Patient Satisfaction and Perceived Quality of Care Among Younger Medicare Beneficiaries According to Activity Limitation Stages.

OBJECTIVE: To examine the association between activity limitation stages and patient satisfaction and perceived quality of medical care among younger Medicare beneficiaries. DESIGN: Cross-sectional study. SETTING: Medicare Current Beneficiary Survey (MCBS) for calendar years 2001-2011. PARTICIPANTS: A population-based sample (N=9323) of Medicare beneficiaries <65 years of age living in the community. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physician (PCP), interpersonal skills of PCP, and quality of information provided by PCP. Persons were classified into an activity limitation stage (0-IV) which was derived from self-reported difficulty performing activities of daily living (ADL) and instrumental activities of daily living (IADL). RESULTS: Compared to beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (95% confidence intervals) for stage I (mild) to stage IV (complete) for satisfaction with access barriers ranged from 0.62 (0.53-0.72) at stage I to a minimum of 0.31 (0.22-0.43) at stage IV. Similarly, compared to beneficiaries at IADL stage 0, satisfaction with access barriers ranged from 0.66 (0.55-0.79) at stage I to a minimum of 0.36 (0.26-0.51) at stage IV. Satisfaction with care coordination and quality and perceived quality of medical care were not associated with activity limitation stages. CONCLUSIONS: Younger Medicare beneficiaries with disabilities reported decreased satisfaction with access to medical care, highlighting the need to improve access to health care and human services and to enhance workforce capacity to meet the needs of this patient population.

Functional Impairments Associated With Patient Activation Among Community-Dwelling Older Adults.

OBJECTIVES: Activity of daily living stages and instrumental activity of daily living stages demonstrated ordered associations with mortality, risk of hospitalization, and receipt of recommended care. This article explores the associations of stages with the following three dimensions of patient activation: self-care efficacy, patient-doctor communication, and health-information seeking. We hypothesized that higher activity of daily living and instrumental activity of daily living stages (greater limitation) are associated with a lower level of patient activation. METHODS: Patient activation factors were derived from the 2004 and 2009 Medicare Current Beneficiary Survey. In this cross-sectional study (N = 8981), the associations of activity limitation stages with patient activation factors were assessed in latent factor models. RESULTS: Greater activity limitation was in general inversely associated with self-efficacy, patient-doctor communication, and health information seeking, even after adjusting for sociodemographic and clinical characteristics. For instance, the mean of self-care efficacy across activity of daily living stages I-IV (mild, moderate, severe, and complete limitation) compared with stage 0 (no limitation) decreased significantly by 0.17, 0.29, 0.34, and 0.60, respectively. Covariates associated with suboptimal patient activation were also identified. DISCUSSION: Our study identified multiple opportunities to improve patient activation, including providing support for older adults with physical impairments, at socioeconomic disadvantages, or with psychological or cognitive impairment.

Preventable hospitalizations, barriers to care, and disability.

The AHRQ's Prevention Quality Indicators assume inpatient hospitalizations for certain conditions, referred as ambulatory-care sensitive (ACS) conditions, are potentially preventable and may indicate reduced access to and a lower quality of ambulatory care. Using a cohort drawn from the Medicare Current Beneficiary Survey (MCBS) linked to Medicare claims, we examined the extent to which barriers to healthcare are associated with ACS hospitalizations and related costs, and whether these associations differ by beneficiaries' disability status. Our results indicate that the regression-adjusted cost of ACS hospitalizations for elderly Medicare beneficiaries with no disabilities was $799. This cost increased six-fold, by $5148, among beneficiaries with mild disability, by $9045 for beneficiaries with moderate disability, by $5513 for those with severe disability, and by $8557 for persons with complete disability (P < 0.001). Persons reporting having foregone or delayed needed medical care because of financial difficulties (+$2082, P = .05), those experiencing low satisfaction with care coordination (+$1714, P = .01), and those reporting low satisfaction with access to care (+$1237, P = .02) also incurred significant excess ACS hospitalization costs relative to persons reporting no such barriers. This pattern held true for those with and without a disability, but were especially marked among persons with no functional limitations. These findings suggest that a better understanding of how public policy might effectively improve care coordination and reduce financial barriers to care is essential to formulating programs that reduce excess hospitalizations among the large and growing number of elderly Medicare beneficiaries.

