Montessori methods enhance function.

BACKGROUND: The health implications of regional differences in Medicare spending are unknown. OBJECTIVE: To determine whether regions with higher Medicare spending achieve better survival, functional status, or satisfaction with care. DESIGN: Cohort study. SETTING: National study of Medicare beneficiaries. PATIENTS: Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (MCBS) (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306). OUTCOME MEASUREMENTS: 5-year mortality rate (all four cohorts), change in functional status (MCBS cohort), and satisfaction (MCBS cohort). RESULTS: Cohort members were similar in baseline health status, but those in regions with higher end-of-life spending received 60% more care. Each 10% increase in regional end-of-life spending was associated with the following relative risks for death: hip fracture cohort, 1.003 (95% CI, 0.999 to 1.006); colorectal cancer cohort, 1.012 (CI, 1.004 to 1.019); acute myocardial infarction cohort, 1.007 (CI, 1.001 to 1.014); and MCBS cohort, 1.01 (CI, 0.99 to 1.03). There were no differences in the rate of decline in functional status across spending levels and no consistent differences in satisfaction. CONCLUSIONS: Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care. Efforts to reduce spending should proceed with caution, but policies to better manage further spending growth are warranted.

Activities of Daily Living↗

PubMed2003

Effects of dynamic strength training on physical function, Valpar 9 work sample test, and working capacity in patients with recent-onset rheumatoid arthritis.

OBJECTIVE: To study the impact of 24 months of strength training on the physical function of patients with early rheumatoid arthritis (RA). METHODS: Seventy patients were assigned to either the strength training (experimental) group (n = 35) or the control group (n = 35). Patients in the experimental group performed strength training for 24 months, and control patients were instructed to perform range of motion exercises. Maximal strength of the knee extensors, trunk flexors, and extensors, as well as grip strength were recorded with dynamometers. Disease activity was assessed by the erythrocyte sedimentation rate and Ritchie's articular index, joint damage was determined by the Larsen x-ray index, and functional capacity was assessed using the Valpar 9 test and the Stanford Health Assessment Questionnaire (HAQ). The employment status of each patient was recorded. RESULTS: In the experimental group, strength training led to significant increases (19-59%) in maximal strength of the trained muscles. Such increases in the control group varied from 1% to 31%. There was a clear training effect on muscular strength in favor of the experimental group, but significant improvements in the HAQ indices as well as in the Valpar 9 test were seen also in control patients. Results of the Valpar 9 and the HAQ were statistically significantly better in patients who remained gainfully employed compared with patients who retired preterm during followup. However, compared with patients who remained in the work force, patients who retired were older, and their work was physically more demanding. CONCLUSION: As expected, strength training led to increased muscle strength, but this increase did not correlate with improved physical function as assessed by the Valpar 9 work sample test. The increased muscle performance did not prevent a substantial proportion of patients from retiring preterm. The 2 items from the Valpar 9 test that were applied were not sensitive enough to differentiate the patients according to their working status.

Activities of Daily Living↗