OBJECTIVES:

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.

DESIGN:

Observational prospective cohort

SETTING and PARTICIPANTS:

Nationally representative sample of retirees over age 65 from the Health and Retirement Study in 2000 and 2002, followed to 2006 (n=6408).

MEASUREMENTS:

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.

RESULTS:

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).

CONCLUSION:

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.

Objectives

We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults.

Methods

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.

Results

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).

Conclusions

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.

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.

Objectives

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.

Results

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.

Conclusion

Rates of in-hospital initiation of osteoporosis treatment for hip fracture patients are very low and may represent an opportunity to improve care.

BACKGROUND

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.

OBJECTIVE

To assess health status and risk of homelessness of older pre-release prisoners, and to compare veterans with non-veterans.

DESIGN/PARTICIPANTS

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.

MAIN MEASURES

Veteran status, health status (based on self-report), and risk of homelessness (homelessness before arrest).

KEY RESULTS

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.

CONCLUSIONS

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.

Context

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.

Objective

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.

Results

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).

Conclusions

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.