Military service and mental health in later life.

This study sought to determine if the self-assessed mental health of older, community-dwelling veterans differs from that of older nonveterans controlling for known demographic, socioeconomic, and clinical covariates of health and well-being. Participants are the older male respondents (65+ years) to the Medical Expenditure Panel Survey (Round 1), conducted in 1996 (N = 1,068). In bivariable analyses using population weights, veterans were significantly less likely than nonveterans to report their mental health as fair to poor. However, when demographic, socioeconomic, and health-related characteristics were controlled, no statistically significant difference in self-assessed mental health was detected between veterans and nonveterans. Military service per se is not a risk factor for poorer self-appraised mental health in old age. Nor does military service confer protection from late-life deficits in mental health. Rather, mental health in later life is largely a function of an individual's health and socioeconomic status.

Stroke rehabilitation outcome variation in Veterans Affairs rehabilitation units: accounting for case-mix.

OBJECTIVE: To assess variation in stroke outcomes and create a case-mix adjustment model for stroke rehabilitation in Veterans Affairs Medical Centers. DESIGN: Observational SETTING AND PATIENTS: Within Veteran's Health Administration hospitals, there are 63 acute rehabilitation bedservice units that care for approximately 2,000 stroke patients annually. MAIN OUTCOME MEASURES: Functional gain in FIM points, length of stay (LOS), LOS efficiency (FIM gain/LOS). RESULTS: Significant variation in average patient functional gain, LOS, and LOS efficiency was observed among the 37 highest-volume rehabilitation units. Using analysis of covariance, a model was developed that adjusted functional gain and LOS (logged LOS) unit means using 10 potential covariates identified in a literature review and in pilot studies. Four and six covariates, respectively, were retained in the final models for FIM gain and LOS. The R2 for FIM gain and LOS accounted for by rehabilitation unit alone increased from .07 to .31 (FIM gain) and from .13 to .34 (logLOS) with the addition of the significant covariates to each model. CONCLUSIONS: As much as 24% of the variation in two important stroke rehabilitation outcomes is attributable to largely immutable patient and system characteristics (eg, patient function on admission, age, days since stroke onset, year of discharge, marital status, and referral source). Hence, controlling for case-mix is critical for accurate comparison of unit outcomes. Further, the variation in LOS efficiency between VA rehabilitation units suggests a large potential for cost and resource utilization savings system-wide.

Does geriatric evaluation and management improve the health behavior of older veterans in psychological distress?

A randomized, controlled trial compared prospective 16-month health service use among 160 frail, elderly veterans receiving outpatient geriatric evaluation and management (GEM) or usual primary care (UPC). In this secondary analysis, multivariable regression was used to determine if the psychosocial assessment and support provided by the GEM team moderated the use of medical services by patients in psychological distress. The results indicate that GEM reduced outpatient use among patients who scored higher on a measure of somatization (p less than or equal to .05), but GEM increased outpatient use among patients with higher manifest anxiety (p less than or equal to .05) Psychological distress was not a factor in the use of inpatient services. GEM had a modest beneficial effect on the health behavior of frail older persons manifesting some symptoms of psychological distress.

Stroke rehabilitation management in the Department of Veterans Affairs: impact of patient referral source on outcomes.

