open-ended questions. Transcripts of the interviews were analysed independently by three researchers and themes were discussed until consensus was reached. RESULTS: Participants' religious background was varied: 17 Protestant, five Catholic, six Jews, and four Other. There was great variation in the frequency of religious service attendance. Religious and/or spiritual belief either increased or stayed the same during the time of health crisis. Analysis of transcripts revealed three themes. Religious and spiritual faith provided respondents with the emotional support necessary to deal with their breast cancer (91%), with social support (70%), and with the ability to make meaning in their everyday life, particularly during their cancer experience (64%). CONCLUSIONS: Religious and spiritual faith provides elderly women newly diagnosed with breast cancer with important tools for coping with their illness and should be recognized by diagnosing physicians. It may be important to encourage these patients to seek religious support and/or to reconnect with their religious community.

A randomized controlled trial of facilitating information giving to patients with chronic medical conditions: effects on outcomes of care.

BACKGROUND: The purpose of this study was to assess the impact of an intervention to facilitate information giving to patients with chronic medical conditions on outcomes of care. METHODS: A consecutive sample of 276 eligible patients with chronic medical conditions at a family medicine clinic was randomized to control and experimental interventions. A total of 205 completed the study. Experimental group patients received copies of their medical record progress notes, and they completed question lists for physician review, while control group patients received health education sheets and completed suggestion lists for improving clinic care. Self-reported physical functioning, global health, and patient satisfaction and adherence were measured at enrollment and after the interventions. Visit lengths and patient response to medical record sharing after the interventions were also measured. RESULTS: After the intervention, experimental group patients reported 3.7% better overall physical functioning than did control patients (mean = 83.6, standard deviation [SD] = 17.6 vs mean = 79.9, SD = 25.3; P = .005 after adjusting for covariates). The experimental group was more satisfied with their physician's care (mean = 31.4, SD = 4.6 vs mean = 31.3, SD = 5.2; P = .045 after adjusting for covariates). They were also more interested in seeing their medical records than were control patients (mean = 12.0, SD = 2.8 vs mean = 11.2, SD = 2.8; P = .002 after adjusting for covariates). Experimental group patients also reported an 8.3% improvement in overall health status (postintervention mean = 3.0, SD = 1.1) compared with their pre-intervention health status (mean = 2.8, SD = 1.0; P =.001). Visit lengths for patients in the experimental group did not differ from those of the control group. CONCLUSIONS: A simple patient-centered intervention to facilitate information giving in the primary health care of patients with chronic medical conditions can improve self-reported health, physical functioning, and satisfaction with care.

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations.

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

Perceived efficacy in patient-physician interactions (PEPPI): validation of an instrument in older persons.

OBJECTIVE: To develop and validate a brief instrument--the Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI)--to measure older patients' self-efficacy in obtaining medical information and attention to their medical concerns from physicians. DESIGN: Two consecutive validation surveys. SETTING: Eleven senior multipurpose centers in Los Angeles County California. POPULATION: A convenience sample of 163 community-dwelling older persons (Survey 1: n=59, mean age=77.1 years, 76.3% female; Survey 2: n=104, mean age=77.4 years, 57.7% female). MEASURES: The 10-item PEPPI, subscales of the Patient Satisfaction Questionnaire, the Medical Outcomes Study (MOS) Coping Scale, the Mastery Scale, and global self-reported health and restricted activity days items. RESULTS: The full 10-item and a 5-item short form of PEFPI demonstrated Cronbach's alphas of 0.91 and 0.83, respectively. PEPPI demonstrated discriminant and convergent validity as hypothesized, correlating negatively with avoidant coping (r=-.27, P=.001) and positively with active coping (r=.17, P=.03) and with patient satisfaction with physician interpersonal manner (r=.49, P < .0001) and communication (r=.51, P < .0001) (values from the overall sample). Further, in the second survey, PEPPI correlated positively with self-reported health (r=.42, P < .0001), education (r = .24, P=.01) and self-mastery (r=.29, P=.01) and negatively with restricted activity days (r=-.25, P=.01). PEPPI-5 demonstrated correlations similar in magnitude, direction, and statistical significance. CONCLUSION: In either the 5- or 10-item version, PEPPI is a valid and reliable measure of older patients' perceived self-efficacy in interacting with physicians. This instrument may be useful in measuring the impact of empowerment interventions to increase older patients' personal sense of effectiveness in obtaining needed health care.

