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Objectives: Activity of daily living stages and instrumental activity of daily living stages demonstrated ordered associations with mortality, risk of hospitalization, and receipt of recommended care. This article explores the associations of stages with the following three dimensions of patient activation: self-care efficacy, patient-doctor communication, and health-information seeking. We hypothesized that higher activity of daily living and instrumental activity of daily living stages (greater limitation) are associated with a lower level of patient activation., Methods: Patient activation factors were derived from the 2004 and 2009 Medicare Current Beneficiary Survey. In this cross-sectional study (N = 8981), the associations of activity limitation stages with patient activation factors were assessed in latent factor models., Results: Greater activity limitation was in general inversely associated with self-efficacy, patient-doctor communication, and health information seeking, even after adjusting for sociodemographic and clinical characteristics. For instance, the mean of self-care efficacy across activity of daily living stages I-IV (mild, moderate, severe, and complete limitation) compared with stage 0 (no limitation) decreased significantly by 0.17, 0.29, 0.34, and 0.60, respectively. Covariates associated with suboptimal patient activation were also identified., Discussion: Our study identified multiple opportunities to improve patient activation, including providing support for older adults with physical impairments, at socioeconomic disadvantages, or with psychological or cognitive impairment.

Purpose: To examine the relationship between patient and tumor characteristics, patterns of breast cancer care, and 5-year survival among a population-based cohort of elderly women with incident breast cancer, with a special focus on identifying sources of socioeconomic (SES) disparities in outcomes., Methods: We identified women with newly diagnosed breast cancer in 2006-2009 from the Surveillance and Epidemiology End Result study linked with Medicare claims. A Classification and Regression Tree (CART) model was applied to 13 individual indicators of neoadjuvant and adjuvant breast cancer treatment, tumor characteristics, and patient sociodemographic variables to identify patterns with the greatest discriminant value in predicting 5-year survival. We subsequently examined the extent to which these patterns varied by the patient's SES., Results: Survival probabilities associated with the 18 unique CART-identified patterns ranged from 22 to 87%. The number of positive axillary nodes was the best single discriminator between high and lower survival outcomes. The most common discriminant factor among patterns with poor (< 25%) survival was the absence of radiation treatment, followed by the presence of comorbidities, tumor size > 2 cm, and no breast surgery. Relative to high SES women, poor women were nearly four times (12.3% vs. 3.2%, p < 0.001) as likely to be classified in the pattern associated with worse survival, and less likely (31.7% vs. 52.9%, p = 0.04) to receive the pattern associated with the greatest survival., Conclusions: Greater adoption of effective patterns of care could improve survival of elderly women with incident breast cancer overall, and reduce SES disparities therein.

Background: Despite clear guidelines for its use and wide adoption, no population-based study has examined the extent to which patients with early stage breast cancer are benefiting from sentinel lymph node biopsy (SLNB) by being spared a potentially avoidable axillary lymph node dissection (ALND) and its associated morbidity., Objective: Examine variation in type of axillary surgery performed by surgeon volume; investigate the extent and consequences of potentially avoidable ALND., Research Design/subjects: Observational study of older women with pathologically node-negative stage I-II invasive breast cancer who underwent surgery in a SEER state in 2008-2009., Measures: Surgeon annual volume of breast cancer cases and type of axillary surgery were determined by Medicare claims. An estimated probability of excess lymphedema due to ALND was calculated., Results: Among 7686 pathologically node-negative women, 49% underwent ALND (either initially or after SLNB) and 25% were operated on by low-volume surgeons. Even after adjusting for demographic and tumor characteristics, women treated by higher volume surgeons were less likely to undergo ALND [medium volume: odds ratio, 0.69 (95% confidence interval, 0.51-0.82); high volume: odds ratio, 0.59 (95% confidence interval, 0.45-0.76)]. Potentially avoidable ALND cases were estimated to represent 21% of all expected lymphedema cases., Conclusions: In this pathologically node-negative population-based breast cancer cohort, only half underwent solely SLNB. Patients treated by low-volume surgeons were more likely to undergo ALND. Resources and guidelines on the appropriate training and competency of surgeons to assure the optimal performance of SLNB should be considered to decrease rates of potentially avoidable ALND and lymphedema.

