A majority of the US adult population has one or more chronic conditions that require medical intervention and long-term self-management. Such conditions are among the 10 leading causes of mortality; ...an estimated 86% of the nation's $2.7 trillion in annual health care expenditures goes toward their treatment and management. Patient self-management of chronic diseases is increasingly essential to improve health behaviors, health outcomes, and quality of life and, in some cases, has demonstrated effectiveness for reducing health care utilization and the societal cost burden of chronic conditions. This review synthesizes the current state of the science of chronic disease self-management interventions and the evidence for their effectiveness, especially when applied with a systematic application of theories or models that account for a wide range of influences on behavior. Our analysis of selected outcomes from randomized controlled trials of chronic disease self-management interventions contained in 10 Cochrane systematic reviews provides additional evidence to demonstrate that self-management can improve quality of life and reduce utilization across several conditions.
The objective of this prospective, longitudinal study of patients with normal-tension glaucoma (NTG) was to determine whether patients with nocturnal hypotension are at greater risk for visual field ...(VF) loss over 12 months than those without nocturnal hypotension.
Prospective, longitudinal study.
Consecutive patients with NTG with at least 5 prior VF tests were screened for eligibility.
The baseline evaluation assessed demographic and clinical characteristics, covering systemic comorbid conditions, including systemic hypertension. All oral and ophthalmologic medications were recorded. A complete ophthalmological examination was performed at baseline and follow-up. Patients had their blood pressure (BP) monitored every 30 minutes for 48 hours with an ambulatory recording device at baseline and 6 and 12 months.
The primary outcome was based on the global rates of VF progression by linear regression of the mean VF threshold sensitivity over time (decibels/year).
Eighty-five patients with NTG (166 eyes; mean age, 65 years; 67% were women) were included. Of the 85 patients, 29% had progressed in the 5 VFs collected before study enrollment. The nocturnal mean arterial pressure (MAP) was compared with the daytime MAP. Multivariate analysis showed that the total time that sleep MAP was 10 mmHg below the daytime MAP was a significant predictor of subsequent VF progression (P<0.02).
Cumulative nocturnal hypotension predicted VF loss in this cohort. Our data suggest that the duration and magnitude of decrease in nocturnal blood pressure below the daytime MAP, especially pressures that are 10 mmHg lower than daytime MAP, predict progression of NTG. Low nocturnal blood pressure, whether occurring spontaneously or as a result of medications, may lead to worsening of VF defects.
Objective: Given the critical role of behavior in preventing and treating chronic diseases, it is important to accelerate the development of behavioral treatments that can improve chronic disease ...prevention and outcomes. Findings from basic behavioral and social sciences research hold great promise for addressing behaviorally based clinical health problems, yet there is currently no established pathway for translating fundamental behavioral science discoveries into health-related treatments ready for Phase III efficacy testing. This article provides a systematic framework for developing behavioral treatments for preventing and treating chronic diseases. Method: The Obesity-Related Behavioral Intervention Trials (ORBIT) model for behavioral treatment development features a flexible and progressive process, prespecified clinically significant milestones for forward movement, and return to earlier stages for refinement and optimization. Results: This article presents the background and rationale for the ORBIT model, a summary of key questions for each phase, a selection of study designs and methodologies well-suited to answering these questions, and prespecified milestones for forward or backward movement across phases. Conclusions: The ORBIT model provides a progressive, clinically relevant approach to increasing the number of evidence-based behavioral treatments available to prevent and treat chronic diseases.