The performance of simple instruments in detecting geriatric conditions and selecting community-dwelling older people for geriatric assessment.

BACKGROUND: comprehensive geriatric assessment (CGA) appears to be less effective when performed in outpatient clinics than in hospital settings. The effectiveness of outpatient CGA might be improved by selectively targeting frailer community-dwelling elderly people. The purpose of this study was to evaluate the clinical performance of rapidly-administered standard screening measures for geriatric syndromes in selecting community-dwelling older people for outpatient CGA. METHODS: urban-dwelling older people were screened for CGA at community sites using a self-administered questionnaire containing standardized measures for each of four geriatric target conditions: depression, urinary incontinence, falls and functional impairment. The study sample included all 150 consecutive subjects who were screened, failed on one or more of the four target criteria and completed community-based, academically administered CGA. Diagnostic accuracy of the screening instruments was assessed using CGA diagnoses as the 'gold standard'. In addition, patients' potential for benefiting from CGA was determined by whether they received major medical recommendations for further evaluation or treatment. RESULTS: after completing CGA, 60.2% of those failing on functional impairment, 53.5% of those failing on depression, 30.7% of those failing on falls and 92.7% of those on urinary incontinence, were confirmed as having these or highly related conditions as clinical problems. Overall, 81.3% of the subjects completing CGA received the least one major recommendations for further medical intervention; most of these recommendations (79.5%) were for a target-related condition and the further remainder (20.5%) addressed another significant medical condition. CONCLUSION: simple screening instruments used in community settings have variable degrees of accuracy, but may be markers for frailty and thus can identify older people likely to benefit from geriatric assessment.

Managing geriatric syndromes: what geriatric assessment teams recommend, what primary care physicians implement, what patients adhere to.

OBJECTIVES: To evaluate the responses of primary care physicians and patients to recommendations from a community-based comprehensive geriatric assessment (CGA) program for management of four target conditions: falls, depression, urinary incontinence, and functional impairment. DESIGN: Case series. SETTING: Senior centers, meal sites, senior housing, and other community sites as screening locations; and a community-bases academic practice as the location for CGA. PARTICIPANTS: A total of 150 older patients living in the community who have one or more of the four target conditions and who received CGA. MEASUREMENTS: Physician implementation and patient adherence rates were ascertained during a face-to-face structured interview with the patient 3 months after CGA. RESULTS: Two hundred twelve of 528 (40%) CGA recommendations were clearly or possible related to the target or target-related conditions. Of these 212 recommendations, 59% required a physician's order for implementation. The remaining 41% were patient self-care recommendations. Overall physician implementation across conditions was 70%; implementation rates were highest for falls and lowest for functional impairment. Overall patient adherence rate was 85% for physician-implemented recommendations and 46% for self-care recommendations. Patient adherence to recommendations for counseling or support groups and exercise programs was particularly low. CONCLUSIONS: When examining the process of care of community-based CGA, patient as well as physician adherence must be considered. Although patient adherence to physician-initiated recommendations was high for all conditions, it varied substantially across target conditions and types of recommendations for self-care recommendations.

The Prevention for Elderly Persons (PEP) Program: a model of municipal and academic partnership to meet the needs of older persons for preventive services.

OBJECTIVE: To create a program to identify preventive needs for community-dwelling older persons and incorporate intervention strategies to improve implementation of these services. DESIGN: Program development and case-series. SETTING: Community-based meal sites, academically administered program. PARTICIPANTS: Persons 60 years of age or older attending meal sites and their primary care physicians. MEASUREMENTS: Demographic characteristics, self reported preventive health behaviors and services, blood pressure measurement. RESULTS: During the first 2 years of the program, 927 persons 60 years of age or older were screened. The most common physician-initiated preventive recommendations were: tetanus booster (72%), aspirin prophylaxis (68%), pneumonia vaccination (61%), and colorectal cancer screening (51%). The most common self-care recommendations have been: calcium supplementation (54% of women) and breast self examinations (51% of women). As part of the adherence intervention, we were able to complete health educator calls for 600 (65%) subjects. In addition, the physicians of 599 (65%) subjects were contacted either by telephone (n = 496) or by letter only (n = 97). CONCLUSION: A community based preventive services program can identify large numbers of unmet preventive services needs, and a dual intervention strategy aimed at meeting these needs can be delivered successfully to the majority of participants. Implementation rates of specific recommendations and impacts on health outcomes remain to be determined.