Background: The purpose of this study was to examine variations in delivery of several breast cancer processes of care that are correlated with lower mortality and disease recurrence, and to determine the extent to which hospital volume explains this variation., Methods: Women who were diagnosed with stage I-III unilateral breast cancer between 2007 and 2011 were identified within the National Cancer Data Base. Multiple logistic regression models were developed to determine whether hospital volume was independently associated with each of 10 individual process of care measures addressing diagnosis and treatment, and 2 composite measures assessing appropriateness of systemic treatment (chemotherapy and hormonal therapy) and locoregional treatment (margin status and radiation therapy)., Results: Among 573,571 women treated at 1755 different hospitals, 38%, 51%, and 10% were treated at high-, medium-, and low-volume hospitals, respectively. On multivariate analysis controlling for patient sociodemographic characteristics, treatment year and geographic location, hospital volume was a significant predictor for cancer diagnosis by initial biopsy (medium volume: odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.05-1.25; high volume: OR = 1.30, 95% CI = 1.14-1.49), negative surgical margins (medium volume: OR = 1.15, 95% CI = 1.06-1.24; high volume: OR = 1.28, 95% CI = 1.13-1.44), and appropriate locoregional treatment (medium volume: OR = 1.12, 95% CI = 1.07-1.17; high volume: OR = 1.16, 95% CI = 1.09-1.24)., Conclusions: Diagnosis of breast cancer before initial surgery, negative surgical margins and appropriate use of radiation therapy may partially explain the volume-survival relationship. Dissemination of these processes of care to a broader group of hospitals could potentially improve the overall quality of care and outcomes of breast cancer survivors. Cancer 2017;123:957-66. © 2016 American Cancer Society., (© 2016 American Cancer Society.)

Background: Breast cancer patients exhibit survival disparities based on socioeconomic status (SES). Disparities may be attributable to access to expensive oral endocrine agents., Objectives: Define recent socioeconomic disparities in breast cancer survival and determine whether these improved after implementation of the Medicare Part D program., Design: Difference-in-difference natural experiment of women diagnosed and treated before or after implementation of Medicare Part D., Subjects: Female Medicare beneficiaries with early-stage breast cancer: 54,772 diagnosed in 2001 and 46,371 in 2007., Measures: SES was based on Medicaid enrollment and zip code per capita income, all-cause mortality from Medicare, and cause of death from National Death Index., Results: Among women diagnosed pre-Part D, 40.5% of poor beneficiaries had died within 5 years compared with 20.3% of high-income women (P<0.0001). Post-Part D, 33.6% of poor women and 18.4% of high-income women died by 5 years. After adjustment for potential confounders, improvement in all-cause mortality post-Part D was greater for poorer women compared with more affluent women (P=0.002). However, absolute improvement in breast cancer-specific mortality was 1.8%, 1.2%, and 0.8% (P=0.88 for difference in improvement by SES), respectively for poor, near-poor, and high-income women, whereas analogous improvement in mortality from other causes was 5.1%, 3.8%, and 0.9% (P=0.067 for difference in improvement by SES)., Conclusions: Large survival disparities by SES exist among breast cancer patients. The Part D program successfully ameliorated SES disparities in all-cause mortality. However, improvement was concentrated in causes of death other than breast cancer, suggesting remaining gaps in care.

Objective: To reexamine the relationship of hospital and surgical volume to all-cause and breast cancer-specific mortality, taking into account the potential selection bias in patients treated at high-volume centers or by high-volume surgeons., Data Sources: Elderly (65+) women with early-stage, incident breast cancer surgery in 2003., Study Design: A population-based, prospective survey study., Methods: Two-stage, instrumental variable regression models., Principal Findings: Women treated in high-volume hospitals were significantly less likely to die of any cause by 5 years after surgery, even after adjustments for self-selection and a number of other factors. The relationship was larger and more significant for breast cancer-specific mortality. Although the general pattern of better mortality outcomes held for moderately sized hospitals, the relationships were not statistically significant. In contrast, there was no relationship of surgeon volume with all-cause or breast cancer-specific mortality., Conclusions: Hospital volume, but not surgeon volume, is associated with better survival among women with breast cancer. The magnitude of the potential improvement was substantial and comparable with the benefit conferred by many systemic therapies. These findings highlight the importance of accounting for patient self-selection in volume-outcome analyses, and provide support for policy initiatives aimed at regionalizing breast cancer care in the United States.