Premorbid Activity Limitation Stages Are Associated With Posthospitalization Discharge Disposition.

OBJECTIVE: Activity of daily living stages and instrumental activity of daily living stage have demonstrated associations with mortality and health service use among older adults. This cohort study aims to assess the associations of premorbid activity limitation stages with acute hospital discharge disposition among community-dwelling older adults. DESIGN: Study participants were Medicare beneficiaries aged 65 yrs or older who enrolled in the Medicare Current Beneficiary Survey between 2001 and 2009. Associations of premorbid stages with discharge dispositions were estimated with multinomial logistic regression models adjusted for covariates. RESULTS: The proportions of elderly Medicare patients discharged to home with self-care, home with services, postacute care facilities, and other dispositions were 59%, 15%, 19%, and 7%, respectively. The following adjusted relative risk ratios and 95% confidence intervals of postacute care facilities versus home with self-care discharge increased with higher premorbid activity limitation stages (except nonfitting stage III): 1.7 (1.5-2.0), 2.4 (2.0-2.9), 2.4 (1.9-3.0), and 2.5 (1.6-4.1) for activity of daily living stages I-IV; a similar pattern was found for instrumental activity of daily living stages. The adjusted relative risk ratios of discharge to home with services also increased with higher premorbid activity limitation stages compared with no limitation. CONCLUSIONS: Routinely assessed activity limitation stages predict posthospitalization discharge disposition among older adults and may be used to anticipate postacute care and services use by elderly Medicare beneficiaries.

Improving Access to Collaborative Behavioral Health Care for Rural-Dwelling Older Adults.

OBJECTIVE: This study examined whether a telephone-delivered collaborative care intervention (SUpporting Seniors Receiving Treatment And INtervention [SUSTAIN]) improved access to mental health services similarly among older adults in rural areas and those in urban-suburban areas. METHODS: This cohort study of 8,621 older adults participating in the SUSTAIN program, a clinical service provided to older adults in Pennsylvania newly prescribed a psychotropic medication by a primary care or non-mental health provider, examined rural versus urban-suburban differences in rates of initial clinical interview completion, patient clinical characteristics, and program penetration. RESULTS: Participants in rural counties were more likely than those in urban-suburban counties to complete the initial clinical interview (27.0% versus 24.0%, p=.001). Program penetration was significantly higher in rural than in urban-suburban counties (p=.02). CONCLUSIONS: Telephone-based care management programs such as SUSTAIN may be an effective strategy to facilitate access to collaborative mental health care regardless of patients' geographic location.

Predicting 3-year mortality and admission to acute-care hospitals, skilled nursing facilities, and long-term care facilities in Medicare beneficiaries.

PURPOSE: The ability to predict mortality and admission to acute care hospitals, skilled nursing facilities (SNFs), and long-term care (LTC) facilities in the elderly and how it varies by activity of daily living (ADL) and instrumental ADL (IADL) status could be useful in measuring the success or failure of economic, social, or health policies aimed at disability prevention and management. We sought to derive and assess the predictive performance of rules to predict 3-year mortality and admission to acute care hospitals, SNFs, and LTC facilities among Medicare beneficiaries with differing ADL and IADL functioning levels. METHODS: Prospective cohort using Medicare Current Beneficiary Survey data from the 2001 to 2007 entry panels. In all, 23,407 community-dwelling Medicare beneficiaries were included. Multivariable logistic models created predicted probabilities for all-cause mortality and admission to acute care hospitals, SNFs, and LTC facilities, adjusting for sociodemographics, health conditions, impairments, behavior, and function. RESULTS: Sixteen, 22, 14, and 14 predictors remained in the final parsimonious model predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission, respectively. The C-statistic for predicting 3-year all-cause mortality, inpatient admission, SNF admission, and LTC facility admission was 0.779, 0.672, 0.753, and 0.826 in the ADL activity limitation stage development cohorts, respectively, and 0.788, 0.669, 0.748, and 0.799 in the ADL activity limitation stage validation cohorts, respectively. CONCLUSIONS: Parsimonious models can identify elderly Medicare beneficiaries at risk of poor outcomes and can aid policymakers, clinicians, and family members in improving care for older adults and supporting successful aging in the community.

