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author:("saliva, Debra")
1.  The Vulnerable Elders-13 Survey Predicts Hospital Complications and Mortality Among Geriatric Trauma Patients: A Pilot Study 
OBJECTIVE
Pre-injury functional status has not been prospectively studied as a predictor of risk in trauma patients. We hypothesized that the VES-13, a survey based on functional status that has been validated among uninjured older populations, will predict complications and mortality among injured geriatric patients.
DESIGN
Prospective observational pilot study
SETTING
Level-1 trauma center
PARTICIPANTS
63 geriatric patients (age ≥65 years) with a traumatic injury, who survived and required inpatient care for at least 24 hours.
MEASUREMENTS
Predictor: Pre-injury VES-13 score (0-10 points, higher = greater risk) obtained by interview of patients or proxies. Outcomes: composite outcome of one or more medical complication (e.g., aspiration pneumonia, respiratory failure) or death; discharge destination (home versus nursing home versus death); length of stay; hospital charges. Co-variates: Charlson Comorbidity Index (CCI), Injury Severity Score (ISS), and gender.
RESULTS
Of the 63 patients, four (6%) died, 21 (33%) developed one or more complications, 30 (48%) were discharged to home and 28 (44%) to a nursing facility. In a model that also controlled for ISS and co-morbidity, each additional VES-13 point was associated with increased risk of complication or death (OR 1.53 per point, 95% CI 1.12-2.07).
CONCLUSIONS
These results suggest that the VES-13, in combination with injury severity, may be useful early in the hospital course to predict complications and death among geriatric trauma patients, potentially identifying candidates who may benefit from additional inpatient geriatric services.
doi:10.1111/j.1532-5415.2011.03493.x
PMCID: PMC3710109  PMID: 21718276
Trauma; acute surgical care; functional status
2.  All-Cause 1-, 5-, and 10-Year Mortality Among Elderly People According to Activities of Daily Living Stage 
Background
Limitation in the activities of daily living (ADLs) is strongly prognostic for mortality. Current ADL assessments based on numbers of limitations (counts) obscure the particular activities limited, thus lacking clinical interpretability.
Objectives
To examine the independent association of 5 stages of ADL with mortality after accounting for known diagnostic and sociodemographic risk factors.
Design
For five stages (ADL 0 to IV), describing both the severity and pattern of ADLs limited, we estimated unadjusted life expectancies and adjusted associations with mortality using a Cox proportional hazards regression model.
Setting
Community
Participants
Included were 9,447 persons 70 years of age and older from the second Longitudinal Study of Aging.
Measurements
1-, 5-, and 10-year survival and time to death.
Results
For those with no ADL limitations, the median life expectancy was 10.6 years compared to 6.5, 5.1, 3.8, and 1.6 years for those at ADL I, II, III, and IV, respectively. The sociodemographic and diagnostic-adjusted hazard of death at 1 year was 5-fold greater at stage IV compared to stage 0 (hazard ratio=5.6; 95% confidence interval, 3.8–8.3). The associations of ADL stage with mortality declined over time, but remained statistically significant at 5 and 10 years.
Conclusion
ADL stage continued to explain mortality risk after adjusting for known risk factors including advanced age, stroke, and cancer. ADL stages might aid clinical care planning and policy as a powerful prognostic indicator particularly of short-term mortality, improving on current ADL measures by profiling activity limitations of relevance to determining community support needs.
doi:10.1111/j.1532-5415.2011.03867.x
PMCID: PMC3302958  PMID: 22352414
Activities of Daily Living; Staging; Mortality; Risk factors
3.  Do Correlates of Dual Use by American Indian and Alaska Native Veterans Operate Uniformly Across the Veterans Health Administration and the Indian Health Service? 
Journal of General Internal Medicine  2011;26(Suppl 2):662-668.
OBJECTIVE
To determine if the combined effects of patient-level (demographic and clinical characteristics) and organizational-level (structure and strategies to improve access) factors are uniformly associated with utilization of Indian Health Service (IHS) and/or Veterans Health Administration (VHA) by American Indian and Alaska Native (AIAN) Veterans to inform policy which promotes dual use.