There is a growing body of literature linking hospital volume to outcomes in breast cancer. However, the mechanism through which volume influences outcome is poorly understood. The purpose of this study was to examine the relationship between hospital volume of breast cancer cases and patterns of processes of care in a population-based cohort of Medicare patients. A previously described and validated algorithm was applied to Medicare claims for newly diagnosed breast cancer cases in 2003 to identify potential subjects. Breast cancer patients were recruited to participate in a survey study examining breast cancer outcomes, and data were merged with Medicare claims and state tumor registries. Hospital volume was divided into tertiles. A Classification and Regression Tree (CART) model was performed to look for statistically significant relationships between patterns of processes of care and hospital volume. Using CART analysis, eight patterns of care were identified that differentiated breast cancer care at high- versus low-volume hospitals. Sentinel lymph node dissection (SLND) was the single process of care that demonstrated the greatest differentiation across hospitals with differing volumes. Four patterns of care significantly predicted that a patient was less likely to be treated at a high-volume hospital. Our study demonstrates differences in patterns of processes of care between low- and high-volume hospitals. Hospital volume was associated with several patterns of care that reflect the most current standards of care, particularly SLND. Greater adoption of these patterns by low-volume hospitals could improve the overall quality of care for breast cancer.

Objective: To examine whether patient satisfaction and perceived quality of medical care are related to stages of activity limitations among older adults., Design: Cross-sectional study., Setting: Medicare Current Beneficiary Survey (MCBS) for calendar years 2001 to 2011., Participants: A population-based sample (N=42,584) of persons aged ≥65 years living in the community., Interventions: Not applicable., Main Outcome Measures: MCBS questions were categorized under 5 patient satisfaction and perceived quality dimensions: care coordination and quality, access barriers, technical skills of primary care physicians, interpersonal skills of primary care physicians, and quality of information provided by primary care physicians. Persons were classified into a stage of activity limitation (0-IV) derived from self-reported difficulty levels performing activities of daily living (ADL) and instrumental ADL., Results: Compared with older beneficiaries with no limitations at ADL stage 0, the adjusted odds ratios (ORs) for stage I (mild) to stage III (severe) for satisfaction with care coordination and quality ranged from .85 (95% confidence interval [CI], .80-.92) to .79 (95% CI, .70-.89). Compared with ADL stage 0, satisfaction with access barriers ranged from OR=.81 (95% CI, .76-.87) at stage I to a minimum of OR=.67 (95% CI, .59-.76) at stage III. Similarly, compared with older beneficiaries at ADL stage 0, perceived quality of the technical skills of their primary care physician ranged from OR=.87 (95% CI, .82-.94) at stage I to a minimum of OR=.81 (95% CI, .72-.91) at stage III., Conclusions: Medicare beneficiaries at higher stages of activity limitation, although not necessarily the highest stage of activity limitation, reported less satisfaction with medical care., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The high expense of newer, more effective adjuvant endocrine therapy agents (aromatase inhibitors [AIs]) for postmenopausal breast cancer contributes to socioeconomic disparities in breast cancer outcomes. This study compares endocrine therapy costs for breast cancer patients during the first five years of Medicare Part D implementation, and when generic alternatives became available., Methods: The out of pocket patient costs for AIs and tamoxifen under Medicare Part D drug plans were determined for 2006-2011 from the CMS Website for the 50 US states and District of Columbia., Results: Between 2006 and 2010, the mean annual patient drug cost under Medicare Part D in the median state rose 19% for tamoxifen, 113% for anastrozole, 89% for exemestane, and 129% for letrozole, resulting in median annual out of pocket costs in 2010 of $701, $3050, $2804, and $3664 respectively. However, the 2011 availability of generic AI preparations led to median annual costs in 2011 of $804, $872, $1837, and $2217 respectively. Not included in the reported patient costs, the mean monthly drug premiums in the median state increased 58% in 2011 compared to 2007., Conclusions: The more effective AI agents became considerably more expensive during the first several years of the Medicare Part D program. Cost decreased with the introduction of generic agents, an intervention that was independent of the Part D program. It is unlikely that the Part D program ameliorated existing socioeconomic disparities in survival among breast cancer patients, but the availability of generic agents may do so.