Abstract Objective (1) To determine chronic illness costs for large cohort of primary care patients, (2) to develop prospective model predicting total costs over one year, using demographic and ...clinical information including widely used comorbidity index. Study Design and Setting Data including diagnostic, medication, and resource utilization were obtained for 5,861 patients from practice-based computer system over a 1-year period beginning December 1, 1993, for retrospective analysis. Hospital cost data were obtained from hospital cost accounting system. Results Average annual per patient cost was $2,655. Older patients and those with Medicare or Medicaid had higher costs. Hospital costs were $1,558, accounting for 58.7% of total costs. In the predictive model, individuals with higher comorbidity incurred exponentially higher annual costs, from $4,317 with comorbidity score of two, to $5,986 with score of three, to $13,326 with scores greater than seven. To use an adapted comorbidity index to predict total yearly costs, four conditions should be added to the index: hypertension, depression, and use of warfarin with a weight of one, skin ulcers/cellulitis, a weight of two. Conclusion The adapted comorbidity index can be used to predict resource utilization. Predictive models may help to identify targets for reducing high costs, by prospectively identifying those at high risk.
Abstract Purpose The mechanisms by which depressive symptoms negatively affect clinical outcomes in patients with coronary artery disease (CAD) remain poorly understood. Previous interventions that ...have attempted to treat depressive symptoms in patients with CAD to improve their clinical outcomes have been disappointing. Our objectives were, among a cohort of CAD patients, to evaluate the impact of depressive symptoms over time, controlling for comorbidity, in determining both successful long-term lifestyle change (ie, increased physical activity), and cardiovascular morbidity and mortality outcomes. In addition, we examined the impact of physical activity changes over time on 2 known mediators of cardiovascular morbidity: parasympathetic tone and inflammation. Methods Clinical data were previously collected (2004–2006) from 242 elective/urgent coronary angioplasty patients who participated in a prospective randomized controlled trial evaluating the efficacy of a behavioral intervention versus an educational control to motivate physical activity over 12 months. Exclusion criteria included: (1) inability to walk; (2) enrollment in other risk-reduction trials; (3) non-English speaking; and (4) lack of cardiologist’s permission to increase physical activity. Participants were assessed every 2 months for interval clinical events and physical activity. In addition, biomarkers were collected at baseline and at 12 months in a subset of 54 participants; these biomarkers included low-frequency heart rate variability (lfHRV), high-frequency heart rate variability (hfHRV), serum C-reactive protein, interleukin-6, and salivary cortisol. Findings The mean age of participants was 63 years and 30% were female. Overall, 37% had high depressive symptoms at baseline. Patients with high depressive symptoms who achieved an increase in physical activity of ≥336 kilocalories(kcal)/week by 12 months had significantly lower rates of cardiovascular morbidity/mortality (5.1% vs. 21.3%; odds ratio OR, 0.20, 95% CI, 0.04–0.98; P = 0.03). In a multivariate model examining cardiovascular morbidity/mortality in patients with high depressive symptoms, an increase in physical activity of ≥336 kcal/week reduced the risk of new cardiovascular morbidity/mortality (OR, 0.11 95% CI, 0.02–0.81; P < 0.03), and comorbidity increased the risk (OR, 1.58 95% CI, 1.18–2.13; P = 0.002). In a generalized structural equation model, increasing physical activity by ≥336 kcal/week decreased the risk of complications, and comorbidity increased the risk. Furthermore, increasing physical activity (≥336 kcal/week) predicted an increase in hfHRV, a marker of parasympathetic tone, and the increase in hfHRV predicted a reduction in the proinflammatory mediators interleukin-6 and C-reactive protein. Implications This study found a threshold in physical activity in CAD patients with depressive symptoms that is associated with a decrease in cardiovascular morbidity and mortality. Exercise maintenance at this level may improve clinical outcomes via enhanced parasympathetic tone and decreased inflammation. ClinicalTrials.gov identifier: NCT00248846.
ABSTRACT
BACKGROUND
Financial exploitation is the most common and least studied form of elder abuse. Previous research estimating the prevalence of financial exploitation of older adults (FEOA) is ...limited by a broader emphasis on traditional forms of elder mistreatment (e.g., physical, sexual, emotional abuse/neglect).
OBJECTIVES
1) estimate the one-year period prevalence and lifetime prevalence of FEOA; 2) describe major FEOA types; and 3) identify factors associated with FEOA.
DESIGN
Prevalence study with a random, stratified probability sample.