METHODS
We estimated correlates and compared two separate multilevel logistic regression models of VHA-IHS dual versus IHS-only and VHA-IHS dual versus VHA-only in a sample of 18,892 AIAN Veterans receiving care at 201 VHA and IHS facilities during FY02 and FY03. Demographic, diagnostic, eligibility, and utilization data were drawn from administrative records. A survey of VHA and IHS facilities defined availability of services and strategies to enhance access to healthcare for AIAN Veterans.
RESULTS
Facility level strategies that are generally associated with enhancing access to healthcare (e.g., population-based services and programs, transportation or co-location) were not significant factors associated with dual use. In both models the common variable of dual use was related to medical need, defined as the number of diagnoses per patient. Other significant demographic, medical need and organizational factors operated in opposing manners. For instance, age increased the likelihood of dual use versus IHS-only but decreased the likelihood of dual use versus VHA-only.
CONCLUSIONS
Efforts to enhance access through population-based and consumer-driven strategies may add value but be less important to utilization than availability of healthcare resources needed by this population. Sharing health records and co-management strategies would improve quality of care while policies allow and promote dual use.
doi:10.1007/s11606-011-1834-2
PMCID: PMC3191227  PMID: 21989619
access; underserved populations; health services research
4.  Home Accessibility, Living Circumstances, Stage of Activity Limitation, and Nursing Home Use 
Objective
To explore the influence of physical home and social environments and disability patterns on nursing home (NH) use.
Design
Longitudinal cohort study. Self- or proxy-reported perception of home environmental barriers accessibility, 5 stages expressing the severity and pattern of activities of daily living (ADLs) limitations, and other characteristics at baseline were applied to predict NH use within 2 years or prior to death through logistic regression.
Setting
General community.
Participants
Population-based, community-dwelling individuals (N=7836; ≥70y) from the Second Longitudinal Study of Aging interviewed in 1994 with 2-year follow-up that was prospectively collected.
Interventions
Not applicable.
Main Outcome Measure
NH use within 2 years.
Results
Perceptions of home environmental barriers and living alone were both associated with approximately 40% increased odds of NH use after adjustment for other factors. Compared with those with no limitations at ADL stage 0, the odds of NH use peaked for those with severe limitations at ADL stage III (odds ratio [OR]=3.12; 95% confidence interval [CI], 2.20 – 4.41), then declined sharply for those with total limitations at ADL stage IV (OR=.96; 95% CI, .33–2.81). Sensitivity analyses for missing NH use showed similar results.
Conclusions
Accessibility of home environment, living circumstance, and ADL stage represent potentially modifiable targets for rehabilitation interventions for decreasing NH use in the aging U.S. population.
doi:10.1016/j.apmr.2012.03.027
PMCID: PMC3461316  PMID: 22484216
Activities of daily living; Nursing homes; Rehabilitation
5.  Staging Activity Limitation and Participation Restriction in Elderly Community-Dwelling Persons According to Difficulties in Self-Care and Domestic Life Functioning 
Objective
This study aimed to describe the conceptual foundation and development of an activity limitation and participation restriction staging system for community-dwelling people 70 yrs or older according to the severity and types of self-care (activities of daily living [ADLs]) and domestic life (instrumental ADLs (IADLs)) limitations experienced.
Design
Data from the second Longitudinal Study of Aging (N = 9447) were used to develop IADL stages through the analyses of self- and proxy-reported difficulties in performing IADLs. An analysis of activity limitation profiles identified hierarchical thresholds of difficulty that defined each stage. IADL stages are combined with ADL stages to profile status for independent living.
Results
IADL stages define five ordered thresholds of increasing activity limitations and a “not relevant” stage for those who normally have someone else do those activities. Approximately 42% of the population experience IADL limitations. To achieve a stage, a person must meet or exceed stage-specific thresholds of retained functioning defined for each activity. Combined ADL and IADL stages de-fine 29 patterns of activity limitations expressing the individual’s potential for participating in life situations pertinent to self-care and independent community life.
