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1.  Glycemic Control and Urinary Incontinence in Women with Diabetes Mellitus 
Journal of Women's Health  2013;22(12):1049-1055.
Although many studies have shown that diabetes increases the risk for urinary incontinence, it is unclear whether poor glycemic control in women with diabetes is associated with incontinence. This study aims to determine the relationship between the hemoglobin A1c (HbA1c) level and urinary incontinence in a large, diverse cohort of older women.
We examined 6026 older women who responded to a survey (62% response rate) and were enrolled in the Diabetes and Aging Study, an ethnically stratified random sample of patients with diabetes enrolled in Kaiser Permanente Northern California. Our primary independent variable was the mean of all HbA1c measurements in the year preceding the survey. Outcomes included the presence/absence of incontinence and limitations in daily activities due to incontinence. We used modified Poisson regression and ordinal logistic regression models to account for age, race, body mass index, parity, diabetes treatment, duration of diabetes, and comorbidity.
Sixty-five percent of women reported incontinence (mean age 59±10 years). After adjustment, HbA1c levels were not associated with the presence or absence of incontinence. However, among women reporting incontinence, HbA1c ≥9% was associated with more limitations due to incontinence than HbA1c <6% (adjusted odds ratio 1.67, 95% confidence interval: 1.09–2.57).
In this cross-sectional analysis, HbA1c level is not associated with the presence or absence of incontinence. However, for women with incontinence, poor glycemic control (HbA1c ≥9%) is associated with more limitations in daily activities due to incontinence. Longitudinal studies are needed to determine whether improving glycemic control to HbA1c <9% leads to fewer limitations in daily activities due to incontinence.
PMCID: PMC3852603  PMID: 24032999
2.  Response Letter to Gazzaruso et al 
PMCID: PMC3759678  PMID: 23581935
4.  Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans 
Annals of internal medicine  2009;150(7):465-473.
The Veterans Health Administration, the American Cancer Society, and the American Geriatrics Society recommend colorectal cancer screening for older adults unless they are unlikely to live 5 years or have significant comorbidity that would preclude treatment.
To determine whether colorectal cancer screening is targeted to healthy older patients and is avoided in older patients with severe comorbidity who have life expectancies < 5 years.
Cohort study.
Minneapolis, Durham, Portland, and West LA VA’s with linked national VA and Medicare administrative claims.
27,068 patients > 70 years who had an outpatient visit in 2000 and an outpatient visit at 1 of 4 VA’s during 2001–2002 and due for screening.
The main outcome was receipt of fecal occult blood testing (FOBT), colonoscopy, sigmoidoscopy, or barium enema during 2001–2002 based on national VA and Medicare claims. Charlson comorbidity scores were used to stratify patients into 3 groups ranging from no comorbidity (score=0) to severe comorbidity (score > 4) and 5-year mortality was determined for each group.
46% of patients were screened during 2001–2002. Only 47% of patients with no comorbidity were screened despite having life expectancies > 5 years (5-year mortality=19%). While the incidence of screening declined with age and worsening comorbidity, it was still 41% for patients with severe comorbidity who had life expectancies < 5 years (5-year mortality=55%). The number of VA outpatient visits predicted screening independent of comorbidity, such that patients with severe comorbidity and > 4 visits had similar or higher screening rates than healthier patients with fewer visits.
Some tests may have been performed for non-screening reasons. The generalizability of findings to persons who do not use the VA is uncertain.
Advancing age was inversely associated with colorectal cancer screening while comorbidity was a weaker predictor. More attention to comorbidity is needed to better target screening to older patients with substantial life expectancies and avoid screening older patients with limited life expectancies.
PMCID: PMC3769097  PMID: 19349631
6.  The Risks and Benefits of Implementing Glycemic Control Guidelines in Frail Elders with Diabetes 
To determine the hypo- and hyper-glycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for Hemoglobin A1c (HbA1c)<8% in frail older patients with diabets.
Guideline Implementation in PACE (Program of All-Inclusive Care for the Elderly)
All patients in the Before (10/02–12/04, n=338), Early (1/05–6/06, n=289) and Late phases of guideline implementation (7/06–12/08, n=385) with a diagnosis of diabetes mellitus and at least one HbA1c measurement.