PARTICIPANTS
Four thousand, one hundred and fifty-six community-dwelling, cognitively intact adults age ≥ 60 years.
SETTING
New York State.
MAIN MEASURES
Comprehensive tool developed for this study measured five FEOA domains: 1) stolen or misappropriated money/property; 2) coercion resulting in surrendering rights/property; 3) impersonation to obtain property/services; 4) inadequate contributions toward household expenses, but respondent still had enough money for necessities and 5) respondent was destitute and did not receive necessary assistance from family/friends.
KEY RESULTS
One-year period FEOA prevalence was 2.7 % (95 % CI, 2.29–3.29) and lifetime prevalence was 4.7 % (95 % CI, 4.05–5.34). Greater relative risk (RR) of one-year period prevalence was associated with African American/black race (RR, 3.80; 95 % CI, 1.11–13.04), poverty (RR, 1.72; 95 % CI, 1.09–2.71), increasing number of non-spousal household members (RR, 1.16; 95 % CI, 1.06–1.27), and ≥ 1 instrumental activity of daily living (IADL) impairments (RR, 1.69; 95 % CI, 1.12–2.53). Greater RR of lifetime prevalence was associated with African American/black race (RR, 2.61; 95 % CI, 1.37–4.98), poverty (RR, 1.47; 95 % CI, 1.04–2.09), increasing number of non-spousal household members (RR, 1.16; 95 % CI, 1.12–1.21), and having ≥1 IADL (RR, 1.45; 95 % CI, 1.11–1.90) or ≥1 ADL (RR, 1.52; 95 % CI, 1.06–2.18) impairment. Living with a spouse/partner was associated with a significantly lower RR of lifetime prevalence (RR, 0.39; 95 % CI, 0.26–0.59)
CONCLUSIONS
Financial exploitation of older adults is a common and serious problem. Elders from groups traditionally considered to be economically, medically, and sociodemographically vulnerable are more likely to self-report financial exploitation.
Objective
To examine social network member characteristics associated with weight loss.
Methods
A cross‐sectional examination included egocentric network data from 245 Black and Hispanic adults with ...BMI ≥ 25 kg/m2 enrolled in a small change weight loss study. The relationships between weight loss at 12 months and characteristics of helpful and harmful network members (relationship, contact frequency, living proximity, and body size) were examined.
Results
There were 2,571 network members identified. Mean weight loss was −4.8 (±11.3) lbs. among participants with network help and no harm with eating goals vs. +3.4 (±7.8) lbs. among participants with network harm alone. In a multivariable regression model, greater weight loss was associated with help from a child with eating goals (P = 0.0002) and coworker help with physical activity (P = 0.01). Weight gain was associated with having network members with obesity living in the home (P = 0.048) and increased network size (P = 0.002).
Conclusions
There was greater weight loss among participants with support from children and coworkers. Weight gain was associated with harmful network behaviors and having network members with obesity in the home. Incorporating child and coworker support and evaluating network harm and the body size of network members should be considered in future weight loss interventions.
Participant attrition in longitudinal studies can introduce systematic bias, favoring participants who return for follow-up, and increase the likelihood that those with complications will be ...underestimated. Our aim was to examine the effectiveness of home follow-up (Home F/U) to complete the final study evaluation on potentially "lost" participants by: 1) evaluating the impact of including and excluding potentially "lost" participants (e.g., those who required Home F/U to complete the final evaluation) on the rates of study complications; 2) examining the relationship between timing and number of complications on the requirement for subsequent Home F/U; and 3) determining predictors of those who required Home F/U.
We used data from a randomized controlled trial (RCT) conducted from 1991-1994 among coronary artery bypass graft surgery patients that investigated the effect of High mean arterial pressure (MAP) (intervention) vs. Low MAP (control) during cardiopulmonary bypass on 5 complications: cardiac morbidity/mortality, neurologic morbidity/mortality, all-cause mortality, neurocognitive dysfunction and functional decline. We enhanced completion of the final 6-month evaluation using Home F/U.