Conclusions
ADL and IADL stages can serve to distinguish between groups of people according to both severity and the types of limitations experienced during home or outpatient assessments, in population surveillance, and in research.
doi:10.1097/PHM.0b013e318241200d
PMCID: PMC3298888  PMID: 22248806
Independent Living; Aging; Daily Living Activities; ICF
6.  Activity of Daily Living Staging, Chronic Health Conditions, and Perceived Lack of Home Accessibility Features for Elderly People Living in the Community 
OBJECTIVE
To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older.
DESIGN
Cross-sectional.
SETTING
Community.
PARTICIPANTS
Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II).
MEASUREMENTS
Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV).
RESULTS
ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI) = 2.4–4.4) to 41.9 (95% CI = 19.6–89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR = 17.8, 95% CI = 13.0–24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race.
CONCLUSIONS
ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.
doi:10.1111/j.1532-5415.2010.03287.x
PMCID: PMC3073492  PMID: 21361881
activities of daily living; staging; chronic disease; environment; biopsycho-ecological framework
7.  Can Standardized Sleep Questionnaires be Used to Identify Excessive Daytime Sleeping in Older Post-Acute Rehabilitation Patients? 
OBJECTIVES
Excessive daytime sleeping is associated with poorer functional outcomes in rehabilitation populations and may be improved with targeted interventions. The purpose of this study was to test simple methods of screening for excessive daytime sleeping among older adults admitted for post-acute rehabilitation.
DESIGN
Secondary analysis of data from two clinical samples.
SETTING
Two post-acute rehabilitation (PAR) units in southern California.
PARTICIPANTS
Two hundred twenty-six patients aged > 65 years with Mini-Mental State Examination (MMSE) score > 11 undergoing rehabilitation.
INTERVENTIONS
N/A
MEASUREMENTS
The primary outcome was excessive daytime sleeping, defined as greater than 15% (1.8 hours) of daytime hours (8AM to 8PM) sleeping as measured by actigraphy.
RESULTS
Participants spent, on average, 16.2% (SD 12.5%) of daytime hours sleeping as measured by actigraphy. Thirty nine percent of participants had excessive daytime sleeping. The Pittsburgh Sleep Quality Index (PSQI) was significantly associated with actigraphically-measured daytime sleeping (p= 0.0038), but the Epworth Sleepiness Scale (ESS) was not (p = 0.49). Neither the ESS nor the PSQI achieved sufficient sensitivity and specificity to be used as a screening tool for excessive daytime sleeping. Two additional models using items from these questionnaires were not significantly associated with the outcome.
CONCLUSIONS
In an older PAR population, self-report items from existing sleep questionnaires do not identify excessive daytime sleeping. Therefore we recommend objective measures for the evaluation of excessive daytime sleeping as well as further research to identify new self-report items that may be more applicable in PAR populations.
doi:10.1016/j.jamda.2010.05.004
PMCID: PMC3128693  PMID: 21450184
sleep; post-acute care; rehabilitation; screen
8.  The Vulnerable Elders-13 Survey Predicts 5-year Functional Decline and Mortality Outcomes Among Older Ambulatory Care Patients 
BACKGROUND
The Vulnerable Elders-13 Survey (VES-13) is a short tool that predicts functional decline and mortality over a 1–2 year follow-up interval. Prognosis over longer intervals is often needed in clinical care.
OBJECTIVE
To test the predictive properties of the VES-13 over a 5-year interval.
DESIGN
Longitudinal evaluation with mean follow-up of 4.5 years.
SETTING
Two managed-care organizations.
PARTICIPANTS
649 community-dwelling elders (age ≥75 and older) enrolled in the Assessing Care of Vulnerable Elders (ACOVE) observational study who screened positively for symptoms of fear of falling/falls, bothersome urinary incontinence, or memory problems.
MEASUREMENTS
VES-13 score (range 1–10, higher indicates worse prognosis); functional decline (defined as decline in count of 5 activities of daily living or nursing home entry); deaths.
RESULTS
Greater VES-13 scores are associated with greater predicted probability of death and decline among older patients over a mean observation period of 4.5 years. For each additional VES-13 point, the odds of the combined outcome of functional decline or death was 1.37 (95% CI 1.25–1.50), and the area under the receiver operating curve (AUC) was 0.75 (95% CI .71–.80). In the Cox proportional hazards model predicting time to death, the hazard ratio was 1.23 (95% CI 1.19–1.27) per additional VES-13 point.
