Biomedical subjects
David B Reuben
Publications and source records attributed to David B Reuben.
Patients' global ratings of their health care are not associated with the technical quality of their care.
BACKGROUND: Patient global ratings of care are commonly used to assess health care. However, the extent to which these assessments of care are related to the technical quality of care received is not well understood. OBJECTIVE: To investigate the relationship between patient-reported global ratings of health care and the quality of providers' communication and technical quality of care. DESIGN: Observational cohort study. SETTING: 2 managed care organizations. PATIENTS: Vulnerable older patients identified by brief interviews of a random sample of community-dwelling adults 65 years of age or older who received care in 2 managed care organizations during a 13-month period. MEASUREMENTS: Survey questions from the second stage of the Consumer Assessment of Healthcare Providers and Systems program were used to determine patients' global rating of health care and provider communication. A set of 236 quality indicators, defined by the Assessing Care of Vulnerable Elders project, were used to measure technical quality of care given for 22 clinical conditions; 207 quality indicators were evaluated by using data from chart abstraction or patient interview. RESULTS: Data on the global rating item, communication scale, and technical quality of care score were available for 236 vulnerable older patients. In a multivariate logistic regression model that included patient and clinical factors, better communication was associated with higher global ratings of health care. Technical quality of care was not significantly associated with the global rating of care. LIMITATIONS: Findings were limited to vulnerable elders who were enrolled in managed care organizations and may not be generalizable to other age groups or types of insurance coverage. CONCLUSIONS: Vulnerable elders' global ratings of care should not be used as a marker of technical quality of care. Assessments of quality of care should include both patient evaluations and independent assessments of technical quality.
Quality of osteoarthritis care for community-dwelling older adults.
OBJECTIVE: To describe the quality of osteoarthritis care provided to community-dwelling elderly patients and to characterize arthritis-related function in these patients. METHODS: Two medical groups in the western United States participated in a practice-redesign intervention targeted at falls and mobility disorders, incontinence, and cognitive impairment, but not osteoarthritis. From 339 individuals reporting a diagnosis of arthritis, we collected information on demographics, functional status, and quality of care via patient interviews and mailed questionnaires. Eight quality indicators measured osteoarthritis care: 4 indicators measuring the provision of effective osteoarthritis care (osteoarthritis treatment indicators) and 4 measuring the provision of safe osteoarthritis care (medication safety indicators). RESULTS: The mean +/- SD Short Form 12 physical component summary score was 35 +/- 11 points, indicating a physically frail population. The overall indicator pass rate was 57.0% (95% confidence interval [95% CI] 53.9-60.2). Pass rates were higher for indicators of osteoarthritis treatment (63.5%, 95% CI 59.8-67.2) than for indicators of medication safety (43.8%, 95% CI 38.2-49.4). Patients with hip or knee pain had mean +/- SD Western Ontario and McMaster Universities Osteoarthritis Index pain, stiffness, and function scores of 6.0 +/- 4.0, 3.1 +/- 1.7, and 25 +/- 12 points, respectively. CONCLUSION: Quality of osteoarthritis care for older adults is suboptimal, particularly with regard to medication safety. Given the high prevalence of osteoarthritis in older age groups, the population impact of any improvement in quality would be substantial. Quality improvement efforts for osteoarthritis should target appropriate use of and counseling regarding medications, as well as underuse of efficacious therapy for osteoarthritis.
Progestins affect mechanism of estrogen-induced C-reactive protein stimulation.