Clinician education in 2005 with annual monitoring of the proportion of each clinician’s patients with diabetes with HbA1c<8%.
Hypoglycemia (Blood sugar or BS<50), hyperglycemia (BS>400) and severe hypoglycemia (Emergency room or ER visit for hypoglycemia)
Before, Early and Late groups were similar in mean age, race/ethnicity, comorbidity and functional dependency. Antihyperglycemic medication use increased with more patients using metformin (28% Before versus 42% Late, p<0.001) and insulin (23% Before versus 34% Late, p<0.001), with more patients achieving the AGS glycemic target of HbA1c<8% (74% Before versus 84% Late, p<0.001). Episodes of hyperglycemia (per 100 person-years) decreased dramatically (159 Before versus 46 Late, p<0.001) and episodes of hypoglycemia were unchanged (10.1 versus 9.3, p=0.50). Episodes of severe hypoglycemia were increased in the Early period (1.1 Before versus 2.9 Early, p=0.03).
Implementing the AGS glycemic control guideline for frail elders led to fewer hyperglycemic episodes, but more severe hypoglycemic episodes requiring ER visits in the Early implementation period. Future glycemic control guideline implementation efforts should be coupled with close monitoring for severe hypoglycemia in the early implementation period.
PMCID: PMC3764989  PMID: 21480838
glycemic control; guideline; hypoglycemia; PACE; diabetes mellitus
7.  Predictors of urinary incontinence in community-dwelling frail older adults with diabetes mellitus in a cross-sectional study 
BMC Geriatrics  2014;14(1):137.
Diabetes mellitus is a potent risk factor for urinary incontinence. Previous studies of incontinence in patients with diabetes have focused on younger, healthier patients. Our objective was to characterize risk factors for urinary incontinence among frail older adults with diabetes mellitus in a real-world clinical setting.
We performed a cross-sectional analysis on enrollees at On Lok (the original Program for All-Inclusive Care of the Elderly) between October 2004 and December 2010. Enrollees were community-dwelling, nursing home-eligible older adults with diabetes mellitus (N = 447). Our outcome was urinary incontinence measures (n = 2602) assessed every 6 months as “never incontinent”, “seldom incontinent” (occurring less than once per week), or “often incontinent” (occurring more than once per week). Urinary incontinence was dichotomized (“never” versus “seldom” and “often” incontinent). We performed multivariate mixed effects logistic regression analysis with demographic (age, gender and ethnicity), geriatric (dependence on others for ambulation or transferring; cognitive impairment), diabetes-related factors (hemoglobin A1c level; use of insulin and other glucose-lowering medications; presence of renal, ophthalmologic, neurological and peripheral vascular complications), depressive symptoms and diuretic use.
The majority of participants were 75 years or older (72%), Asian (65%) and female (66%). Demographic factors independently associated with incontinence included older age (OR for age >85, 3.13, 95% CI: 2.15-4.56; Reference: Age <75) and African American or other race (OR 2.12, 95% CI: 1.14-3.93; Reference: Asian). Geriatric factors included: dependence on others for ambulation (OR 1.48, 95% CI: 1.19-1.84) and transferring (OR 2.02, 95% CI: 1.58-2.58) and being cognitively impaired (OR 1.41, 95% CI: 1.15-1.73). Diabetes-related factors associated included use of insulin (OR 2.62, 95% CI: 1.67-4.13) and oral glucose-lowering agents (OR 1.81, 95% CI: 1.33-2.45). Urinary incontinence was not associated with gender, hemoglobin A1c level or depressive symptoms.
Geriatric factors such as the inability to ambulate or transfer independently are important predictors of urinary incontinence among frail older adults with diabetes mellitus. Clinicians should address mobility and cognitive impairment as much as diabetes-related factors in their assessment of urinary incontinence in this population.
PMCID: PMC4274753  PMID: 25514968
Urinary incontinence; Frail older adults; Diabetes mellitus
8.  A Clinical Index to Predict Progression from Mild Cognitive Impairment to Dementia Due to Alzheimer's Disease 
PLoS ONE  2014;9(12):e113535.
Mild cognitive impairment is often a precursor to dementia due to Alzheimer's disease, but many patients with mild cognitive impairment never develop dementia. New diagnostic criteria may lead to more patients receiving a diagnosis of mild cognitive impairment.
