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OBJECTIVES: To examine the associations between major and minor depression and categories of Medicare home healthcare use. DESIGN: Observational prospective study (1997–1999). SETTING: Visiting nurse agency in suburban New York State. PARTCIPANTS: Five hundred thirty-nine new Medicare admissions aged 65 and older (mean age 78.4), 65.1% female, and 15.0% nonwhite. Approximately 13.5% were diagnosed with major depression and another 10.8% with minor depression. MEASUREMENTS: Consensus “best estimate”Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses for major and minor depression assessed using Structured Clinical Interviews for DSM-IV (SCID) plus medical charts. RESULTS: Major and minor depression appear to have little association with probability and amount of use of the types of Medicare home health care (skilled nurse, home health aide, therapist (physical, occupational, and speech), and medical social services). Overall, patients with minor depression appear to have utilization similar to that of patients with major depression. CONCLUSION: It seems likely that any potential incremental depression effect on utilization is being offset by the transitional medical state of the patients that entered Medicare home healthcare directly from a hospital, nursing home, or rehabilitation facility, and the overall severity of disability and chronic illness present in long-term home healthcare patients. Further research is required to determine whether similar findings occur in other home healthcare agencies and whether these are present under the current Medicare Prospective Payment System reimbursement mechanism.

Purpose: The Program of All-Inclusive Care for the Elderly (PACE) is a community-based program providing primary, acute, and long-term care to frail elderly individuals. A central component of the PACE model is the interdisciplinary care team, which includes both professionals and non-professionals. The purpose of this study was to examine the association between the team’s overall performance and the risk-adjusted health outcomes of program enrollees. Design and Methods: The study included interdisciplinary teams in 26 PACE programs and 3,401 individuals enrolled in them. We combined information about individuals’ health, functional, and mental status from DataPACE with an overall measure of team performance. We used multivariate regression techniques to test the hypothesis that better team performance is associated with better risk-adjusted health outcomes: survival and short-term (within 3 months of enrollment) and long-term (within 12 months of enrollment) improvements in functional status and in urinary incontinence. Results: Team performance was significantly associated with better functional outcomes (both short and long term) and with better long-term urinary incontinence outcomes. There was no significant association with survival. Implications: This study provides empirical evidence for the relationship between team performance and patient outcomes in long-term care. It suggests that PACE programs can improve patient outcomes by improving the functioning of care teams.

Objectives: To examine criterion and construct validity of the five-item Mental Health Index (MHI-5) of the 36-item Short Form health survey (SF-36) in relation to the presence of major depression in functionally impaired, community-dwelling elderly patients and of eight subsamples defined by cognitive functioning, levels of functional impairment, and proxy report versus self-report. Design: Cross-sectional observational. Setting: Nineteen counties in western New York, West Virginia, and Ohio. Participants: One thousand four hundred forty-four functionally impaired, community-dwelling Medicare beneficiaries aged 65 and older who participated in the Medicare Primary and Consumer-Directed Care Demonstration. Measurements: MHI-5, Mini-International Neuropsychiatric Interview Major Depressive Episode (MINI-MDE) module. Results: The MHI-5 demonstrated sufficient criterion validity (area under the receiver operating characteristic curve=0.837; sensitivity=78.7% and specificity=72.1% using a cutpoint of 59/60) with respect to the presence of depression for the entire sample. A significant correlation between MHI-5 scores and presence of major depression as identified using the MINI-MDE (Spearman correlation=−0.426, P

OBJECTIVES: To examine the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15), a brief depression screening measure. DESIGN: Cross-sectional. SETTING: Nineteen counties in western New York, West Virginia, and Ohio. PARTICIPANTS: Nine hundred sixty functionally impaired, cognitively intact, community-dwelling primary care patients aged 65 and older. MEASUREMENTS: The GDS-15, major depression as measured using the Mini-International Neuropsychiatric Interview, depressed mood, life satisfaction, suicidal ideation, and reported suicide attempts. RESULTS: Exploratory factor analyses suggested a two-factor structure for the GDS-15 in this category of patients, with component subscales assessing depression and positive affect. Cronbach alpha coefficients provide evidence for moderate, although acceptable, internal consistency reliability. Significant associations between the GDS-15 and measures of depressed mood, life satisfaction, and suicidal ideation demonstrated construct validity, whereas acceptable sensitivity and specificity to discriminate between depressed and nondepressed patients demonstrated criterion validity. Internal consistency reliability and construct validity did not differ significantly between patients with low and high functional impairment. A significant weakness of the scale is its low correlation with suicide attempt status. CONCLUSION: In general, this study provides evidence of impressive psychometric properties of the GDS-15 when administered to a sample of functionally impaired, cognitively intact, community-dwelling primary care patients.