The Association Between Activity Limitation Stages and Admission to Facilities Providing Long-term Care Among Older Medicare Beneficiaries.

OBJECTIVE: This study aimed to examine whether activity limitation stages are associated with admission to facilities providing long-term care (LTC). DESIGN: Cohort study using Medicare Current Beneficiary Survey data from the 2005-2009 entry panels. A total of 14,580 community-dwelling Medicare beneficiaries 65 years or older were included. Proportional subhazard models examined associations between activity limitation stages and time to first LTC admission, adjusting for baseline sociodemographics and health conditions. RESULTS: The weighted annual rate of LTC admission was 1.1%. In the adjusted model, compared to activity of daily living (ADL) stage 0, the hazard ratios (95% confidence intervals [CIs]) were 2.0 (1.5-2.7), 3.9 (2.9-5.4), 3.6 (2.5-5.3), and 4.7 (2.5-9.0) for ADL stage I (mild limitation), ADL stage II (moderate limitation), ADL stage III (severe limitation), and ADL stage IV (complete limitation), respectively. Compared to instrumental ADL (IADL) stage 0, the hazard ratios, and 95% CIs for IADL stages I to IV were 2.0 (1.4-2.7), 3.7 (2.6-5.4), 4.6 (3.3-6.5), and 7.6 (4.6-12.3), respectively. CONCLUSIONS: Activity limitation stages are strongly associated with future admission to LTC and may therefore be useful in identifying specific supportive care needs among vulnerable older community-dwelling adults, which may reduce or the delay need for admission to LTC.

Psychosocial Well-Being Associated With Activity of Daily Living Stages Among Community-Dwelling Older Adults.

Objectives: Activity of daily living (ADL) stages demonstrated ordered associations with risk of chronic conditions, hospitalization, nursing home use, and mortality among community-living elderly. This article explores the association of stages with psychosocial well-being. We hypothesized that higher ADL stages (greater ADL limitation) are associated with more restricted social networks, less perceived social support, greater social isolation, and poorer mental health. Methods: Cross-sectional data from the National Social Life, Health, and Aging Project (N = 3,002) were analyzed in regression models and latent factor models. Results: Although ADL stages had a nearly monotonic relationship with most mental health measures (e.g., Center for Epidemiologic Studies Depression Scale [CES-D]), only the complete limitation stage (Stage IV) showed significant disadvantage in the majority of social network measures. Discussion: The study may aid clinicians and policy makers to better understand the social and mental health needs of older adults at different ADL stages and provide well-planned social and mental health care.

Perceived barriers to healthcare and receipt of recommended medical care among elderly Medicare beneficiaries.

PURPOSE: Many Medicare beneficiaries perceive barriers to receiving healthcare, although the consequences are unknown. Facilitators can aid in the receipt of healthcare services. The objective was to assess the relationship between perceived facilitators and barriers to healthcare and actual receipt of recommended medical care among elderly beneficiaries. METHODS: A cohort study using data from the 2001-2008 entry panels of the Medicare Current Beneficiary Survey that included 24,607 community-dwelling beneficiaries 65 years of age and older. Surveys elicited perceptions of healthcare with respect to: care coordination and quality; access to medical care; getting or delaying healthcare because of financial reasons; transportation; and usual source of care. The outcome was receipt of recommended medical care, expressed as an aggregate of 38 indicators covering initial evaluation, diagnostic tests, therapeutic interventions, hospitalization follow-up, and routine preventive care. Multivariable survey logistic regression produced odds ratios (ORs) and 95% confidence intervals (CIs) for receipt of recommended medical care, adjusted for sociodemographics, insurance, comorbidities, and disability. RESULTS: Beneficiaries who reported having trouble getting or reported delaying healthcare because of financial reasons (barrier) (adjusted OR=0.79, 95% CI: 0.73-0.86) and those who reported having no usual source of care (facilitator) (adjusted OR=0.55, 95% CI: 0.48-0.63) were less likely to receive recommended medical care. CONCLUSIONS: Survey data that capture patient perceptions of facilitators and barriers to healthcare may be useful for identifying system factors that affect timely receipt of recommended medical care. This information can inform the design of policies and programs to improve the healthcare of older adults.

Presence of Vision Impairment and Risk of Hospitalization among Elderly Medicare Beneficiaries.