To develop a prediction index for the 3-year risk of progression from mild cognitive impairment to dementia relying only on information that can be readily obtained in most clinical settings.
Design and Participants
382 participants diagnosed with amnestic mild cognitive impairment enrolled in the Alzheimer's Disease Neuroimaging Initiative (ADNI), a multi-site, longitudinal, observational study.
Main Predictors Measures
Demographics, comorbid conditions, caregiver report of participant symptoms and function, and participant performance on individual items from basic neuropsychological scales.
Main Outcome Measure
Progression to probable Alzheimer's disease.
Key Results
Subjects had a mean (SD) age of 75 (7) years and 43% progressed to probable Alzheimer's disease within 3 years. Important independent predictors of progression included being female, resisting help, becoming upset when separated from caregiver, difficulty shopping alone, forgetting appointments, number of words recalled from a 10-word list, orientation and difficulty drawing a clock. The final point score could range from 0 to 16 (mean [SD]: 4.2 [2.9]). The optimism-corrected Harrell's c-statistic was 0.71(95% CI: 0.68–0.75). Fourteen percent of subjects with low risk scores (0–2 points, n = 124) converted to probable Alzheimer's disease over 3 years, compared to 51% of those with moderate risk scores (3–8 points, n = 223) and 91% of those with high risk scores (9–16 points, n = 35).
An index using factors that can be obtained in most clinical settings can predict progression from amnestic mild cognitive impairment to probable Alzheimer's disease and may help clinicians differentiate between mild cognitive impairment patients at low vs. high risk of progression.
PMCID: PMC4259326  PMID: 25486250
9.  Hemoglobin A1c and Functional Decline in Community-Dwelling, Nursing-Home Eligible Elders with Diabetes 
Diabetes mellitus is a strong risk factor for functional decline in older patients. It is unclear whether Hemoglobin A1c (HbA1c) levels predict functional decline.
Longitudinal cohort study
Community-dwelling, nursing-home (NH) eligible patients with diabetes enrolled at On Lok between 10/2002 and 12/2008 (367 patients, 1579 HbA1c measurements).
On Lok Lifeways, the original model for Programs of All-Inclusive Care for the Elderly (PACE).
The outcomes were 1) functional decline and 2) functional decline or death at 2 years. Our primary predictor was HbA1c. We adjusted for age, gender, race/ethnicity, baseline function, comorbid conditions, length of time enrolled at On Lok, insulin use, as well as the clustering of HbA1c within patients with mixed-effects Poisson regression.
Mean age was 80 years and 185 patients (50%) were taking insulin. Sixty-three percent of our participants experienced functional decline and 75% experienced death or functional decline during the study period. At 2 years, higher HbA1c was associated with less functional decline or death (p for trend=0.006). Accounting for clustering and confounding factors, HbA1c 8–8.9% was associated with a decreased relative risk of functional decline or death compared to HbA1c 7–7.9% (0.88, 95% CI: 0.79–0.99).
Among community-dwelling, NH-eligible patients with diabetes, HbA1c of 8–8.9% is associated with better functional outcomes at 2 years compared to HbA1c of 7–7.9%. Our results suggest that the current AGS guideline recommending a HbA1c target of ≤8% for older patients with limited life expectancy may be lower than necessary to maintain function.
PMCID: PMC3566776  PMID: 22702660
Glycemic control; functional decline; Hemoglobin A1c
10.  Diabetes Mellitus Performance Measures in Patients with Limited Life Expectancy 
PMCID: PMC3281549  PMID: 22332676
11.  Transitional Care Challenges of Rehospitalized Veterans: Listening to Patients and Providers 
Population Health Management  2013;16(5):326-331.
