Elizabeth Phelan - Academia.edu (original) (raw)

Papers by Elizabeth Phelan

empirical data to elucidate this finding are few. Suboptimalmanagement in the outpatient setting ... more empirical data to elucidate this finding are few. Suboptimalmanagement in the outpatient setting may be a contribut-ingfactor,assuggestedbylowerprescrip-tiondrugcosts and feweroffice visits af-terdiagnosis.4Accomplishingadequate chronicdiseasemanagement ismoredif-ficult in persons with dementia, which may lead tohospitalization for acute ex-acerbation of comorbid conditions.4,5 Nonelective hospitalization of older people, particularly thosewith demen-tia, is not a trivial event. Among older personswithoutdementia, hospitaliza-tion for serious illness is associatedwith subsequentcognitivedecline,10 and frail elders, including those with dementia, are at increased risk of delirium, func-tional decline, and iatrogenic compli-cations during an inpatient stay.11-13 Identifying conditions that precipitate hospitalizationofelderlyindividualswith dementia could focus clinical priorities on secondary and tertiaryprevention in theoutpatientsettingandimprovehealth care for this vulnerable and ...

International Journal of Environmental Research and Public Health, 2021

This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY

The Journal of Alternative and Complementary Medicine, 2020

Objectives: T'ai chi (TC) has been found effective for improving chronic low back pain (cLBP). Ho... more Objectives: T'ai chi (TC) has been found effective for improving chronic low back pain (cLBP). However, such studies did not include adults over 65 years of age. This study was designed to evaluate the feasibility and acceptability of TC in this population compared with Health Education (HE) and with Usual Care (UC). Design: Feasibility randomized controlled trial. Settings/Location: Participants were recruited from Kaiser Permanente Washington and classes took place in a Kaiser facility. Patients: Adults 65 years of age and older with cLBP. Interventions: Twenty-eight participants were randomized to 12 weeks of TC followed by a 24-week tapered TC program, 12 were assigned to a 12-week HE intervention and 17 were assigned to UC only. Outcome Measures: Feasibility and acceptability were determined by recruitment, retention and 12-, 26-, and 52-week follow-up rates, instructor adherence to protocol, class attendance, TC home practice, class satisfaction, and adverse events. Results: Fifty-seven participants were enrolled in two cohorts of 28 and 29 during two 4-month recruitment periods. Questionnaire follow-up completion rates ranged between 88% and 93%. Two major class protocol deviations were noted in TC and none in HE. Sixty-two percent of TC participants versus 50% of HE participants attended at least 70% of the classes during the 12-week initial intervention period. Weekly rates of TC home practice were high among class attendees (median of 4.2 days) at 12 weeks, with fewer people practicing at 26 and 52 weeks. By 52 weeks, 70% of TC participants reported practicing the week before, with a median of 3 days per week and 15 min/session. TC participants rated the helpfulness of their classes significantly higher than did HE participants, but the groups were similarly likely to recommend the classes. Conclusion: The TC intervention is feasible in this population, while the HE group requires modifications in delivery.

American journal of preventive medicine, 2017

Care management has been found to be more effective than usual care for some chronic conditions, ... more Care management has been found to be more effective than usual care for some chronic conditions, but few studies have tested care management for prevention of elder falls. This study aimed to assess the feasibility and preliminary efficacy of telephone care management of older adults presenting for medical attention due to a fall. The setting was an independent practice association in western Washington serving 1,300 Medicare Advantage-insured patients. Patients aged ≥65 years treated for a fall in an emergency department or their primary care provider's office were contacted via telephone by a care manager within 48 hours of their fall-related visit and invited to participate in a telephone-administered interview to identify modifiable fall risk factors and receive recommendations and follow-up to address identified risk factors. Data from care manager records, patient medical records, and healthcare claims for the first 6 months (November 2009-April 2010) of program implementa...