PURPOSE: To examine the association between vision impairment and all-cause hospitalization among elderly Medicare beneficiaries. METHODS: A population-based study (N = 22,681) of community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Current Beneficiary Survey for the years 2001-2007. Beneficiaries were classified into self-reported presence of vision impairment versus no vision impairment. Inpatient hospitalizations were identified using Medicare claims data. A multivariable Cox proportional hazard model examined the association between presence of vision impairment and time to first hospitalization within 3 years of survey entry after adjusting for sociodemographics, comorbidities, hearing impairment, and activity limitation stages derived from difficulty performing the activities of daily living. RESULTS: Medicare beneficiaries who self-reported the presence of vision impairment were significantly more likely to be hospitalized over 3 years compared to beneficiaries without vision impairment even after adjustment for potentially influential covariates (hazard ratio = 1.14 and 95% confidence interval: 1.05-1.23). CONCLUSIONS: Medicare beneficiaries with self-reported vision impairment were at higher risk of hospitalization during a 3-year period. Further research may identify reasons that are amenable to policy interventions.

Disparities in receipt of recommended care among younger versus older medicare beneficiaries: a cohort study.

BACKGROUND: Although health disparities have been documented between Medicare beneficiaries based on age (<65 years vs. older age groups), underuse of recommended medical care in younger beneficiaries has not been thoroughly investigated. In this study, we aim to identify and characterize vulnerabilities of the younger Medicare age group (aged <65 years) in relation to older age groups (aged 65-74 years and ≥75 years) and to explore age group as a determinant of use of recommended care among Medicare beneficiaries. METHODS: We conducted a cohort study of community-dwelling Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey between 2001 and 2008 (N = 30,117). Age group characteristics were compared using cross-sectional data at baseline. During follow-up, we assessed the association between age and receipt of recommended care on 38 recommended care indicators, adjusting for sociodemographic and clinical characteristics. Follow-up periods differed by component indicator. RESULTS: At baseline, a higher proportion of younger beneficiaries experienced social disadvantage, disability and certain morbidities than older age groups. During follow-up, younger beneficiaries were significantly less likely to receive overall recommended care compared to those 65-74 years of age (adjusted odds ratio and 95% confidence interval: 0.75, 0.70-0.80). In addition, male gender, non-Hispanic black race, less than high school education, living alone, with children or with others, psychiatric disorders and higher activity limitation stages were all associated with underuse of recommended care. CONCLUSIONS: Younger Medicare beneficiary status appears to be an independent risk factor for underuse of appropriate care. Support to ameliorate disparities in different social and health aspects may be warranted.

Potentially Avoidable Hospitalizations among People at Different Activity of Daily Living Limitation Stages.

OBJECTIVE: To determine whether higher activity of daily living (ADL) limitation stages are associated with increased risk of hospitalization, particularly for ambulatory care sensitive (ACS) conditions. DATA SOURCE: Secondary data analysis, including 8,815 beneficiaries from 2005 to 2006 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN: ADL limitation stages (0-IV) were determined at the end of 2005. Hospitalization rates were calculated for 2006 and age adjusted using direct standardization. Multivariate negative binomial regression, adjusting for baseline demographic and health characteristics, with the outcome hospitalization count was performed to estimate the adjusted rate ratio of ACS and non-ACS hospitalizations for beneficiaries with ADL stages > 0 compared to beneficiaries without limitations. DATA COLLECTION: Baseline ADL stage and health conditions were assessed using 2005 MCBS data and count of hospitalization determined using 2006 MCBS data. PRINCIPAL FINDINGS: Referenced to stage 0, the adjusted rate ratios (95 percent confidence interval) for stage I to stage IV ranged from 1.9 (1.4-2.5) to 4.1 (2.2-7.8) for ACS hospitalizations compared with from 1.6 (1.3-1.9) to 1.8 (1.4-2.5) for non-ACS hospitalizations. CONCLUSIONS: Hospitalization rates for ACS conditions increased more dramatically with ADL limitation stage than did rates for non-ACS conditions. Adults with ADL limitations appear particularly vulnerable to potentially preventable hospitalizations for conditions typically manageable in ambulatory settings.

Activity Limitation Stages Are Associated With Risk of Hospitalization Among Medicare Beneficiaries.