Objective: To test the hypotheses that patients undergoing major lower limb amputations who received postacute care at an inpatient rehabilitation facility (IRF) would experience higher prosthesis use and satisfaction and lower prosthesis-related adverse effects than those treated at a skilled nursing facility (SNF) or at home., Design: Population-based, observational, prospective, multicenter study., Setting: Hospitals and communities in 2 racially and geographically diverse states., Participants: Patients 21 years and older who were identified during the surgical acute care stay as undergoing major lower limb amputations., Main Outcome Measures: Prosthesis use; satisfaction with prosthesis' comfort, appearance, and gait; and the presence of skin irritation, pain, and wounds as a result of prosthesis use., Methods: Two-stage instrumental variable models applied to data collected from medical records and patient interviews., Results: Only 149 (50.2%) of the 297 study participants had a prosthesis at the 6-month follow-up. Regression-adjusted outcomes indicate that patients treated at IRFs used their prosthesis more hours per week (52.8 versus 36.2 h/wk or 46% higher use), were less likely to experience prosthesis-related pain (16% versus 33.7%) and were significantly more likely to be satisfied with their gait (76.1% versus 59.3%) than were patients treated at SNFs. No significant differences in outcomes were found between patients who received care at an IRF and patients who were discharged home., Conclusions: These results add to the growing body of literature suggesting a general pattern of better outcomes for persons with vascular-related amputations who receive postacute care at IRFs relative to SNFs., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Growing numbers of older women receive adjuvant breast cancer therapies, but little is known about the long-term effects of current therapies upon health-related quality of life outside of clinical trials., Methods: A population-based cohort of postmenopausal women with incident breast cancer aged sixty-five and older was identified from Medicare claims from four states and followed over five years. General health-related quality of life (HRQOL) was assessed using the Medical Outcomes Study SF-12 Health Survey, and breast cancer-related HRQOL was assessed using the breast cancer subscale of the functional assessment of cancer therapy (FACT-B BCS). The association of HRQOL with sociodemographic variables, comorbidity, and breast cancer variables (stage, treatments, and treatment sequelae) was examined in longitudinal models., Results: Among the 3083 older breast cancer survivors, general HRQOL as measured by SF-12 mental and physical component scores was similar to norms for non-cancer populations, and remained stable throughout follow-up. Breast cancer treatments, including surgery and radiation, adjuvant hormonal therapy, and cytotoxic chemotherapy were not associated with worsened general health scores. A similar pattern was seen for breast cancer-related HRQOL scores, except that chemotherapy was associated with slightly worse scores. Lymphedema occurred in 17% of the cohort, and was strongly associated with all measures of HRQOL. Reductions in general HRQOL with lymphedema development were larger than those with an age increase of 10 years., Conclusions: There is little association of breast cancer treatment with HRQOL in older breast cancer patients followed for up to five years, but the development of lymphedema is associated with substantial reductions in HRQOL., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The authors examined the effects of marital status and family structure on disability, institutionalization, and longevity for a nationally representative sample of elderly persons using Gompertz duration models applied to longitudinal data from 3 cohorts of the Health and Retirement Study ( N = 11,481). They found that parents with only stepchildren have worse outcomes than parents with only biological children. Elderly mothers with only stepchildren become disabled and institutionalized sooner, and elderly men with only stepchildren have shorter longevity relative to their counterparts with only biological children. The effect of membership in a blended family differs by gender. Relative to those with only biological children, women in blended families have greater longevity and become disabled later, whereas men in blended families have reduced longevity. The findings indicate that changing marital patterns and increased complexity in family life have adverse effects on late-life health outcomes.

