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1.  So Much Insulin, So Much Hypoglycemia 
JAMA internal medicine  2014;174(5):686-688.
doi:10.1001/jamainternmed.2013.13307
PMCID: PMC4067162  PMID: 24614940
2.  Glycemic Control and Urinary Incontinence in Women with Diabetes Mellitus 
Journal of Women's Health  2013;22(12):1049-1055.
Abstract
Background
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.
Methods
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.
Results
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).
Conclusion
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.
doi:10.1089/jwh.2012.4093
PMCID: PMC3852603  PMID: 24032999
3.  Response Letter to Gazzaruso et al 
doi:10.1111/jgs.12192
PMCID: PMC3759678  PMID: 23581935
5.  Impact of Age and Comorbidity on Colorectal Cancer Screening Among Older Veterans 
Annals of internal medicine  2009;150(7):465-473.
Background
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.
Objective
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.
Design
Cohort study.
Setting
Minneapolis, Durham, Portland, and West LA VA’s with linked national VA and Medicare administrative claims.
Patients
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.
Measurements
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.
Results
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.
Limitations
Some tests may have been performed for non-screening reasons. The generalizability of findings to persons who do not use the VA is uncertain.
Conclusions
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
7.  The Risks and Benefits of Implementing Glycemic Control Guidelines in Frail Elders with Diabetes 
BACKGROUND/OBJECTIVES
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.
DESIGN/SETTING
Guideline Implementation in PACE (Program of All-Inclusive Care for the Elderly)
PARTICIPANTS
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.
INTERVENTION
Clinician education in 2005 with annual monitoring of the proportion of each clinician’s patients with diabetes with HbA1c<8%.
MEASUREMENTS
Hypoglycemia (Blood sugar or BS<50), hyperglycemia (BS>400) and severe hypoglycemia (Emergency room or ER visit for hypoglycemia)
RESULTS
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).
CONCLUSION
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.
doi:10.1111/j.1532-5415.2011.03362.x
PMCID: PMC3764989  PMID: 21480838
glycemic control; guideline; hypoglycemia; PACE; diabetes mellitus
8.  Hemoglobin A1c and Functional Decline in Community-Dwelling, Nursing-Home Eligible Elders with Diabetes 
Background/Objectives
Diabetes mellitus is a strong risk factor for functional decline in older patients. It is unclear whether Hemoglobin A1c (HbA1c) levels predict functional decline.
Design
Longitudinal cohort study
Participants
Community-dwelling, nursing-home (NH) eligible patients with diabetes enrolled at On Lok between 10/2002 and 12/2008 (367 patients, 1579 HbA1c measurements).
Setting
On Lok Lifeways, the original model for Programs of All-Inclusive Care for the Elderly (PACE).
Measurements
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.
Results
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).
Conclusion
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.
doi:10.1111/j.1532-5415.2012.04041.x
PMCID: PMC3566776  PMID: 22702660
Glycemic control; functional decline; Hemoglobin A1c
9.  Diabetes Mellitus Performance Measures in Patients with Limited Life Expectancy 
doi:10.1111/j.1532-5415.2011.03783.x
PMCID: PMC3281549  PMID: 22332676
10.  Quality Indicators for Older Adults: Preventing Unintended Harms 
Jama  2011;306(13):1481-1482.
doi:10.1001/jama.2011.1418
PMCID: PMC3285267  PMID: 21972311
Quality Indicators; Aging
11.  Volunteering, Driving Status and Mortality in US Retirees 
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.
doi:10.1111/j.1532-5415.2010.03265.x
PMCID: PMC3089440  PMID: 21314648
mortality; volunteerism; driving
12.  Missed Opportunities for Osteoporosis Treatment in Patients Hospitalized for Hip Fracture 
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.
doi:10.1111/j.1532-5415.2010.02769.x
PMCID: PMC2858360  PMID: 20398147
Osteoporosis; Hip Fracture; Calcium; Vitamin D
14.  Potential Overtreatment of Diabetes Mellitus in Older Adults With Tight Glycemic Control 
JAMA internal medicine  2015;175(3):356-362.
IMPORTANCE
In older adults with multiple serious comorbidities and functional limitations, the harms of intensive glycemic control likely exceed the benefits.
OBJECTIVES
To examine glycemic control levels among older adults with diabetes mellitus by health status and to estimate the prevalence of potential overtreatment of diabetes.