What influences physician practice behavior? An interview study of physicians who received consultative geriatric assessment recommendations.

BACKGROUND: Comprehensive geriatric assessment (CGA) in outpatient settings has not been shown to be as effective in reducing mortality and improving health as in hospital settings; this difference has been attributed in part to a lack of direct control over recommendation implementation. OBJECTIVE: To identify inhibiting and facilitating factors in physicians' compliance with consultative CGA recommendations, so that the effectiveness of outpatient CGA might be improved. METHODS: A 49-item questionnaire was administered via the telephone to 87 eligible community primary care physicians in Los Angeles, Calif, whose patients had received consultative outpatient CGAs as part of a study of CGA (response rate, 96%). The questionnaire assessed physician compliance with CGA recommendations, reasons for implementing or not implementing the recommendations, and specific physician attitudes, perceptions, and characteristics. The focus of the interview was the CGA recommendation that was determined to be the "most important" by the evaluating geriatrician. Recommendations addressed geriatric syndromes, general medical problems, or psychiatric conditions. RESULTS: Of the 87 physician respondents, 62 (71%) implemented the most important recommendation. In multivariate analysis, 4 variables were predictive of physician compliance: (1) a patient's request that the recommendation be implemented (odds ratio [OR], 10.8; 95% confidence interval [CI], 1.9-61.3; P = .007); (2) perceived legal liability resulting from nonimplementation of the recommendation (OR, 10.8; 95% CI, 1.1-108.2; P = .04); (3) female physician gender (OR, 9.6; 95% CI, 1.4-67.9; P = .04); and (4) perceived cost-effectiveness of the recommendation (OR, 7.0; 95% CI, 1.6-30.5; P = .01). CONCLUSIONS: Patient behavior, which may be modifiable, was among the strongest determinants of physician compliance with recommended care. Specifically, when patients requested that a recommendation be implemented, physicians were highly likely to comply. Changing patient behavior within the physician-patient relationship as a way of effecting desired changes in physician health care practices merits further attention.

Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment.

PURPOSE: The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence. PATIENTS AND METHODS: One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients. RESULTS: Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7). CONCLUSIONS: These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".

Recognition and treatment of substance abuse in the elderly.

Elderly people do use substances to alter mood and states of awareness. Detection is difficult because presenting symptoms are often those that are commonly associated with aging itself. All patients who present with symptoms of self-neglect, falls, cognitive and affective impairment, and social withdrawal should be screened for substance abuse. The CAGE and MAST, although not perfect, can be used. When abuse is found, the elderly should be treated as aggressively as their younger counterparts, with slow, careful detoxification and the use of some form of group therapy, such as AA.

Early recognition of chemical dependence.

Chemical dependence is a leading cause of morbidity and death in the United States. At least 20% of patients seen by primary care physicians in both the outpatient and inpatient setting are chemically dependent. Up to 90% of these patients go undiagnosed by their primary physicians. Chemical dependence is defined as a chronic, progressive illness characterized by the repeated and persistent use of alcohol or drugs despite negative health, family, work, financial, or legal consequences. Primary care physicians are in an ideal position to detect chemical dependence at its earliest stages, when irreversible medical consequences and death are most likely preventable. Alcohol is the most common drug of abuse. Improving the rate of recognition of chemical dependence depends on being familiar with the constellation of physical, mental, and social indicators. Early medical manifestations of alcoholism common in the primary care setting include: gastric complaints, elevated blood pressure, palpitations, traumatic injuries, headaches, impotence, and gout. Early psychosocial manifestations common in both alcohol and drug dependence include anxiety, depression, insomnia, persistent relationship conflicts, work or school problems, and financial or legal problems. Particularly useful laboratory indicators of alcoholism include elevated levels of GGT and MCV, both displaying high specificity, with the GGT level being the most sensitive. Similarly specific laboratory tests for drug dependence are not available. Any patient presenting with any of the above medical, psychosocial, or laboratory manifestations should be screened for chemical dependence. The CAGE questionnaire for alcoholism, a four-question test, is particularly well suited to the primary care setting, where it can be administered in fewer than 60 seconds. The CAGE has demonstrated high sensitivity (in the 80% range) and specificity (approximately 85%) for alcoholism. Comparably convenient instruments do not yet exist for drug dependence, although a 28-item instrument, the DAST (Drug Abuse Screening Test), has demonstrated high sensitivity and specificity for drug abuse.