PURPOSE: To determine whether the mechanisms of C-reactive protein production differ depending on the presence or absence of a progestin in the regimen. SUBJECTS AND METHODS: We examined data from the Postmenopausal Estrogen Progestin Intervention (PEPI) study, a 5-group (3 different combined estrogen-progestin regimens, conjugated equine estrogen-only, and placebo) randomized clinical trial. This substudy included 221 postmenopausal women assigned to active treatment groups who took at least 80% of pills and had stored plasma specimens available to assess 12-month changes in estrone, sex hormone binding globulin, interleukin (IL)-6, and C-reactive protein levels. RESULTS: All treatments resulted in increases in estrone, sex hormone binding globulin, and C-reactive protein at 12 months compared with baseline values. In all progestin-containing groups, 12-month change in IL-6 was positively correlated with 12-month change in C-reactive protein (r between 0.34 and 0.65, each P <.010). By contrast, in the conjugated equine estrogen-only group, 12-month change in IL-6 was negatively correlated with 12-month change in C-reactive protein (r value -0.31, P = .055). In adjusted models predicting 12-month C-reactive protein change, an interaction between change in IL-6 and treatment group was highly significant (P=.0008-P <.0001) for each of the progestin-containing groups compared with the conjugated equine estrogen-only group. In the conjugated equine estrogen-only group, the change in C-reactive protein per unit increase in IL-6 was -0.88, whereas in the progestin-containing groups it ranged from 1.46 to 2.85 (P <.0001 for each comparison with conjugated equine estrogen-only). CONCLUSION: Progestins in combination with conjugated equine estrogen potentiate the IL-6 (inflammatory)-mediated stimulation of C-reactive protein. These findings support the hypothesis that progestins plus estrogen, not estrogen alone, generate C-reactive protein through an inflammatory mechanism.
Is weight loss in the nursing home a reversible problem?
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Meeting the needs of disabled older persons: can the fragments be pieced together?
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Association between serum beta-carotene levels and decline of cognitive function in high-functioning older persons with or without apolipoprotein E 4 alleles: MacArthur studies of successful aging.
BACKGROUND: Growing evidence from animal studies suggests an interaction between antioxidants and apolipoprotein E (APOE) alleles on cognitive functioning. We used data from a 7-year cohort study of high-functioning older persons to explore whether the associations between serum beta-carotene level and subsequent decline of cognitive function differed by APOE 4 genotype. METHODS: Baseline information on sociodemographic characteristics, serum beta-carotene level, inflammation markers, APOE genotype, and cognitive functioning measured by a 9-item Short Portable Mental Status Questionnaire (SPMSQ) was obtained in 455 survivors. Multivariable logistic regression analyses were used to examine the relation between high serum beta-carotene level and risk of SPMSQ score decline in participants with or without APOE 4 alleles, while adjusting for age, sex, race, baseline SPMSQ score, and other covariates. RESULTS: Nine (2%) study participants had homozygous and 97 (21%) had heterozygous APOE 4 alleles. Two hundred forty-nine (55%) had decline of SPMSQ scores during the follow-up. The presence of an APOE 4 allele was associated with higher risk and larger magnitude of SPMSQ score decline. The adjusted odds ratio of high beta-carotene level for cognitive decline was 0.11 (95% confidence interval, 0.02-0.57) in participants with at least one APOE 4 allele and 0.89 (95% confidence interval, 0.54-1.47) among those who were APOE 4 negative. CONCLUSION: Among high-functioning older persons, antioxidants and beta-carotene in particular may offer protection from cognitive decline in persons with greater genetic susceptibility as evidenced by the presence of the APOE 4 allele.
Do proxies reflect patients' health concerns about urinary incontinence and gait problems?