Objective: To examine the effect of postacute rehabilitation settings on depression and emotional and social functioning among patients undergoing major lower extremity dysvascular amputations., Design: A population-based, prospective cohort study., Setting: Two racially diverse metropolitan areas (Baltimore, Maryland, and Milwaukee, Wisconsin)., Patients: Persons undergoing major amputation., Methods: Data were collected from medical records and patient interviews during acute hospitalization, and 6-month postamputation data were analyzed with use of multivariate regression techniques., Main Outcome Measures: Multivariate regressions were used to examine the independent effect of postacute rehabilitation setting on the probability of experiencing depression, low mental health, low social functioning, and low emotional role functioning 6 months postindex amputation, while controlling for preamputation functioning and an array of potential confounders, including pre-existing medical conditions, sociodemographic characteristics, baseline health, and functional status described previously., Results: Of the 297 patients participating in the study, 43.4% received most of their inpatient postacute care at an inpatient rehabilitation facility (IRF), 32% at a skilled nursing facility (SNF), and 24.6% were discharged home with no inpatient rehabilitation. Even after we adjusted for preamputation characteristics and potential selection bias into the postacute care setting, patients receiving postacute care at an IRF were significantly less likely than those receiving postacute care at an SNF or home to experience depressive symptoms. Patients receiving care at IRFs were also less likely to report low emotional functioning than their counterparts receiving postamputation care at home or in an SNF. Patients in IRFs also reported better social functioning than did those who received postacute care in SNFs., Conclusions: This study showed an association between reduction in depressive symptoms and emotional suffering and management after lower limb amputation on an inpatient rehabilitation unit. These results add to the growing body of literature suggesting better outcomes for persons with vascular-related amputations who receive care at an IRF relative to other postacute care settings., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Purpose: Population-based studies have revealed higher mortality among breast cancer patients treated in low-volume hospitals. Other studies have demonstrated disparities in race and socioeconomic status (SES) in breast cancer survival. The purpose of our study was to determine whether nonwhite or low-SES patients are disproportionately treated in low-volume hospitals., Methods: A population-based cohort of 2,777 Medicare breast cancer patients who underwent breast cancer surgery in 2003 participated in a survey study examining breast cancer outcomes. Information was obtained from survey responses, Medicare claims, and state tumor registry data., Results: On univariate analysis, patients treated at low-volume hospitals were less likely to be white, less likely to live in an urban location, and more likely to have a low SES with less social support and live a greater distance from a high-volume hospital. Education, marital status, total household income, having additional insurance besides Medicare, population density of primary residence, and tangible support were associated with distance to the nearest high-volume hospital. On multivariate analysis, the independent predictors of treatment at a low-volume hospital were being nonwhite (P = 0.003), having a lower household income (P < 0.0001), residence in a rural location (P = 0.01), and living a greater distance from a high-volume hospital (P < 0.0001)., Conclusions: In this large population-based cohort, women who were poorer, nonwhite, and who lived in a rural location or at a greater distance from a high-volume hospital were more likely to be treated at low-volume hospitals. These differences may partially explain racial and SES disparities in breast cancer outcomes.