BACKGROUND: Activity limitation stages based on activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are associated with 3-year mortality in elderly Medicare beneficiaries, yet their associations with hospitalization risk in this population have not been studied. OBJECTIVE: To examine the independent association of activity limitation stages with risk of hospitalization within a year among Medicare beneficiaries aged 65 years and older. DESIGN: Cohort study. SETTING: Community. PARTICIPANTS: A total of 9447 community-dwelling elderly Medicare beneficiaries from the Medicare Current Beneficiary Survey for years 2005-2009. METHODS: Stages were derived for ADLs and IADLs separately. Associations of stages with time to first hospitalization and time to recurrent hospitalizations within a year were assessed with Cox proportional hazards models, with which we accounted for baseline sociodemographics, smoking status, comorbidities, and the year of survey entry. MAIN OUTCOMES: Time to first hospitalization and time to recurrent hospitalizations within 1 year. PRINCIPLE FINDINGS: The adjusted risk of first hospitalization increased with greater activity limitation stages (except stage III). The hazard ratios (95% confidence intervals) for ADL stages I-IV compared with stage 0 (no limitations) were 1.49 (1.36-1.63), 1.61 (1.44-1.80), 1.54 (1.35-1.76), and 2.06 (1.61-2.63), respectively. The pattern for IADL stages was similar. For recurrent hospitalizations, activity limitation stages were associated with the risk of the first hospitalization but not with subsequent hospitalizations. CONCLUSION: Activity limitation stages are associated with the risk of first hospitalization in the subsequent year among elderly Medicare beneficiaries. Stages capture clinically interpretable profiles of ADL and IADL functionality and describe preserved functions and activity limitation in an aggregated measure. Stage can inform interventions to ameliorate disability and thus reduce the risk of a subsequent hospitalization in this population. LEVEL OF EVIDENCE: IV.

Patient Satisfaction and Prognosis for Functional Improvement and Deterioration, Institutionalization, and Death Among Medicare Beneficiaries Over 2 Years.

OBJECTIVE: To examine how patient satisfaction with care coordination and quality and access to medical care influence functional improvement or deterioration (activity limitation stage transitions), institutionalization, or death among older adults. DESIGN: National representative sample with 2-year follow-up. SETTING: Medicare Current Beneficiary Survey from calendar years 2001 to 2008. PARTICIPANTS: Community-dwelling adults (N=23,470) aged ≥65 years followed for 2 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A multinomial logistic regression model taking into account the complex survey design was used to examine the association between patient satisfaction with care coordination and quality and patient satisfaction with access to medical care and activities of daily living (ADL) stage transitions, institutionalization, or death after 2 years, adjusting for baseline socioeconomics and health-related characteristics. RESULTS: Out of 23,470 Medicare beneficiaries, 14,979 (63.8% weighted) remained stable in ADL stage, 2508 (10.7% weighted) improved, 3210 (13.3% weighted) deteriorated, 582 (2.5% weighted) were institutionalized, and 2281 (9.7% weighted) died. Beneficiaries who were in the top quartile of satisfaction with care coordination and quality were less likely to be institutionalized (adjusted relative risk ratio [RRR], .68; 95% confidence interval [CI], .54-.86). Beneficiaries who were in the top quartile of satisfaction with access to medical care were less likely to functionally deteriorate (adjusted RRR, .87; 95% CI, .79-.97), be institutionalized (adjusted RRR, .72; 95% CI, .56-.92), or die (adjusted RRR, .86; 95% CI, .75-.98). CONCLUSIONS: Knowledge of patient satisfaction with medical care and risk of functional deterioration may be helpful for monitoring and addressing disability-related health care disparities and the effect of ongoing policy changes among Medicare beneficiaries.

Disability Stages and Trouble Getting Needed Health Care Among Medicare Beneficiaries.