DESIGN, SETTING, AND PARTICIPANTS
Cross-sectional analysis of the data on 1288 older adults (≥65 years) with diabetes from the National Health and Nutrition Examination Survey (NHANES) from 2001 through 2010 who had a hemoglobin A1c (HbA1c) measurement. All analyses incorporated complex survey design to produce nationally representative estimates.
EXPOSURES
Health status categories: very complex/poor, based on difficulty with 2 or more activities of daily living or dialysis dependence; complex/intermediate, based on difficulty with 2 or more instrumental activities of daily living or presence of 3 or more chronic conditions; and relatively healthy if none of these were present.
MAIN OUTCOMES AND MEASURES
Tight glycemic control (HbA1c level, <7%) and use of diabetes medications likely to result in hypoglycemia (insulin or sulfonylureas).
RESULTS
Of 1288 older adults with diabetes, 50.7% (95% CI, 46.6%–54.8%), representing 3.1 million (95% CI, 2.7–3.5), were relatively healthy, 28.1% (95% CI, 24.8%–31.5%), representing 1.7 million (95% CI, 1.4–2.0), had complex/intermediate health, and 21.2% (95% CI, 18.3%–24.4%), representing 1.3 million (95% CI, 1.1–1.5), had very complex/poor health. Overall, 61.5% (95% CI, 57.5%–65.3%), representing 3.8 million (95% CI, 3.4–4.2), had an HbA1c level of less than 7%; this proportion did not differ across health status categories (62.8% [95% CI, 56.9%–68.3%]) were relatively healthy, 63.0% (95% CI, 57.0%–68.6%) had complex/intermediate health, and 56.4% (95% CI, 49.7%–62.9%) had very complex/poor health (P = .26). Of the older adults with an HbA1c level of less than 7%, 54.9% (95% CI, 50.4%–59.3%) were treated with either insulin or sulfonylureas; this proportion was similar across health status categories (50.8% [95% CI, 45.1%–56.5%] were relatively healthy, 58.7% [95% CI, 49.4%–67.5%] had complex/intermediate health, and 60.0% [95% CI, 51.4%–68.1%] had very complex/poor health; P = .14). During the 10 study years, there were no significant changes in the proportion of older adults with an HbA1c level of less than 7% (P = .34), the proportion with an HbA1c level of less than 7% who had complex/intermediate or very complex/poor health (P = .27), or the proportion with an HbA1c level of less than 7% who were treated with insulin or sulfonylureas despite having complex/intermediate or very complex/poor health (P = .65).
CONCLUSIONS AND RELEVANCE
Although the harms of intensive treatment likely exceed the benefits for older patients with complex/intermediate or very complex/poor health status, most of these adults reached tight glycemic targets between 2001 and 2010. Most of them were treated with insulin or sulfonylureas, which may lead to severe hypoglycemia. Our findings suggest that a substantial proportion of older adults with diabetes were potentially overtreated.
doi:10.1001/jamainternmed.2014.7345
PMCID: PMC4426991  PMID: 25581565
15.  Chronic Conditions and Mortality Among the Oldest Old 
American journal of public health  2008;98(7):1209-1214.
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.
doi:10.2105/AJPH.2007.130955
PMCID: PMC2424085  PMID: 18511714
16.  Time to benefit for colorectal cancer screening: survival meta-analysis of flexible sigmoidoscopy trials 
Objective To determine the time to benefit of using flexible sigmoidoscopy for colorectal cancer screening.
Design Survival meta-analysis.
Data sources A Cochrane Collaboration systematic review published in 2013, Medline, and Cochrane Library databases.
Eligibility criteria Randomized controlled trials comparing screening flexible sigmoidoscopy with no screening. Trials with fewer than 100 flexible sigmoidoscopy screenings were excluded.
Results Four studies were eligible (total n=459 814). They were similar for patients’ age (50-74 years), length of follow-up (11.2-11.9 years), and relative risk for colorectal cancer related mortality (0.69-0.78 with flexible sigmoidoscopy screening). For every 1000 people screened at five and 10 years, 0.3 and 1.2 colorectal cancer related deaths, respectively, were prevented. It took 4.3 years (95% confidence interval 2.8 to 5.8) to observe an absolute risk reduction of 0.0002 (one colorectal cancer related death prevented for every 5000 flexible sigmoidoscopy screenings). It took 9.4 years (7.6 to 11.3) to observe an absolute risk reduction of 0.001 (one colorectal cancer related death prevented for every 1000 flexible sigmoidoscopy screenings).