Frontiers in Public Health, 2016

Preventing Chronic Disease, 2012

Background Lack of adequate physical activity among older adults has been widely documented. Alth... more Background Lack of adequate physical activity among older adults has been widely documented. Although interventions aimed at increasing physical activity that are based on behavioral strategies and theories have been shown to increase activity levels among older adults, little is known about responses to these interventions in different population segments. Community Context The Physical Activity for a Lifetime of Success (PALS) program attempted to translate a telephone-based, motivational support program for physical activity, Active Choices, for use by a low-income, ethnically diverse population of older adults living in southeast Seattle. This article describes the evaluation of PALS at the end of the 5-year program. Methods Evaluation data included a data set of participant physical activity assessments; internal study documents; and interviews with key PALS stakeholders, participants, volunteers, and people eligible for PALS who declined to enroll when invited. Outcome PALS demonstrated improved physical activity levels among the sedentary older adults who participated in the program, but the PALS model did not appeal widely to a diverse, low-income target population. Extensive recruitment efforts resulted in a low number of participants, and attempts to recruit peer volunteers were largely unsuccessful. Interpretation Considering the resources required to engage both participants and volunteers, PALS does not appear to be a sustainable model for delivering support for physical activity to community-dwelling minority and low-income older adults. Physical activity interventions based on behavioral strategies and theories increase levels of participation among older adults (7). However, little is known about how responses to these interventions differ depending on the population segment involved, because few have been disseminated in nonresearch settings. The Physical Activity for a Lifetime of Success (PALS) program was based on Active Choices, an evidence-based program developed at Stanford University. PALS aimed to increase the physical activity levels of sedentary older adults through one-on-one telephone support delivered by adult volunteers who were trained in motivational interviewing.

Medical care, 2015

To conduct a systematic literature review to determine if there were any intervention strategies ... more To conduct a systematic literature review to determine if there were any intervention strategies that had any measurable effect on acute-care hospitalizations among community-dwelling adults with dementia. Studies were identified by a professional research librarian and content experts. Community dwelling. Participants were diagnosed with dementia, severity ranging from mild to severe, and were recruited from health care and community agencies. A study met the inclusion criteria if it: (a) was published in English; (b) included a control or comparison group; (c) published outcome data from the intervention under study; (d) reported hospitalization as one of the outcomes; (e) included community-dwelling older adults; and (f) enrolled participants with dementia. Ten studies met all inclusion criteria. Of the 10 studies included, most assessed health services use (ie, hospitalizations) as a secondary outcome. Participants were recruited from a range of health care and community agencie...

Objectives-Involuntary weight loss affects 20% of community dwelling older adults. The underlying... more Objectives-Involuntary weight loss affects 20% of community dwelling older adults. The underlying mechanism for this disorder is unknown. Objective is to determine if failure of older persons to regain weight is associated with elevated pro-inflammatory cytokine and leptin levels. Design-Prospective diet intervention study.

Journal of the American Geriatrics Society, 2014

Background/Objectives-The role of chronic pain in the occurrence of falls and as a target for fal... more Background/Objectives-The role of chronic pain in the occurrence of falls and as a target for falls prevention has received limited attention. We sought to determine the prevalence of clinically relevant falls-related outcomes according to pain status in the older population of the United States. Design-Cross-sectional analysis of the 2011 National Health and Aging Trends Study, a sample of Medicare enrollees aged ≥65 years (response rate= 71.0%). Setting-In-person assessments were conducted in the home or residential care facility of the sampled study participant.

Medical Clinics of North America, 2015

BACKGROUND: Older persons account for the majority of hospitalizations in the United States. 1 Id... more BACKGROUND: Older persons account for the majority of hospitalizations in the United States. 1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors-for example, living alone-may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+). OBJECTIVES: To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old. DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: 2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation. MAIN MEASURES: Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data. KEY RESULTS: At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR=0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR=0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR=0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations. CONCLUSION: Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.