Readmissions to the hospital are common and costly, often resulting from poor care coordination. Despite increased attention given to improving the quality and safety of care transitions, little is known about patient and provider perspectives of the transitional care needs of rehospitalized Veterans. As part of a larger quality improvement initiative to reduce hospital readmissions, the authors conducted semi-structured interviews with 25 patients and 14 of their interdisciplinary health care providers to better understand their perspectives of the transitional care needs and challenges faced by rehospitalized Veterans. Patients identified 3 common themes that led to rehospitalization: (1) knowledge gaps and deferred power; (2) difficulties navigating the health care system; and (3) complex psychiatric and social needs. Providers identified different themes that led to rehospitalization: (1) substance abuse and mental illness; (2) lack of social or financial support and homelessness; (3) premature discharge and poor communication; and (4) nonadherence with follow-up. Results underscore that rehospitalized Veterans have a complex overlapping profile of real and perceived physical, mental, and social needs. A paradigm of disempowerment and deferred responsibility appears to exist between patients and providers that contributes to ineffective care transitions, resulting in readmissions. These results highlight the cultural constraints on systems of care and suggest that process improvements should focus on increasing the sense of partnership between patients and providers, while simultaneously creating a culture of empowerment, ownership, and engagement, to achieve success in reducing hospital readmissions. (Population Health Management 2013;16:326–331)
PMCID: PMC3780306  PMID: 23560514
12.  Individualizing Life Expectancy Estimates for Older Adults Using the Gompertz Law of Human Mortality 
PLoS ONE  2014;9(9):e108540.
Guidelines recommend incorporating life expectancy (LE) into clinical decision-making for preventive interventions such as cancer screening. Previous research focused on mortality risk (e.g. 28% at 4 years) which is more difficult to interpret than LE (e.g. 7.3 years) for both patients and clinicians. Our objective was to utilize the Gompertz Law of Human Mortality which states that mortality risk doubles in a fixed time interval to transform the Lee mortality index into a LE calculator.
We examined community-dwelling older adults age 50 and over enrolled in the nationally representative 1998 wave of the Health and Retirement Study or HRS (response rate 81%), dividing study respondents into development (n = 11701) and validation (n = 8009) cohorts. In the development cohort, we fit proportional hazards Gompertz survival functions for each of the risk groups defined by the Lee mortality index. We validated our LE estimates by comparing our predicted LE with observed survival in the HRS validation cohort and an external validation cohort from the 2004 wave of the English Longitudinal Study on Ageing or ELSA (n = 7042).
The ELSA cohort had a lower 8-year mortality risk (14%) compared to our HRS development (23%) and validation cohorts (25%). Our model had good discrimination in the validation cohorts (Harrell’s c 0.78 in HRS and 0.80 in the ELSA). Our predicted LE’s were similar to observed survival in the HRS validation cohort without evidence of miscalibration (Hosmer-Lemeshow, p = 0.2 at 8 years). However, our predicted LE’s were longer than observed survival in the ELSA cohort with evidence of miscalibration (Hosmer-Lemeshow, p<0.001 at 8 years) reflecting the lower mortality rate in ELSA.
We transformed a previously validated mortality index into a LE calculator that incorporated patient-level risk factors. Our LE calculator may help clinicians determine which preventive interventions are most appropriate for older US adults.
PMCID: PMC4180452  PMID: 25265291
13.  Patterns of Multimorbidity in Elderly Veterans 
To determine patterns of co-occurring diseases in older adults and the extent to which these patterns vary between the young-old and the old-old.
Observational study.
Department of Veterans Affairs.
Veterans aged 65 years and older (1.9 million male, mean age 76 ± 7; 39,000 female, mean age 77 ± 8) with two or more visits to Department of Veterans Affairs (VA) or Medicare settings in 2007 and 2008.
The presence of 23 common conditions was assessed using hospital discharge diagnoses and outpatient encounter diagnoses from the VA and Medicare.
The mean number of chronic conditions (out of 23 possible) was 5.5 ± 2.6 for men and 5.1 ± 2.6 for women. The prevalence of most conditions increased with advancing age, although diabetes mellitus and hyperlipidemia were 11% to 13% less prevalent in men and women aged 85 and older than in those aged 65 to 74 (P < .001 for each). In men, the most common three-way combination of conditions was hypertension, hyperlipidemia, and coronary heart disease, which together were present in 37% of men. For women, the most common combination was hypertension, hyperlipidemia, and arthritis, which co-occurred in 25% of women. Reflecting their high population prevalence, hypertension and hyperlipidemia were both present in 9 of the 15 most common three-way disease combinations in men and in 11 of the 15 most common combinations in women. The prevalence of many disease combinations varied substantially between young-old and old-old adults.
Specific combinations of diseases are highly prevalent in older adults and inform the development of guidelines that account for the simultaneous presence of multiple chronic conditions.