Objective: To examine the factors affecting postacute care discharge decisions among persons undergoing major lower limb amputations as a result of dysvascular causes., Design: A population-based, multicenter prospective study., Setting: Eighteen participating hospitals in Baltimore, Maryland, and Milwaukee, Wisconsin, served as the referral base for this study., Patients: The study population consisted of patients aged 21 years or older who underwent a major (foot or higher level) lower limb amputation as a result of dysvascular causes., Methods: Patients were identified and recruited during their acute hospital admission at one of the participating hospitals. Data were drawn from (1) acute care medical chart reviews; (2) surveys administered shortly after patients underwent amputation, while they were receiving acute care, that assessed their function the month before amputation and other demographic and social information; and (3) a 6-month follow-up telephone interview., Main Outcome Measures: The outcome of interest was the postacute discharge setting in which the initial rehabilitation services, if any, were delivered to the patient during the reference period of 6 months after index amputation surgery. Discharge to alternative postacute settings--inpatient rehabilitation facility (IRF), skilled nursing facility (SNF, reference category), and home--were contrasted with use of t- and χ(2) test statistics. A 3-category, multinominal logit model was used to examine the independent effects of sociodemographic, geographic, health, and amputation-related characteristics on the likelihood of discharge to alternative settings., Results: A total of 348 patients consented to participate in the study, with an overall participation rate of 87.1%. One hundred ninety-two patients (55.2%) were discharged to an IRF, 73 (21%) were discharged to an SNF, and 83 (23.8%) were discharged directly home. The mean age of the sample was 63.7 years; the majority (59.2%) were men, and more than one quarter African Americans. More than half of those reporting were poor (income <$15,000/year). On average, patients had 5 co-morbidities, and nearly half had an amputation at the below-knee level. Discharge to an IRF (versus an SNF) was more likely in patients who were married, had greater cognitive functioning, had unilateral below-knee amputations, had Medicaid coverage, and were living in Milwaukee, Wisconsin. Patients were less likely to be discharged home (versus to an SNF) if they were older, unmarried, had a previous history of nursing home residence, and had more perioperative complications. Discharge destination was not affected by gender or race., Conclusion: Postacute care decisions largely appear to be made on the basis of medical and family support factors. The findings of this research provide a necessary first step in the challenging task of assessing and quantitatively modeling the long-term functional outcomes of persons who receive postacute care in alternative settings by allowing more optimal case mix adjustment for factors that simultaneously influence rehabilitation setting and outcomes., (Copyright © 2011 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background: Blood pressure (BP) control remains elusive for many Americans. Although home health nurses are uniquely positioned to help vulnerable individuals achieve BP control, hypertension (HTN) management has not been a high priority in post-acute care., Objective: To examine the effects of two home-based interventions designed to improve BP outcomes among high-risk African-American patients., Design: Cluster randomized controlled trial., Participants: A total of 845 newly admitted patients with uncontrolled HTN (JNC7 stages 1 or 2)., Interventions: The "basic" intervention delivered key HTN information to clinicians and patients, and a home BP monitor to patients, while the patients received usual post-acute care. The "augmented" intervention provided more intensive and extensive HTN information, monitoring and feedback for 3 months beyond the index home care admission., Measures: Primary: BP control. Secondary: reductions in mmHG SBP and DBP, improvements in proportions improving JNC7 stage or achieving clinically meaningful reductions in SBP and DBP., Methods: Multivariate regression models., Key Results: The basic intervention produced no significant BP improvements; the augmented intervention significantly improved stage 2 patients' outcomes. Among stage 2 patients, the augmented intervention increased BP control by 8.7 percentage points relative to usual care (8.9% vs. 17.6%; p=0.01), yielded an 8.3 mmHG relative reduction in SBP (p=0.01), and increased the proportion achieving at least a 20 mmHG reduction in SBP by 16.4 percentage points (p=0.01)., Conclusion: Among stage 2 patients, a nurse-led intervention providing additional HTN medication review and patient self-management support during the 3-month post-acute care period yielded significant improvements in 3-month BP control, plus improvements in secondary BP outcomes.

Objectives: To examine whether stability of living arrangements and changes in household composition-both types and frequency-influence nursing home placement or timing to entry among older people., Methods: Data from the first 5 waves of the Assets and Health Dynamics of the Elderly (1993-2002) on 8,093 persons aged 70 years or older at baseline are used in probit and hazard models to predict nursing home entry and time to entry., Results: Stable living arrangements carry different risks of institutionalization. Those living continuously alone or with others were at highest risk; at lowest risk were those living continuously with a spouse or the same child (lowest overall). Changes in household composition were protective against nursing home entry and slowed time to entry; types of change were not influential when number of changes was taken into account., Discussion: Results suggest that stability of living arrangements in and of itself is not protective against institutionalization. Having options that allow one to change living arrangements over time in response to changing needs for assistance is of importance if the goal is to avoid institutional care or extend community residence prior to entry.