Preventing chronic disease, 2008

Regular physical activity is an important goal for elders with chronic health conditions. This re... more Regular physical activity is an important goal for elders with chronic health conditions. This report describes Physical Activity for a Lifetime of Success (PALS), an attempt to translate a motivational support program for physical activity, Active Choices, for use by a group of diverse, low-income, community-dwelling elders with diabetes. PALS linked physical activity assessment and brief counseling by primary care providers with a structured referral to a community-based motivational telephone support program delivered by older adult volunteers. People with diabetes aged 65 years or older who were receiving care at two community clinics were randomized to receive either immediate or delayed intervention. The main intended outcome measure was physical activity level; the secondary outcome measure was mean hemoglobin A1c. One-third of those offered referral to the PALS program in the clinic setting declined. Another 44% subsequently declined enrollment or were unreachable by the sup...

Preventing Chronic Disease, 2014

Introduction This study investigated facilitators and barriers to adoption of an at-scene patient... more Introduction This study investigated facilitators and barriers to adoption of an at-scene patient education program by firefighter emergency medical technicians (EMTs) in King County, Washington. Methods We consulted providers of emergency medical services (EMS) to develop a patient education pamphlet in the form of a tear-off sheet that could be attached to the EMT medical incident report. The pamphlet included resources for at-scene patient education on high blood pressure, blood glucose, falls, and social services. The program was launched in 29 fire departments in King County, Washington, on January 1, 2010, and a formal evaluation was conducted in late 2011. We developed a survey based on diffusion theory to assess 1) awareness of the pamphlet, 2) evaluation of the pamphlet attributes, 3) encouragement by peers and superiors for handing out the pamphlet, 4) perceived behavioral norms, and 5) demographic variables associated with self-reported adoption of the at-scene patient education program. The survey was completed by 822 (40.1%) of 2,047 firefighter emergency medical technicians. We conducted bivariate and multivariable analyses to assess associations between independent variables and self-reported adoption of the program. Results Adoption of the at-scene patient education intervention was significantly associated with positive evaluation of the pamphlet, encouragement from peers and superiors, and perceived behavioral norms. EMS providers reported they were most likely to hand out the pamphlet to patients in private residences who were treated and left at the scene. Conclusion Attributes of chronic disease prevention programs and encouragement from peers and supervisors are necessary in diffusion of patient education interventions in the prehospital care setting.

Journal of the American Geriatrics Society, 2007

To assess the effect of a team of geriatrics specialists on the practice style of primary care pr... more To assess the effect of a team of geriatrics specialists on the practice style of primary care providers (PCPs) and the functioning of their patients aged 75 and older. DESIGN: Randomized, controlled trial. SETTING: Two primary care clinics in the Seattle, Washington, area. PARTICIPANTS: Thirty-one PCPs and 874 patients aged 75 and older. INTERVENTION: An interdisciplinary team of geriatrics specialists worked with patients and providers to enhance the geriatric focus of care. MEASUREMENTS: Main outcomes were a practice style reflecting a geriatric orientation and patient scores on the physical and affect subscales of the Arthritis Impact Measurement Scale 2FShort Form. Secondary outcomes were hospitalizations, incident disability in activities of daily living (ADLs), and PCP perceptions of the intervention. Death rates were also assessed. RESULTS: Intervention providers screened significantly more for geriatric syndromes at 12 months, but this finding did not persist at 24 months. There were no significant differences in adequate hypertension control or high-risk prescribing at 12 or 24 months of follow-up. There were no significant differences in patient functioning or significant differences in hospitalization rates at either time point. Meaningful differences were observed in ADL disability at 12 but not 24 months. PCPs viewed the intervention favorably. Seventy-eight participants died over the 24 months of follow-up; the proportion dying was higher in the intervention group (11.4% in intervention group vs 7.1% of controls, P 5.03). CONCLUSION: The addition of an interdisciplinary geriatric team was acceptable to PCPs and had some effect on care of geriatric conditions but little effect on patient function or the use of inpatient care and was associated with greater mortality.