PMCID: PMC4133992  PMID: 23035702
multimorbidity; aged; veterans; age effects
14.  Quality Indicators for Older Adults: Preventing Unintended Harms 
Jama  2011;306(13):1481-1482.
PMCID: PMC3285267  PMID: 21972311
Quality Indicators; Aging
15.  Volunteering, Driving Status and Mortality in US Retirees 
Volunteering is associated with lower mortality in the elderly. Driving is associated with health and well-being and driving cessation has been associated with decreased out-of-home activity levels including volunteering. We evaluated how accounting for driving status altered the relationship between volunteering and mortality in US retirees.
Observational prospective cohort
Nationally representative sample of retirees over age 65 from the Health and Retirement Study in 2000 and 2002, followed to 2006 (n=6408).
Participants self-reported their volunteering, driving status, age, gender and race/ethnicity, presence of chronic conditions, geriatrics syndromes, socioeconomic factors, functional limitations and psychosocial factors. Death by December 31, 2006 was the outcome.
For drivers, the mortality rates between volunteers (9%) and non-volunteers (12%) were similar; for limited or non-drivers, the mortality rate for volunteers (15%) was markedly lower compared to non-volunteers (32%). Our adjusted results showed that for drivers, the volunteering-mortality Odds Ratio (OR) was 0.90 (95%CI: 0.66–1.22), whereas for limited or non-drivers, the OR was 0.62 (95%CI: 0.49–0.78), (interaction p=0.05). The impact of driving status was greater for rural participants, with greater differences between rural drivers versus rural limited or non-drivers (interaction p=0.02) compared to urban drivers versus urban limited or non-drivers (interaction p=0.81).
The influence of volunteering in decreasing mortality seems to be stronger among rural retirees who are limited or non-drivers. This may be because rural or non-driving retirees are more likely to be socially isolated and thus receive more benefit from the increased social integration from volunteering.
PMCID: PMC3089440  PMID: 21314648
mortality; volunteerism; driving
17.  Missed Opportunities for Osteoporosis Treatment in Patients Hospitalized for Hip Fracture 
Although osteoporosis treatment with a combination of calcium, vitamin D (Cal+D) and an antiresorptive or bone-forming drug can dramatically reduce fracture risk, rates of treatment following hip fracture remain low. In-hospital initiation of recommended medications has improved outcomes in heart disease; hospitalization for hip fracture may represent a similar opportunity for improvement. Our objective was to examine rates of in-hospital treatment with 1) Cal+D and 2) antiresorptive or bone-forming medications in patients hospitalized for hip fractures.
Design, Setting, Participants and Measurements
Using pharmacy and discharge records from Perspective, a database developed to measure quality and health care utilization, we examined in-hospital osteoporosis treatment in 51,346 patients over age 65 hospitalized for osteoporotic hip fracture at 318 hospitals between October 2003 and September 2005. Our main outcome measures were the in-hospital administration of 1) Cal+D and 2) antiresorptive or bone-forming medications.
3,405 patients (6.6%) received Cal+D anytime after a procedure to correct femoral fracture. 3,763 patients (7.3%) received antiresorptive or bone-forming medications. Only 1023 patients (2%) were prescribed ideal therapy, receiving Cal+D and an antiresorptive or bone-forming medication. Treatment rates remained low across virtually all patient, provider, and hospital level characteristics. The strongest predictor of treatment with Cal+D was the receipt of an antiresorptive or bone-forming medication (Adjusted OR=5.50, 95% CI: 4.84–6.25); however, only 27% of patients who received these medications also received Cal+D.
Rates of in-hospital initiation of osteoporosis treatment for hip fracture patients are very low and may represent an opportunity to improve care.
PMCID: PMC2858360  PMID: 20398147
Osteoporosis; Hip Fracture; Calcium; Vitamin D
19.  Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study 
BMC Geriatrics  2014;14:35.
Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.
We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.
Twenty-nine percent of our cohort was considered “comatose” and “without any discernible consciousness”, suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.
ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.
PMCID: PMC3994482  PMID: 24650076
Tube feeding; Cognitive impairment; Nursing home; Emergency department; Hospitalization; Ambulatory care sensitive
20.  Chronic Conditions and Mortality Among the Oldest Old 
American journal of public health  2008;98(7):1209-1214.
We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults.