Rationale: Adjuvant hormone therapy (HT) based on tamoxifen (TX) or aromatase inhibitors (AIs) has become the standard of care for treating hormone receptor -positive (HR+) breast cancer (BC) over the past 20 years. Based on clinical trial results, AI use is recommended by the American Society of Clinical Oncology for treatment of postmenopausal women with HR+ breast cancer. AIs, however, are significantly more expensive than TX, raising concerns about access and use of effective treatment among women of lower socio-economic status., Objectives: To examine the relationship between adjuvant HT modality and experience of financial hardship among a cohort of older BC survivors. Also, to examine the extent to which financial concerns affect the probability of switching between adjuvant HT modalities., Design: Population-based, prospective survey study., Participants: Elderly (65+) women who had an incident BC surgery in 2003 and who reported receiving adjuvant HT during the first 12 months post-surgery., Methods: Multivariate regression models., Results: Use of AIs was associated with a significantly higher probability of financial hardship. Women who had taken only an AI were more likely to experience financial difficulty than women who took only TX (OR = 1.4; 95% CI: 1.1-1.7), but women who switched between TX and AI were not more likely to experience financial difficulty. Breast cancer survivors with no drug coverage (OR = 4.5; 95% CI: 3.3-5.9) or partial drug coverage (OR = 3.6; 95% CI: 2.8-4.5) were more likely to experience financial difficulty compared to those with full coverage. Lack of drug coverage was also the main factor associated with the likelihood that BC survivors did not switch adjuvant HT modalities., Conclusions: Adjuvant HTs have important economic consequences for BC survivors. These consequences are ameliorated by full, but not partial, drug coverage.

Do adult children affect the care elderly parents provide each other? We develop two models in which the anticipated behavior of adult children provides incentives for nondisabled elderly parents to increase care for their disabled spouses. The "demonstration effect" postulates that adult children learn from a parent's example that family caregiving is appropriate behavior. The "punishment effect" postulates that adult children may punish parents who fail to provide spousal care by not providing future care for the nondisabled spouse if and when necessary. Thus, joint children act as a commitment mechanism, increasing the probability that elderly parents will provide care for their disabled spouses. We argue that stepchildren provide weaker incentives for spousal care because the attachment of a stepchild to a stepparent is likely to be weaker than the attachment of children to parents in a traditional nuclear family. Using data from the HRS, we find evidence consistent with the hypothesis that joint children provide stronger incentives than stepchildren for nondisabled elderly parents to provide care for their disabled spouse.

Objective: To examine sociodemographic, clinical, and self-management characteristics of a sample of urban, African American patients admitted to home health care with uncontrolled hypertension and to determine the extent to which these factors are associated with disease severity., Methods: We conducted a cross-sectional study of 498 hypertensive African American patients newly admitted to home health care. Data for this study were drawn from patient-level clinical and functional assessment data derived from the uniform home health assessment system mandated by the Centers for Medicare and Medicaid Services and patient in-home interviews., Results: Forty percent of patients had stage 1 hypertension, and 60% had the more severe uncontrolled stage 2. Multivariate analyses found that factors associated with stage 2 were co-morbid diabetes, poor appointment keeping, low activation, and longer time since diagnosis. Protective factors associated with a lower likelihood of severe uncontrolled hypertension were older age and recent discharge from a hospital. More co-morbid conditions also appeared to be protective, although the association did not reach significance., Conclusions: Our findings highlight the need to address hypertension control among the African American, dually diagnosed diabetic hypertensive population and underscore the critical role of treatment adherence, widely recognized as a key issue in managing hypertension and other chronic conditions. Successful strategies will likely require more aggressive action by home health nurses, both to alert patients' primary care providers to ongoing, unsuccessfully treated hypertension and to remediate patients' inadequate self-management preparedness.