OBJECTIVE: The aim of this study was to examine whether activity limitation stages were associated with patient-reported trouble getting needed health care among Medicare beneficiaries. DESIGN: This was a population-based study (n = 35,912) of Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey for years 2001-2010. Beneficiaries were classified into an activity limitation stage from 0 (no limitation) to IV (complete) derived from self-reported or proxy-reported difficulty performing activities of daily living and instrumental activities of daily living. Beneficiaries reported whether they had trouble getting health care in the subsequent year. A multivariable logistic regression model examined the association between activity limitation stages and trouble getting needed care. RESULTS: Compared with beneficiaries with no limitations (activities of daily living stage 0), the adjusted odds ratios (ORs) (95% confidence intervals [CIs]) for stage I (mild) to stage IV (complete) for trouble getting needed health care ranged from OR = 1.53 (95% CI, 1.32-1.76) to OR = 2.86 (95% CI, 1.97-4.14). High costs (31.7%), not having enough money (31.2%), and supplies/services not covered (24.2%) were the most common reasons for reporting trouble getting needed health care. CONCLUSION: Medicare beneficiaries at higher stages of activity limitations reported trouble getting needed health care, which was commonly attributed to financial barriers.

Disability stage and receipt of recommended care among elderly medicare beneficiaries.

BACKGROUND: Receipt of recommended care among older adults is generally low. Findings regarding service use among persons with disabilities supports the notion of disparities but provides inconsistent evidence of underuse of recommended care. OBJECTIVE: To examine the extent to which receipt of recommended care among older Medicare beneficiaries varies by disability status, using a newly developed staging method to classify individuals according to disability. METHODS: In a cohort study, we included community-dwelling Medicare beneficiaries aged 65 and older who participated in the Medicare Current Beneficiary Survey between 2001 and 2008. Logistic regression modeling assessed the association of receiving recommended care on 38 indicators across different activity limitation stages. RESULTS: Nearly one out of every three elderly Medicare beneficiaries did not receive overall recommended care. Adjusted odds ratios (ORs) revealed a decrease in use of recommended care with increasing activity limitation stage. For instance, ORs (95% CIs) across mild, moderate, severe and complete limitation stages (stages I-IV) compared to no limitation (stage 0) in ADLs were 0.99 (0.94-1.05), 0.89 (0.83-0.95), 0.81 (0.75-0.89) and 0.56 (0.46-0.68). Disparities in receipt of recommended care by disability stage were most marked for care related to post-hospitalization follow-up and, to a lesser degree, care of chronic conditions and preventive care. CONCLUSIONS: Elderly beneficiaries at higher activity limitation stages experienced substantial disparities in receipt of recommended care. Tailored interventions may be needed to reduce disparities in receipt of recommended medical care in this population.

Identifying neuropsychiatric disorders in the Medicare Current Beneficiary Survey: the benefits of combining health survey and claims data.

BACKGROUND: To address the impact of using multiple sources of data in the United States Medicare Current Beneficiary Survey (MCBS) compared to using only one source of data to identify those with neuropsychiatric diagnoses. METHODS: Our data source was the 2010 MCBS with associated Medicare claims files (N = 14, 672 beneficiaries). The MCBS uses a stratified multistage probability sample design to select a nationally representative sample of Medicare beneficiaries. We excluded those participants in Medicare Health Maintenance Organizations (n = 3894) and performed a cross-sectional analysis. We classified neuropsychiatric conditions according to four broad categories: intellectual/developmental disorders, neurological conditions affecting the central nervous system (Neuro-CNS), dementia, and psychiatric conditions. To account for different baseline prevalence differences of the categories we calculated the relative increase in prevalence that occurred from adding information from claims in addition to the absolute increase to allow comparison among categories. RESULTS: The estimated proportion of the sample with neuropsychiatric disorders increased to 50.0 (both sources) compared to 38.9 (health survey only) and 33.2 (claims only) with an overlap between sources of only 44.1 %. Augmenting health survey data with claims led to an increase in estimated percentage of intellectual/developmental disorders, psychiatric disorders, Neuro-CNS disorders and dementia of 1.3, 5.9, 11.5 and 3.8 respectively. In the community sample, the largest relative increases were seen for dementia (147.6 %) and Neuro-CNS disorders (87.4 %). With the exception of dementia, larger relative increases were seen in the facility sample with the greatest being for intellectual/developmental disorders (121.5 %) and Neuro-CNS disorders (93.8 %). CONCLUSIONS: The magnitude of potentially underestimated sample proportions using health survey only data varied strikingly according to the category of diagnosis and setting. Augmentation of survey data with claims appears essential particularly when attempting to estimate proportion of the sample affected by conditions that cause cognitive impairment which may affect ability to self-report. Augmenting proxy survey data with claims data also appears to be essential when ascertaining proportion of the facility-dwelling sample affected by neuropsychiatric disorders.