Conclusion Our findings suggest that screening flexible sigmoidoscopy is most appropriate for older adults with a life expectancy greater than approximately 10 years.
doi:10.1136/bmj.h1662
PMCID: PMC4399600  PMID: 25881903
17.  Journalists, district attorneys and researchers: why IRBs should get in the middle 
BMC Medical Ethics  2015;16:19.
Background
Federal regulations in the United States have shaped Institutional Review Boards (IRBs) to focus on protecting individual human subjects. Health services research studies focusing on healthcare institutions such as hospitals or clinics do not have individual human subjects. Since U.S. federal regulations are silent on what type of review, if any, these studies require, different IRBs may approach similar studies differently, resulting in undesirable variation in the review of studies focusing on healthcare institutions. Further, although these studies do not focus on individual human subjects, they may pose risks to participating institutions, as well as individuals who work at those institutions, if identifying information becomes public.
Discussion
Using two recent health services research studies conducted in the U.S. as examples, we discuss variations in the level of IRB oversight for studies focusing on institutions rather than individual human subjects. We highlight how lack of IRB guidance poses challenges for researchers who wish to both protect their subjects and work appropriately with the public, journalists or the legal system in the U.S. Competing interests include the public’s interest in transparency, the researcher’s interest in their science, and the research participants’ interests in confidentiality. Potential solutions that may help guide health services researchers to balance these competing interests include: 1) creating consensus guidelines and standard practices that address confidentiality risk to healthcare institutions and their employees; and 2) expanding the IRB role to conduct a streamlined review of health services research studies focusing on healthcare institutions to balance the competing interest of stakeholders on a case-by-case basis.
Summary
For health services research studies focusing on healthcare institutions, we outline the competing interests of researchers, healthcare institutions and the public. We propose solutions to decrease undesirable variations in the review of these studies.
doi:10.1186/s12910-015-0015-y
PMCID: PMC4392736  PMID: 25889147
18.  Predictors of urinary incontinence in community-dwelling frail older adults with diabetes mellitus in a cross-sectional study 
BMC Geriatrics  2014;14:137.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2318-14-137
PMCID: PMC4274753  PMID: 25514968
Urinary incontinence; Frail older adults; Diabetes mellitus
19.  A Clinical Index to Predict Progression from Mild Cognitive Impairment to Dementia Due to Alzheimer's Disease 
PLoS ONE  2014;9(12):e113535.
Background
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.
Objective
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).
Conclusions
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.
doi:10.1371/journal.pone.0113535
PMCID: PMC4259326  PMID: 25486250
20.  Transitional Care Challenges of Rehospitalized Veterans: Listening to Patients and Providers 
Population Health Management  2013;16(5):326-331.
Abstract
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)
doi:10.1089/pop.2012.0104
PMCID: PMC3780306  PMID: 23560514
21.  Individualizing Life Expectancy Estimates for Older Adults Using the Gompertz Law of Human Mortality 
PLoS ONE  2014;9(9):e108540.
Background
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.
Methods
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).
Results
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.
Conclusion
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.
doi:10.1371/journal.pone.0108540
PMCID: PMC4180452  PMID: 25265291
22.  Patterns of Multimorbidity in Elderly Veterans 
OBJECTIVES
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.
DESIGN
Observational study.
SETTING
Department of Veterans Affairs.
PARTICIPANTS
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.
MEASUREMENTS
The presence of 23 common conditions was assessed using hospital discharge diagnoses and outpatient encounter diagnoses from the VA and Medicare.
RESULTS
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.
CONCLUSIONS
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.
doi:10.1111/j.1532-5415.2012.04158.x
PMCID: PMC4133992  PMID: 23035702
multimorbidity; aged; veterans; age effects
23.  “When Will it Help?” Incorporating Lagtime to Benefit into Prevention Decisions for Older Adults 
JAMA  2013;310(24):2609-2610.
doi:10.1001/jama.2013.282612
PMCID: PMC4049260  PMID: 24322396
24.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2318-14-35
PMCID: PMC3994482  PMID: 24650076
Tube feeding; Cognitive impairment; Nursing home; Emergency department; Hospitalization; Ambulatory care sensitive
25.  Prognostic Indices for Older Adults: A Systematic Review 
Context
To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions.
Objectives
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.
Results
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.
Conclusion
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.
doi:10.1001/jama.2011.1966
PMCID: PMC3792853  PMID: 22235089

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