OBJECTIVE: To assess the relation between the source of stroke patients' referral to the rehabilitation unit and rehabilitation outcome. DESIGN: Multivariate analysis of rehabilitation outcomes prospectively collected and supplemented by data from Department of Veterans Affairs (VA) administrative records. SETTING: Fifty-three hospital-based VA rehabilitation units located nationwide. PATIENTS: A total of 2,031 first-admission stroke patients discharged from VA rehabilitation units in fiscal years 1993-1994. INTERVENTIONS: Observational study. OUTCOME MEASURES: Functional Independence Measure (FIM) at admission, gains in motor and cognitive function, rehabilitation length of stay (LOS), and the probability of discharge to home. RESULTS: Controlling for clinical, demographic, and unit characteristics, referral source predicted admission function, LOS, and home discharge (p < or = .0001), but did not predict motor or cognitive gain (p > .05). Patients referred from long-term care and other acute hospitals (Acute Other) had significantly lower adjusted admission FIM scores than patients referred directly from home (respectively, 12.9 and 17.0 FIM units lower), and from the acute care services of the VA hospital providing rehabilitation (4.8 and 8.9 units lower). Acute Other referrals had longer risk-adjusted LOS than referrals from any other source (4.6 to 6.4 days longer), and patients from both Acute Other and long-term care had a lower probability of home discharge than the remaining two referral groups (reduction in probability range: .06 to .27). CONCLUSION: VA administrators and clinicians need to consider referral source when evaluating and comparing unit performance in stroke rehabilitation. Patients referred from Acute Other and long-term care settings may require more intensive management to offset their functional and social deficits, and to reduce LOS and increase home discharge rates. Referral source also identified highly functional patients who possibly could be cared for approximately in less costly rehabilitation settings. These issues warrant further research especially as the VA seeks to achieve cost savings in this era of reduced funding.

Outpatient geriatric evaluation and management: is there an investment effect?

The effectiveness and efficiency of outpatient geriatric evaluation and management (GEM) was compared to usual outpatient primary care (UPC). Although GEM had no overall impact on health care utilization or cost of care for the entire study period, significant reductions were found during the sixteen- to twenty-four-month study period, suggesting a possible investment effect. In the first eight months of the study, GEM patients incurred 34.8% more in health care costs than UPC patients, but in the final eight months of the study the cost of care for UPC patients exceeded that for GEM patients by 37.8%.

The effectiveness and efficiency of outpatient geriatric evaluation and management.

OBJECTIVE: To compare the effectiveness of geriatric evaluation and management (GEM) with usual primary care (UPC). DESIGN: A 2 x 3 randomized controlled group design. SETTING: A 450-bed Department of Veterans Affairs Medical Center (VAMC) that provides general medical and surgical care to eligible veterans. PARTICIPANTS: One-hundred sixty male subjects (mean age = 72 years), who were above average users of VAMC outpatient clinics and who had at least two Activity of Daily Living (ADL) or Instrumental Activity of Daily Living (IADL) impairments, were assigned to GEM (n = 80) or UPC (n = 80). MEASUREMENTS: Data were collected about patients' (1) health and functional status, (2) psychosocial well-being, (3) quality of health and social care, (4) health care utilization, and (5) health care costs. Data were obtained before randomization, and again at 8 and 16 months. RESULTS: The results indicated that GEM was more effective than UPC in improving some aspects of the quality of health and social care and in increasing patient satisfaction with care. GEM also reduced emergency room use, and showed a trend toward decreasing acute admissions. It was not effective, however, in improving patients' psychosocial well-being. Except for a short-term survival advantage, it was also not effective in preventing deterioration in their health and functional status. Further, GEM did not reduce overall utilization of outpatient or inpatient services, and it significantly increased total outpatient health care costs. CONCLUSIONS: Outpatient GEM improves patient satisfaction and some aspects of the quality of care patients' receive but does not reduce the cost of outpatient or inpatient care. Longer-term follow-up studies are needed to determine whether reductions in emergency room use and inpatient admissions persist over time and result in reductions in the overall cost of care.

Outpatient geriatric evaluation and management. Results of a randomized trial.

The effectiveness and efficiency of outpatient geriatric evaluation and management (GEM) was compared with usual outpatient primary care (UPC). One hundred sixty frail elderly outpatients were assigned randomly to GEM or UPC and assessed at baseline and at 8 months on measures of (1) health and functional status, (2) psychosocial well-being, (3) quality of health and social care, (4) use of inpatient and outpatient services, and (5) cost of care. The results indicate that GEM was significantly more effective than UPC in reducing mortality, increasing patient satisfaction, and improving the quality of health and social care. However, it was not effective in reducing health care use or the cost of care.