CONCLUSION
This study extends the utility of the VES-13 to clinical decisions that require longer-term prognostic estimates of functional status and survival.
doi:10.1111/j.1532-5415.2009.02497.x
PMCID: PMC3181130  PMID: 19793154
vulnerable elder; functional decline; survival
9.  Formative evaluation of the telecare fall prevention project for older veterans 
Background
Fall prevention interventions for community-dwelling older adults have been found to reduce falls in some research studies. However, wider implementation of fall prevention activities in routine care has yielded mixed results. We implemented a theory-driven program to improve care for falls at our Veterans Affairs healthcare facility. The first project arising from this program used a nurse advice telephone line to identify patients' risk factors for falls and to triage patients to appropriate services. Here we report the formative evaluation of this project.
Methods
To evaluate the intervention we: 1) interviewed patient and employee stakeholders, 2) reviewed participating patients' electronic health record data and 3) abstracted information from meeting minutes. We describe the implementation process, including whether the project was implemented according to plan; identify barriers and facilitators to implementation; and assess the incremental benefit to the quality of health care for fall prevention received by patients in the project. We also estimate the cost of developing the pilot project.
Results
The project underwent multiple changes over its life span, including the addition of an option to mail patients educational materials about falls. During the project's lifespan, 113 patients were considered for inclusion and 35 participated. Patient and employee interviews suggested support for the project, but revealed that transportation to medical care was a major barrier in following up on fall risks identified by nurse telephone triage. Medical record review showed that the project enhanced usual medical care with respect to home safety counseling. We discontinued the program after 18 months due to staffing limitations and competing priorities. We estimated a cost of $9194 for meeting time to develop the project.
Conclusions
The project appeared feasible at its outset but could not be sustained past the first cycle of evaluation due to insufficient resources and a waning of local leadership support due to competing national priorities. Future projects will need both front-level staff commitment and prolonged high-level leadership involvement to thrive.
doi:10.1186/1472-6963-11-119
PMCID: PMC3127979  PMID: 21605438
10.  Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system 
Background
Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development.
Methods
We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.
Results
The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.
Conclusion
A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.
doi:10.1186/1472-6963-9-206
PMCID: PMC2779811  PMID: 19917122
11.  A Short Functional Survey is Responsive to Changes in Functional Status Among Vulnerable Elders 
OBJECTIVES
To investigate whether an abbreviated 5-item functional status survey consisting of 5 activities of daily living (ADLs) reflects changes measured over time in a full 12-item functional status survey (12 ADLs).
DESIGN
Longitudinal evaluation with mean follow-up of 11 months.
SETTING
Two managed-care organizations in the United States.
PARTICIPANTS
420 community-dwelling elders at moderate to high risk of death and functional decline enrolled in the Assessing Care of Vulnerable Elders (ACOVE) observational study.
MEASURES
Number of ADL abilities by the short (range 0–5) and full functional status surveys (range 0–12). Change in function as defined by a 1-point change in short score and 1–2 point change in full survey scores.
RESULTS
Changes in short functional status survey scores were highly correlated to changes in long survey scores (r=.88). On average, a 1-point change in the short survey score was associated with a 1.4 point change on the long survey score (p<.001). The short survey correctly classified 93% of those who declined by the long survey adjusting for chance agreement (kappa=.82) and was responsive to decline in function (sensitivity 82–94%, specificity 94–97%, and area under the receiver operating curve 0.91–0.93 for 1–2 point decreases in full survey ADL counts).
CONCLUSION
The short functional status survey is an efficient way to detect changes in functional status among vulnerable older populations for clinical and research purposes.
doi:10.1111/j.1532-5415.2008.01921.x
PMCID: PMC2597478  PMID: 18775036
Vulnerable Elders; Functional Decline; Functional Change
12.  How Much Is Postacute Care Use Affected by Its Availability? 
Health Services Research  2005;40(2):413-434.
Objective
To assess the relative impact of clinical factors versus nonclinical factors—such as postacute care (PAC) supply—in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care.
Data Sources and Study Setting
Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data.
Study Design
We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements.
Data Collection/Extraction Methods
A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999.
Principal Findings
PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there.