Understanding non-performance reports for instrumental activity of daily living items in population analyses: a cross sectional study.

BACKGROUND: Concerns about using Instrumental Activities of Daily Living (IADLs) in national surveys come up frequently in geriatric and rehabilitation medicine due to high rates of non-performance for reasons other than health. We aim to evaluate the effect of different strategies of classifying "does not do" responses to IADL questions when estimating prevalence of IADL limitations in a national survey. METHODS: Cross-sectional analysis of a nationally representative sample of 13,879 non-institutionalized adult Medicare beneficiaries included in the 2010 Medicare Current Beneficiary Survey (MCBS). Sample persons or proxies were asked about difficulties performing six IADLs. Tested strategies to classify non-performance of IADL(s) for reasons other than health were to 1) derive through multiple imputation, 2) exclude (for incomplete data), 3) classify as "no difficulty," or 4) classify as "difficulty." IADL stage prevalence estimates were compared across these four strategies. RESULTS: In the sample, 1853 sample persons (12.4 % weighted) did not do one or more IADLs for reasons other than physical problems or health. Yet, IADL stage prevalence estimates differed little across the four alternative strategies. Classification as "no difficulty" led to slightly lower, while classification as "difficulty" raised the estimated population prevalence of disability. CONCLUSIONS: These analyses encourage clinicians, researchers, and policy end-users of IADL survey data to be cognizant of possible small differences that can result from alternative ways of handling unrated IADL information. At the population-level, the resulting differences appear trivial when applying MCBS data, providing reassurance that IADL items can be used to estimate the prevalence of activity limitation despite high rates of non-performance.

Comparison of predictive value of activity limitation staging systems based on dichotomous versus trichotomous responses in the Medicare Current Beneficiary Survey.

BACKGROUND: Traditional ways of measuring disability include summary indices, binary expressions, or counts of limitations. However, counts of activity of daily living (ADL) or instrumental activity of daily living (IADL) limitations do not specify which activities are limited. Activity limitation staging systems within the ADL and IADL domains depict both the severity and types of limitations experienced and specify clinically meaningful patterns of increasing difficulty with self-care. OBJECTIVE: To compare the predictive value and utility of ADL and IADL stages based on dichotomous versus trichotomous responses to ADL and IADL questions based on "difficulty" and "receive help" responses. METHODS: Data were analyzed from the 2005, 2006, and 2007 Medicare Current Beneficiary Survey (MCBS) entry panels on 11,706 beneficiaries. This was a prospective cohort study that examined time to inpatient admission, all-cause mortality, skilled nursing facility (SNF) admission, and long-term care (LTC) facility admission based on dichotomous versus trichotomous stages. RESULTS: For both ADLs and IADLs, Akaike information criteria for most outcomes were lower (indicating better-performing models) for the trichotomous staging systems than the dichotomous staging systems. The hazard ratios (HRs) and 95% confidence intervals (CIs) of the dichotomous ADL staging system increased as disability increased, whereas the HRs of the other staging systems fluctuated. CONCLUSIONS: Both staging systems have strong associations with each outcome. The dichotomous staging system is more clinically relevant while the trichotomous staging system may provide utility for clinicians, health care organizations, and policy makers seeking to predict death or admission to a hospital, SNF, or LTC facility.

Agitation and Irritability in Alzheimer's Disease: Evidenced-Based Treatments and the Black-Box Warning.

More than five million Americans suffer from Alzheimer's disease (AD), and this number is expected to triple by 2050. While impairments in cognition, particularly memory, are typically the defining features of the clinical syndrome, behavioral symptoms are extremely common, affecting up to 90% of patients. Behavioral symptoms in AD can be difficult to manage and may require a combination of non-pharmacological and pharmacological approaches. The latter is complicated by FDA "black-box warnings" for the medication classes most often used to target these symptoms, and currently there are initiatives in place to limit their use. In this review, we describe common behavioral symptoms of AD-with a particular focus on the challenging symptoms of "agitation" and "irritability"-and discuss evidence-based approaches to their management. Ultimately, multidimensional approaches must be tailored to the patient and their environment, though evidence-based practices should define the treatment of agitation and irritability in AD.