BACKGROUND: While falls and urinary incontinence are prevalent among older patients, who sometimes rely on proxies to provide their health information, the validity of proxy reports of concern about falls and urinary incontinence remains unknown. METHODS: Telephone interviews with 43 consecutive patients with falls or fear of falling and/or bothersome urinary incontinence and their proxies chosen by patients as most knowledgeable about their health. The questionnaire included items derived from the Medical Outcomes Study Short Form 12 (SF-12), a scale assessing concerns about urinary incontinence (UI), and a measure of fear of falling, the Falls Efficacy Scale (FES). Scores were estimated using items asking the proxy perspective (6 items from the SF-12, 10 items from a UI scale, and all 10 FES items). Proxy and patient scores were compared using intraclass correlation coefficients (ICC, one-way model). Variables associated with absolute agreement between patients and proxies were explored. RESULTS: Patients had a mean age of 81 years (range 75-93) and 67% were female while proxies had a mean age of 70 (range 42-87) and 49% were female. ICCs were 0.63 for the SF-12, 0.52 for the UI scale, and 0.29 for the FES. Proxies tended to understate patients' general health and incontinence concern, but overstate patients' concern about falling. Proxies who lived with patients and those who more often see patients more closely reflected patient FES scores compared to those who lived apart or those who saw patients less often. Internal consistency reliability of proxy responses was 0.62 for the SF-12, 0.86 for the I-QOL, and 0.93 for the FES. In addition, construct validity of the proxy FES scale was supported by greater proxy-perceived fear of falling for patients who received medical care after a fall during the past 12 months (p < .05). CONCLUSION: Caution should be exercised when using proxies as a source of information about older patients' health perceptions. Questions asking about proxies' views yield suboptimal agreement with patient responses. However, proxy scales of UI and fall concern are internally consistent and may provide valid independent information.
Quality of care is associated with survival in vulnerable older patients.
BACKGROUND: Although assessment of the quality of medical care often relies on measures of process of care, the linkage between performance of these process measures during usual clinical care and subsequent patient outcomes is unclear. OBJECTIVE: To examine the link between the quality of care that patients received and their survival. DESIGN: Observational cohort study. SETTING: Two managed care organizations. PATIENTS: Community-dwelling high-risk patients 65 years of age or older who were continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999. MEASUREMENTS: Quality of care received by patients (as measured by a set of quality indicators covering 22 clinical conditions) and their survival over the following 3 years. RESULTS: The 372 vulnerable older patients were eligible for a mean of 21 quality indicators (range, 8 to 54) and received, on average, 53% of the care processes prescribed in quality indicators (range, 27% to 88%). Eighty-six (23%) persons died during the 3-year follow-up. There was a graded positive relationship between quality score and 3-year survival. After adjustment for sex, health status, and health service use, quality score was not associated with mortality for the first 500 days, but a higher quality score was associated with lower mortality after 500 days (hazard ratio, 0.64 [95% CI, 0.49 to 0.84] for a 10% higher quality score). LIMITATIONS: The observational design limits causal inference regarding the effect of quality of care on survival. CONCLUSIONS: Better performance on process quality measures is strongly associated with better survival among community-dwelling vulnerable older adults.
The effects of hormone therapy on the markers of inflammation and endothelial function and plasma matrix metalloproteinase-9 level in postmenopausal women: the postmenopausal estrogen progestin intervention (PEPI) trial.
OBJECTIVE: The objective of this study was to determine whether oral conjugated equine estrogen (CEE) alone or with one of the three progestin regimens causes changes in biomarkers predictive of adverse cardiovascular events: C-reactive protein (CRP), interleukin-6 (IL-6), intercellular adhesion molecule (ICAM) and matrix metalloproteinase-9 (MMP-9). METHODS AND RESULTS: The analysis included 271 postmenopausal women from the postmenopausal estrogen progestin intervention (PEPI) trial. Plasma levels of biomarkers were measured on frozen samples obtained at baseline, 1- and 3-year follow-up visits. Multivariable linear mixed effects models were used to estimate changes in CRP, IL-6, ICAM and MMP-9 levels from baseline to follow-up visits by treatment groups. Women assigned to CEE only or CEE plus a progestin had 121 and 150% 1-year increase in CRP levels, respectively. In contrast, these treatments caused no significant change in IL-6 levels. Women assigned to CEE with or without a progestin had a 6-8% decline in ICAM and a 26-33% decline in MMP-9. CONCLUSIONS: The linkage between CEE alone or with a progestin and increased cardiovascular events may be associated with a rise in CRP level, but not through the mechanisms of IL-6-mediated inflammation, endothelial dysfunction or increased MMP activity.
Multidimensional attitudes of medical residents and geriatrics fellows toward older people.