Objective: The objective of this study was to investigate the effect of parental marital status, marital history, and family type on intergenerational living arrangements and adult children's time and cash transfers to their unpartnered disabled elderly parents., Methods: We used data from the Asset and Health Dynamics Among the Oldest Old survey to estimate the joint probabilities that an adult child provides time and/or cash transfers to a parent and to analyze a five-level categorical variable capturing parent-child living arrangements., Result: The estimates suggest significant detrimental effects of parental divorce and step relationship on time transfers and on the probability of coresidence with the index child. Family type, as captured by the composition of the index child's sibling network according to kin relationship to the parent, also affected transfers and living arrangement choices of adult children., Discussion: The findings that transfers from adult children to their unpartnered disabled elderly parents depend on parental marital status and kin relationship suggest that changing family patterns are altering the traditional role of the family as a support network. These findings raise concerns about the care likely to be available to future cohorts of elderly persons who will have experienced substantially higher rates of divorce, remarriage, and step parenthood than the cohort considered in this study.

Objective: To estimate the differences in outcomes across postacute care settings-inpatient rehabilitation, skilled nursing facility (SNF), or home-for dysvascular lower-limb amputees., Design: Medicare claims data for 1996 were used to identify a cohort of elderly persons with major lower-limb dysvascular amputations. One-year outcomes were derived by analyzing claims for this cohort in 1996 and 1997., Setting: Postacute care after amputation., Participants: Dysvascular lower-limb elderly amputees (N=2468)., Interventions: Not applicable., Main Outcome Measures: Mortality, medical stability, reamputations, and prosthetic device acquisition., Results: The 1-year mortality for the elderly amputees was 41%. Multivariate probit models controlling for patient characteristics indicated that patients discharged to inpatient rehabilitation were significantly (P<.001) more likely to have survived 12 months postamputation (75%) than those discharged to an SNF (63%) or those sent home (51%). Acquisition of a prosthesis was significantly (P<.001) more frequent for persons going to inpatient rehabilitation (73%) compared with SNF (58%) and home (49%) dispositions. The number of nonamputee-related hospital admissions was significantly less for persons sent to a rehabilitation service than for those sent home or to an SNF. Subsequent amputations were significantly (P<.025) less likely for amputees receiving inpatient rehabilitation (18%) than for those sent home (25%)., Conclusions: Receiving inpatient rehabilitation care immediately after acute care was associated with reduced mortality, fewer subsequent amputations, greater acquisition of prosthetic devices, and greater medical stability than for patients who were sent home or to an SNF. Such information is vital for health policy makers, physicians, and insurers.

Objectives: To determine (1) the prevalence of selected common musculoskeletal disorders in patients referred for electrodiagnosis when cervical radiculopathy is suspected and (2) whether these findings predict electrodiagnostic study outcome., Design: Prospective study., Setting: Electrodiagnostic laboratories in departments of physical medicine and rehabilitation at 5 participating institutions., Participants: A total of 191 subjects undergoing electrodiagnostic evaluations for upper-limb symptoms when cervical radiculopathy was suspected., Interventions: Not applicable., Main Outcome Measures: Prevalence of certain musculoskeletal disorders (myofascial pain, shoulder impingement, lateral epicondylitis, de Quervain's tenosynovitis) and outcomes of electrodiagnostic testing (normal study, cervical radiculopathy, or another electrodiagnostically confirmed diagnosis)., Results: The total prevalence of musculoskeletal disorders was 42%. The prevalence in those with a normal study was 69%, compared with 29% in those with cervical radiculopathy (P<.001) and 45% in those with another diagnosis (P=.02)., Conclusions: Musculoskeletal disorders are common in patients with suspected cervical radiculopathy. Although the presence of certain musculoskeletal disorders makes having a normal electrodiagnostic evaluation significantly more likely, the high prevalence among both patients with normal studies and those with radiculopathy and other disorders limits the usefulness of this information in precisely predicting study outcome. The presence of musculoskeletal disorders should not preclude electrodiagnostic testing when otherwise indicated.