Participants in the 1998 wave of the Health and Retirement Study (N=19430) were divided into groups by decades of age, and their vital status in 2004 was determined. We used multivariate Cox regression to determine the ability of chronic conditions and functional limitations to predict mortality.
With increasing age, the ability of chronic conditions to predict mortality declines rapidly, whereas the ability of functional limitations to predict mortality declines more slowly. In younger participants (aged 50–59 years), chronic conditions were stronger predictors of death than were functional limitations (Harrell's C statistic 0.78 vs. 0.73; P=.001). In older participants (aged 90–99 years), functional limitations were stronger predictors of death than were chronic conditions (Harrell's C statistic 0.67 vs. 0.61; P=.004).
The importance of chronic conditions as a predictor of death declines rapidly with increasing age. Therefore, risk-adjustment models that only consider comorbidities when comparing mortality rates across providers may be inadequate for adults older than 80 years.
PMCID: PMC2424085  PMID: 18511714
21.  Prognostic Indices for Older Adults: A Systematic Review 
To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions.
We conducted a systematic review to help physicians assess the quality and limitations of prognostic indices for mortality in older adults.
Data Sources
We searched MEDLINE, EMBASE, Cochrane, and Google Scholar through November 2011.
Study Selection
We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was ≥ 60. We excluded indices that estimated ICU, disease-specific, or in-hospital mortality.
Data Extraction
For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy.
We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6-months to 5 years for older adults in a variety of clinical settings: the community (six indices), the nursing home (two indices), and the hospital (eight indices). At least 1 measure of transportability was tested for all but 3 indices. By our measures, no study was free from potential bias. While 13 indices had c-statistics ≥ 0.70, none of the indices had c-statistics ≥ 0.90. Only two indices were independently validated by investigators who were not involved in the index’s development.
We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.
PMCID: PMC3792853  PMID: 22235089
22.  A clinically-guided approach to improving performance measurement for hypertension 
Medical Care  2012;50(5):399-405.
Performance measures often fail to account for legitimate reasons why patients do not achieve recommended treatment targets.
We tested a novel performance measurement system for blood pressure control that was designed to mimic clinical reasoning. This clinically-guided approach focuses on (1) exempting patients for whom tight blood pressure control may not be appropriate or feasible, and (2) assessing blood pressure over time. Trained abstractors conducted structured chart reviews of 201 adults with hypertension in 2 VA healthcare systems. Results were compared with traditional methods of performance measurement.
Among 201 veterans, 183 (91%) were male, and mean age was 71 +/− 11 years. Using the clinically-guided approach, 61 patients (30%) were exempted from performance measurement. The most common reasons for exemption were inadequate opportunity to manage blood pressure (35 patients, 17%) and use of 4 or more antihypertensive medications (19 patients, 9%). Among patients eligible for performance measurement, there was little agreement on the presence of controlled vs. uncontrolled blood pressure when comparing the most recent blood pressure (the traditional approach) with an integrated assessment of control (kappa 0.14). After accounting for clinically-guided exemptions and methods of blood pressure assessment, only 15 of 72 patients (21%) whose last blood pressure was ≥140/90 mm Hg were classified as problematic by the clinically-guided approach.
Many patients have legitimate reasons for not achieving tight blood pressure control, and methods of blood pressure assessment have marked effects on whether a patient is classified as having adequate or inadequate blood pressure control.
PMCID: PMC3368331  PMID: 22627680
quality of health care; quality indicators; health care; hypertension; physician’s prescribing practices
23.  Predicting Alzheimer's risk: why and how? 
Because the pathologic processes that underlie Alzheimer's disease (AD) appear to start 10 to 20 years before symptoms develop, there is currently intense interest in developing techniques to accurately predict which individuals are most likely to become symptomatic. Several AD risk prediction strategies - including identification of biomarkers and neuroimaging techniques and development of risk indices that combine traditional and non-traditional risk factors - are being explored. Most AD risk prediction strategies developed to date have had moderate prognostic accuracy but are limited by two key issues. First, they do not explicitly model mortality along with AD risk and, therefore, do not differentiate individuals who are likely to develop symptomatic AD prior to death from those who are likely to die of other causes. This is critically important so that any preventive treatments can be targeted to maximize the potential benefit and minimize the potential harm. Second, AD risk prediction strategies developed to date have not explored the full range of predictive variables (biomarkers, imaging, and traditional and non-traditional risk factors) over the full preclinical period (10 to 20 years). Sophisticated modeling techniques such as hidden Markov models may enable the development of a more comprehensive AD risk prediction algorithm by combining data from multiple cohorts. As the field moves forward, it will be critically important to develop techniques that simultaneously model the risk of mortality as well as the risk of AD over the full preclinical spectrum and to consider the potential harm as well as the benefit of identifying and treating high-risk older patients.