OBJECTIVES: To examine dimensions of a validated instrument measuring geriatric attitudes of primary care residents and performances on these dimensions between residents and fellows. DESIGN: Cross-sectional and longitudinal studies. SETTING: An academic medical center. PARTICIPANTS: Two hundred thirty-eight primary care residents (n=177) and geriatrics fellows (n=61) participated in the study from 1995 to 2000. MEASUREMENTS: A 14-item, 5-point Likert scale previously validated for measuring primary care residents' attitudes toward older people and geriatric patient care was used. RESULTS: Factor analysis showed four dimensions of the scale, labeled Social Value, Medical Care (MC), Compassion (CP), and Resource Distribution, which demonstrated acceptable reliability. Both groups of subjects showed significantly (P<.001) positive (mean>3) attitudes across the dimensions and times, except for residents, who had near-neutral (mean=3) attitudes on MC. Residents' mean attitude scores on the overall scale and the MC and CP subscales were significantly (P<.001) lower than those of fellows over time. Residents and fellows showed different change patterns in attitudes over time. Residents' attitudes generally improved during the first 2 years of training, whereas fellows' attitudes declined slightly. Personal experience was a strong predictor of residents' attitudes toward older patients. Ethnicity, academic specialty, professional experience, and career interest in geriatrics were also associated with residents' attitude scores. CONCLUSION: The multidimensional analysis of the scale contributes to better understanding of medical trainees' attitudes and sheds light on educational interventions.
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.
Caring for older Americans: the future of geriatric medicine.
In response to the needs and demands of an aging population, geriatric medicine has grown rapidly during the past 3 decades. The discipline has defined its core values as well as the knowledge base and clinical skills needed to improve the health, functioning, and well-being of older persons and to provide appropriate palliative care. Geriatric medicine has developed new models of care, advanced the treatment of common geriatric conditions, and advocated for the health and health care of older persons. Nevertheless, at the beginning of the 21st century, the health care of older persons is at a crossroads. Despite the substantial progress that geriatric medicine has made, much more remains to be done to meet the healthcare needs of our aging population. The clinical, educational, and research approaches of the 20th century are unable to keep pace and require major revisions. Maintaining the status quo will mean falling further and further behind. The healthcare delivery and financing systems need fundamental redesign to improve quality and eliminate waste. The American Geriatrics Society (AGS) Task Force on the Future of Geriatric Medicine has identified five goals aimed at optimizing the health of older persons: To ensure that every older person receives high-quality, patient-centered health care; To expand the geriatrics knowledge base; To increase the number of healthcare professionals who employ the principles of geriatric medicine in caring for older persons; To recruit physicians and other healthcare professionals into careers in geriatric medicine; To unite professional and lay groups in the effort to influence public policy to continually improve the health and health care of seniors. Geriatric medicine cannot accomplish these goals alone. Accordingly, the Task Force has articulated a set of recommendations primarily aimed at the government, organizations, agencies, foundations, and other partners whose collaboration will be essential in accomplishing these goals. The vision described in this document and the accompanying recommendations are only the broad outline of an agenda for the future. Geriatric medicine, through its professional organizations and its partners, will need to mobilize resources to identify and implement the specific steps that will make the vision a reality. Doing so will require broad participation, consensus building, creativity, and perseverance. The consequences of inaction will be profound. The combination of a burgeoning number of older persons and an inadequately prepared, poorly organized physician workforce is a recipe for expensive, fragmented health care that does not meet the needs of our older population. By virtue of their unique skills and advocacy for the health of older persons, geriatricians can be key leaders of change to achieve the goals of geriatric medicine and optimize the health of our aging population. Nevertheless, the goals of geriatric medicine will be accomplished only if geriatricians and their partners work in a system that is designed to provide high-quality, efficient care and recognizes the value of geriatrics.
Predictors of overall quality of care provided to vulnerable older people.