To examine the associations between major and minor depression and categories of Medicare home healthcare use.Observational prospective study (1997-1999).Visiting nurse agency in suburban New York State. PARTCIPANTS: Five hundred thirty-nine new Medicare admissions aged 65 and older (mean age 78.4), 65.1% female, and 15.0% nonwhite. Approximately 13.5% were diagnosed with major depression and another 10.8% with minor depression.Consensus "best estimate"Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses for major and minor depression assessed using Structured Clinical Interviews for DSM-IV (SCID) plus medical charts.Major and minor depression appear to have little association with probability and amount of use of the types of Medicare home health care (skilled nurse, home health aide, therapist (physical, occupational, and speech), and medical social services). Overall, patients with minor depression appear to have utilization similar to that of patients with major depression.It seems likely that any potential incremental depression effect on utilization is being offset by the transitional medical state of the patients that entered Medicare home healthcare directly from a hospital, nursing home, or rehabilitation facility, and the overall severity of disability and chronic illness present in long-term home healthcare patients. Further research is required to determine whether similar findings occur in other home healthcare agencies and whether these are present under the current Medicare Prospective Payment System reimbursement mechanism.

The purpose of this study was to examine the association between dependence in activities of daily living (ADL) and instrumental ADL (IADL) and major depression among 415 community-dwelling primary care patients age 65+ with heart failure and significant ADL or IADL dependence. Main findings include (1) a progressive increase in depression prevalence from 0% for no IADL dependence to about 40% for 6 IADL dependencies ( P < .001), (2) a steady rise in depression prevalence to 40% for 6 ADL dependencies following a “floor effect” at about 10% for 0 to 2 ADL dependencies ( P < .001), and (3) the association in a logistic regression model of major depression with number of IADL dependencies ( P = .016) but not with number of ADL dependencies ( P = .602). Our principal conclusion is that the progressively greater likelihood of major depression as the number of IADL dependencies increases has important clinical, personal, social, and public health relevance.

The Program of All-Inclusive Care for the Elderly (PACE) is a unique program providing a full spectrum of health care services, from primary to acute to long-term care for frail elderly individuals certified to require nursing home care. The objective of this article is to identify program characteristics associated with better risk-adjusted health outcomes: mortality, functional status, and self-assessed health. The article examines statistical analyses of information combining DataPACE (individual-level clinical data), a survey of direct care staff about team performance, and interviews with management in twenty-three PACE programs. Several program characteristics were associated with better functional outcomes. Fewer were associated with long-term self-assessed health, and only one with mortality. These findings offer strategies that may lead to better care.

Objective The objective of this study was to determine whether factors associated with depression differ between elderly residents of rural and urban areas. Methods The research design was cross-sectional and observational. The study subjects consisted of 926 Medicare primary care patients (650 urban and 276 rural) who were age 65+ and cognitively intact and had enrolled in a randomized, controlled Medicare demonstration. Major depression was identified by the Mini International Neuropsychiatric Interview. A logistic regression model was estimated that included a rural–urban indicator variable, additional independent variables, and interaction terms between the rural–urban indicator and independent variables that were significant at p Results A total of 8.3% of the rural and 14.8% of the urban patients were identified as having major depression. Reporting 0–1 close friends (odds ratio [OR]: 6.86; 95% confidence interval [CI]: 2.18–21.58), 2+ emergency room visits during the past 6 months (OR: 4.00; 95% CI: 1.19–13.43), and more financial strain (OR: 1.50; 95% CI: 1.01–2.23) were associated with significantly higher likelihood of major depression among rural as compared with urban patients. The SF-36 Physical Component Summary score had a curvilinear relationship with major depression and was higher for urban patients. The predicted probability for major depression is lower for the rural patients when financial strain is low, about the same for rural and urban patients when strain is intermediate, and higher for rural patients when strain is high. Conclusions Clinicians in rural areas should be vigilant for major depression among patients with very few close friends, several recent emergency department visits, and financial strain.

To examine the psychometric properties of the 15-item Geriatric Depression Scale (GDS-15), a brief depression screening measure.Cross-sectional.Nineteen counties in western New York, West Virginia, and Ohio.Nine hundred sixty functionally impaired, cognitively intact, community-dwelling primary care patients aged 65 and older.The GDS-15, major depression as measured using the Mini-International Neuropsychiatric Interview, depressed mood, life satisfaction, suicidal ideation, and reported suicide attempts.Exploratory factor analyses suggested a two-factor structure for the GDS-15 in this category of patients, with component subscales assessing depression and positive affect. Cronbach alpha coefficients provide evidence for moderate, although acceptable, internal consistency reliability. Significant associations between the GDS-15 and measures of depressed mood, life satisfaction, and suicidal ideation demonstrated construct validity, whereas acceptable sensitivity and specificity to discriminate between depressed and nondepressed patients demonstrated criterion validity. Internal consistency reliability and construct validity did not differ significantly between patients with low and high functional impairment. A significant weakness of the scale is its low correlation with suicide attempt status.In general, this study provides evidence of impressive psychometric properties of the GDS-15 when administered to a sample of functionally impaired, cognitively intact, community-dwelling primary care patients.