Among 248 participants, 61 (25%) required Home F/U and the remaining 187 (75%) received Routine F/U. By employing Home F/U, we detected 11 additional complications at 6 months: 1 major neurologic complication, 6 cases of neurocognitive dysfunction and 4 cases of functional decline. Follow-up of 61 additional Home F/U participants enabled us to reach statistical significance on our main trial outcome. Specifically, the High MAP group had a significantly lower rate of the Combined Trial Outcome compared to the Low MAP group, 16.1% vs. 27.4% (p=0.032). In multivariate analysis, participants who were ≥ 75 years (OR=3.23, 95% CI 1.52-6.88, p=0.002) or on baseline diuretic therapy (OR=2.44, 95% CI 1.14-5.21, p=0.02) were more likely to require Home F/U. In addition, those in the Home F/U group were more likely to have sustained 2 or more complications (p=0.05).
Home visits are an effective approach to reduce attrition and improve accuracy of study outcome reporting. Trial results may be influenced by this method of reducing attrition. Older participants, those with greater medical burden and those who sustain multiple complications are at higher risk for attrition.
Sex and race have emerged as important contributors to the phenotypic heterogeneity of heart failure with preserved ejection fraction (HFpEF). However, there remains a need to identify important sex- ...and race-related differences in characteristics and outcomes using a nationally representative cohort.
Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project-Nationwide Inpatient Sample files between 2008 and 2012. Hospitalizations with a diagnosis of HFpEF were included for analysis. Demographics, hospital characteristics, and age-adjusted comorbidity prevalence rates were compared between men and women and whites and blacks. In-hospital mortality was determined and compared for each subgroup. Multivariable regression analyses were used to identify and compare correlates of in-hospital mortality for each subgroup. A sample of 1 889 608 hospitalizations was analyzed. Men with HFpEF were slightly younger than women with HFpEF and had a higher Elixhauser comorbidity score. Men experienced higher in-hospital mortality compared with women, a finding that was attenuated after adjusting for comorbidity. Blacks with HFpEF were younger than whites with HFpEF, with lower rates of most comorbidities. Hypertension, diabetes, anemia, and chronic renal failure were more common among blacks. Blacks experienced lower in-hospital mortality compared with whites, even after adjusting for age and comorbidity. Important correlates of mortality among all 4 subgroups included pulmonary circulation disorders, liver disease, and chronic renal failure. Atrial fibrillation was an important correlate of mortality only among women and blacks.
Differences in patient characteristics and outcomes reinforce the notion that sex and race contribute to the phenotypic heterogeneity of HFpEF.
•14.9% of adults with incident heart failure (HF) had cognitive impairment (CI).•Age, race, sex, education, and anticoagulation use were associated with CI.•The prevalence of CI among an age-, sex-, ...and race-matched cohort without HF was 13.4%.•Findings suggest that the majority of CI in HF occurs after the HF diagnosis.
Cognitive impairment (CI) is estimated to be present in 25%–80% of heart failure (HF) patients, but its prevalence at diagnosis is unclear. To improve our understanding of cognition in HF, we determined the prevalence of CI among adults with incident HF in the REGARDS study.
REGARDS is a longitudinal cohort study of adults ≥45 years of age recruited in the years 2003–2007. Incident HF was expert adjudicated. Cognitive function was assessed with the Six-Item Screener. The prevalence of CI among those with incident HF was compared with the prevalence of CI among an age-, sex-, and race-matched cohort without HF. The 436 participants with incident HF had a mean age of 70.3 years (SD 8.9), 47% were female, and 39% were black. Old age, black race, female sex, less education, and anticoagulation use were associated with CI. The prevalence of CI among participants with incident HF (14.9% 95% CI 11.7%–18.6%) was similar to the non-HF matched cohort (13.4% 11.6%–15.4%; P < .43).
A total of 14.9% of the adults with incident HF had CI, suggesting that the majority of cognitive decline occurs after HF diagnosis. Increased awareness of CI among newly diagnosed patients and ways to mitigate it in the context of HF management are warranted.
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