OBJECTIVES: Prior research shows that the quality of care provided to vulnerable older persons is suboptimal, but little is known about the factors associated with care quality for this group. In this study, the influences of clinical conditions, types of care processes, and sociodemographic characteristics on the quality of care received by vulnerable older people were evaluated. DESIGN: Observational cohort study. SETTING: Two senior managed care plans. PARTICIPANTS: Three hundred sixty-two community-dwelling patients aged 65 and older identified as vulnerable by the Vulnerable Elder Survey (VES-13). MEASUREMENTS OUTCOME VARIABLE: patients' observed-minus-expected overall quality score. PREDICTOR VARIABLES: types of care processes, types and number of clinical conditions, sex, age, VES-13 score (composite score of function and self-rated health), income, education, mental health status, and number of quality indicators triggered. RESULTS: Patients whose conditions required more history-taking, counseling, and medication-prescribing care processes and patients with diabetes mellitus received lower-than-expected quality of care. A greater number of comorbid conditions was associated with higher-than-expected quality of care. Age, sex, VES-13 score, and other sociodemographic variables were not associated with quality of care. CONCLUSION: Complexity, vulnerability, and age do not predispose older persons to receive poorer-quality care. In contrast, older patients whose care requires time-consuming processes such as history taking and counseling are at risk for worse quality of care and should be a target for intervention to improve care.
Longitudinal patterns and predictors of alcohol consumption in the United States.
OBJECTIVES: We examined demographic predictors of longitudinal patterns in alcohol consumption. METHODS: We used mixed-effects models to describe individual alcohol consumption and change in consumption with age, as well as the associations between consumption and birth year, national alcohol consumption, and demographic factors, among 14 105 adults from the National Health and Nutrition Examination Survey I Epidemiologic Follow-Up Study. RESULTS: Alcohol consumption declined with increasing age, and individual consumption mirrored national consumption. Higher consumption was associated with male gender, being White, being married, having a higher educational level, having a higher income, being employed, and being a smoker. Faster age-related decline in consumption was associated with earlier cohorts, being male, being married, having a lower educational level, and being a smoker. CONCLUSIONS: Compared with alcohol consumption among earlier cohorts, that among recent cohorts declined more slowly with increasing age, suggesting that negative health effects of alcohol could increase in the future.
Perspectives, preferences, care practices, and outcomes in late-stage cancer patients: connecting the dots.
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The quality of pharmacologic care for vulnerable older patients.
BACKGROUND: Although pharmacotherapy is critical to the medical care of older patients, medications can have considerable toxicity in this age group. To date, research has focused on inappropriate prescribing and policy efforts have aimed at access, but no comprehensive measurement of the quality of pharmacologic management using explicit criteria has been performed. OBJECTIVE: To evaluate the broad range of pharmacologic care processes for vulnerable older patients. DESIGN: Observational cohort study. SETTING: 2 managed care organizations enrolling older persons. PATIENTS: Community-dwelling high-risk patients 65 years of age or older continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999. MEASUREMENTS: Patients' receipt of care as specified in 43 quality indicators covering 4 domains of pharmacologic care: 1) prescribing indicated medications; 2) avoiding inappropriate medications; 3) education, continuity, and documentation; and 4) medication monitoring. RESULTS: Of 475 vulnerable older patients, 372 (78%) consented to participate and had medical records that could be abstracted. The percentage of appropriate pharmacologic management ranged from 10% for documentation of risks of nonsteroidal anti-inflammatory drugs to 100% for avoiding short-acting calcium-channel blockers in patients with heart failure and avoiding beta-blockers in patients with asthma. Pass rates for quality indicators in the "avoiding inappropriate medications" domain (97% [95% CI, 96% to 98%]) were significantly higher than pass rates for "prescribing indicated medications" (50% [CI, 45% to 55%]); "education, continuity, and documentation" (81% [CI, 79% to 84%]); and "medication monitoring" (64% [CI, 60% to 68%]). LIMITATIONS: Fewer than 10 patients were eligible for many of the quality indicators measured, and the generalizability of these findings in 2 managed care organizations to the general geriatric population is uncertain. CONCLUSIONS: Failures to prescribe indicated medications, monitor medications appropriately, document necessary information, educate patients, and maintain continuity are more common prescribing problems than use of inappropriate drugs in older patients.