PMCID: PMC3308022  PMID: 22126363
24.  Coming Home: Health Status and Homelessness Risk of Older Pre-release Prisoners 
Journal of General Internal Medicine  2010;25(10):1038-1044.
Older adults comprise an increasing proportion of the prison and homeless populations. While older age is associated with adverse post-release health events and incarceration is a risk factor for homelessness, the health status and homelessness risk of older pre-release prisoners are unknown. Moreover, most post-release services are geared towards veterans; it is unknown whether the needs of non-veterans differ from those of veterans.
To assess health status and risk of homelessness of older pre-release prisoners, and to compare veterans with non-veterans.
Cross-sectional study of 360 prisoners (≥55 years of age) within 2 years of release from prison using data from the 2004 Survey of Inmates in State and Federal Correctional Facilities.
Veteran status, health status (based on self-report), and risk of homelessness (homelessness before arrest).
Mean age was 61 years; 93.8% were men and 56.5% were white. Nearly 40% were veterans, of whom 77.2% reported likely VA service eligibility. Veterans were more likely to be white and to have obtained a high school diploma or GED. Overall, 79.1% reported a medical condition and 13.6% reported a serious mental illness. There was little difference in health status between veterans and non-veterans. Although 1 in 12 prisoners reported a risk factor for homelessness, the risk factors did not differ according to veteran status.
Older pre-release prisoners had a high burden of medical and mental illness and were at risk for post-release homelessness regardless of veteran status. Reentry programs linking pre-release older prisoners to medical and psychiatric services and to homelessness prevention programs are needed for both veterans and non-veterans.
PMCID: PMC2955468  PMID: 20532651
health status; homelessness risk; pre-release prisoners; older prisoners
25.  Association between hospital-reported Leapfrog Safe Practices Scores and Inpatient Mortality 
The Leapfrog Hospital Survey allows hospitals to self-report the steps they have taken towards implementing the “Safe Practices for Better Healthcare” endorsed by the National Quality Forum. Currently Leapfrog ranks hospital performance on the Safe Practices Leap by quartiles, and presents this information to the public on its website. It is unknown how well a hospital's resulting Safe Practices Score correlates with outcomes such as inpatient mortality.
To determine the relationship between hospitals’ Safe Practices Scores and risk-adjusted inpatient mortality rates.
Design, Setting, and Participants
Observational analysis of discharge data for all urban U.S. hospitals completing the 2006 Safe Practices Leap and identifiable in the Nationwide Inpatient Sample (NIS). Leapfrog provided a Safe Practices Score (SPS) for each hospital, as well as three alternative scores based on shorter versions of the original survey. Hierarchical logistic regression was used to determine the relationship between quartiles of SPS and risk-adjusted inpatient mortality, after adjusting for hospitals’ discharge volume and teaching status. Subgroup analyses were done on patients older than 65 years old and patients with greater than 5% expected mortality.
Main Outcome Measures
Inpatient risk-adjusted mortality, by quartiles of survey score.
155 of 1075 (14%) Leapfrog hospitals were identifiable in the NIS (1,772,064 discharges). Raw observed mortality in the primary sample was 2.09%. Fully adjusted mortality rates (95% confidence intervals in parentheses) by quartile of SPS, from lowest to highest, were 1.97% (1.78-2.18%), 2.04% (1.84-2.25%), 1.96% (1.77-2.16%), 2.00% (1.80-2.22%); p for linear trend =0.99. Results were similar in the subgroup analyses. None of the three alternative survey scores was associated with risk-adjusted inpatient mortality, although p values for linear trends were lower (0.80, 0.20, 0.11).
In this sample of 14% of all hospitals nationally that completed the Safe Practices Leap, survey scores were not significantly associated with risk-adjusted inpatient mortality.
PMCID: PMC2851624  PMID: 19336709

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