Conclusions
We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes—or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.
doi:10.1111/j.1475-6773.2005.00365.x
PMCID: PMC1361149  PMID: 15762900
postacute care; provider supply; Medicare; rehabilatation; nursing homes
13.  Quality Improvement Implementation in the Nursing Home 
Health Services Research  2003;38(1 Pt 1):65-83.
Objective
To examine quality improvement (QI) implementation in nursing homes, its association with organizational culture, and its effects on pressure ulcer care.
Data Sources/Study Settings
Primary data were collected from staff at 35 nursing homes maintained by the Department of Veterans Affairs (VA) on measures related to QI implementation and organizational culture. These data were combined with information obtained from abstractions of medical records and analyses of an existing database.
Study Design
A cross-sectional analysis of the association among the different measures was performed.
Data Collection/Extraction Methods
Completed surveys containing information on QI implementation, organizational culture, employee satisfaction, and perceived adoption of guidelines were obtained from 1,065 nursing home staff. Adherence to best practices related to pressure ulcer prevention was abstracted from medical records. Risk-adjusted rates of pressure ulcer development were calculated from an administrative database.
Principal Findings
Nursing homes differed significantly (p<.001) in their extent of QI implementation with scores on this 1 to 5 scale ranging from 2.98 to 4.08. Quality improvement implementation was greater in those nursing homes with an organizational culture that emphasizes innovation and teamwork. Employees of nursing homes with a greater degree of QI implementation were more satisfied with their jobs (a 1-point increase in QI score was associated with a 0.83 increase on the 5-point satisfaction scale, p<.001) and were more likely to report adoption of pressure ulcer clinical guidelines (a 1-point increase in QI score was associated with a 28 percent increase in number of staff reporting adoption, p<.001). No significant association was found, though, between QI implementation and either adherence to guideline recommendations as abstracted from records or the rate of pressure ulcer development.
Conclusions
Quality improvement implementation is most likely to be successful in those VA nursing homes with an underlying culture that promotes innovation. While QI implementation may result in staff who are more satisfied with their jobs and who believe they are providing better care, associations with improved care are uncertain.
doi:10.1111/1475-6773.00105
PMCID: PMC1360874  PMID: 12650381
Quality improvement; quality of care; nursing homes; decubitus ulcers
14.  Hospital Fall Prevention: A Systematic Review of Implementation, Components, Adherence, and Effectiveness 
Objectives
To systematically document the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals.
Design
Systematic review. Studies were identified through existing reviews, searching five electronic databases, screening reference lists, and contacting topic experts for studies published through August 2011.
Setting
U.S. acute care hospitals.
Participants
Studies reporting in-hospital falls for intervention groups and concurrent (e.g., controlled trials) or historic comparators (e.g., before–after studies).
Intervention
Fall prevention interventions.
Measurements
Incidence rate ratios (IRR, ratio of fall rate postintervention or treatment group to the fall rate preintervention or control group) and ratings of study details.
Results
Fifty-nine studies met inclusion criteria. Implementation strategies were sparsely documented (17% not at all) and included staff education, establishing committees, seeking leadership support, and occasionally continuous quality improvement techniques. Most interventions (81%) included multiple components (e.g., risk assessments (often not validated), visual risk alerts, patient education, care rounds, bed-exit alarms, and postfall evaluations). Fifty-four percent did not report on fall prevention measures applied in the comparison group, and 39% neither reported fidelity data nor described adherence strategies such as regular audits and feedback to ensure completion of care processes. Only 45% of concurrent and 15% of historic control studies reported sufficient data to compare fall rates. The pooled postintervention incidence rate ratio (IRR) was 0.77 (95% confidence interval = 0.52–1.12, P = .17; eight studies; I2: 94%). Meta-regressions showed no systematic association between implementation intensity, intervention complexity, comparator information, or adherence levels and IRR.
Conclusion
Promising approaches exist, but better reporting of outcomes, implementation, adherence, intervention components, and comparison group information is necessary to establish evidence on how hospitals can successfully prevent falls.
doi:10.1111/jgs.12169
PMCID: PMC3670303  PMID: 23527904
fall prevention; implementation; hospital; systematic review

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