Journal of the American Geriatrics Society, 2008

Objectives-To determine whether outpatient care by fellowship-trained geriatricians is distinguis... more Objectives-To determine whether outpatient care by fellowship-trained geriatricians is distinguishable from that of generalists caring for older patients. Design-Observational study. Setting-Three primary care clinics of an academic medical center. Participants-Random sample of 140 adults aged 65 or older receiving primary care at one of the clinics. Measurements-A medical chart review involving records of 69 patients receiving primary care from a fellowship-trained geriatrician and 71 patients receiving primary care from a generalist (general internal medicine or family practice) was conducted; information pertaining to two practice behaviors relevant to the care of older adults-avoidance of inappropriate prescribing and proactive assessments for geriatric syndromes-was abstracted. Results-Geriatricians scored 17.6 out of a possible 24 points, on average; generalists, 14.2 (P <. 001). Geriatricians scored higher than generalists on both prescribing and geriatric syndrome assessments. In a linear regression model adjusting for patient age and number of comorbidities

Journal of the American Geriatrics Society, 2010

Although multifactorial fall prevention interventions have been shown to reduce falls and injurio... more Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital-based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age-, sex-, and race-matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall-related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow-up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fallrelated healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow-up; differences in fall-related healthcare use according to study group from baseline to follow-up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real-world clinical practice settings on key outcomes, including injurious falls, downstream fall-related healthcare use, and costs.

Journal of the American Geriatrics Society, 2009

In a pair of randomized controlled trials in Kaiser Colorado in the 1990s, Group Visits for older... more In a pair of randomized controlled trials in Kaiser Colorado in the 1990s, Group Visits for older adults (monthly non disease-specific group medical appointments for a cohort of patients led by primary care teams) were proven to reduce costs, decrease hospitalizations, and improve patient and provider satisfaction. As part of a translational effort, this Group Visit intervention was replicated in a delivery system in Seattle, WA, and the log of total health care costs measured in the first year of the intervention. Utilization and patient and physician satisfaction were secondary outcomes. For the cost and utilization analysis, a retrospective case-control design compared 221 case patients 65 years of age and older with high outpatient utilization in the previous 18 months with 1,015 control patient selected randomly from clinics not participating in the intervention. Controls were matched to cases on the number of primary care visits in the prior 18 months. Total costs were not statistically different for intervention patients compared to controls ($8,845 vs. $10,288, p=0.11), nor were there statistically significant differences in utilization, including hospital admissions and outpatient visits. However, patient and provider satisfaction was high. This translational effort did not demonstrate the cost savings of the original efficacy trials. Possible explanations for these divergent results may have to do with differences in those who participated and differences between the two delivery systems.

Journal of Hospital Medicine, 2011

The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2004

Background. Disability in basic activities of daily living (ADLs) implies a loss of independence ... more Background. Disability in basic activities of daily living (ADLs) implies a loss of independence and increases the risk for hospitalization, nursing home admission, and death. Little is known about ways by which ADL disability can be prevented or reversed. The authors evaluated the efficacy of the Health Enhancement Program in preventing and reducing ADL disability in community-dwelling older adults. Methods. The authors analyzed data from a 12-month, randomized, single-blinded, controlled trial of a disability prevention, chronic disease self-management program involving 201 adults aged 70 years and older that was conducted from February 1995 to June 1996 at a senior center in western Washington state. Activities of daily living disability incidence, improvement, and worsening were assessed using intention-to-treat methods. Results. The cumulative incidence of ADL disability among those who were not ADL disabled at baseline (n ¼ 56 in the intervention group, n ¼ 57 in the control group) was modestly lower in the intervention group than in the control group at 12 months (14.3% vs 21.3%, p ¼ .466). Cumulative improvement in ADL function among those who reported any ADL disability at baseline (n ¼ 41 in the intervention group, n ¼ 43 in the control group) was greater in the intervention group at 12 months (80.5% vs 46.5%, p ¼ .026). The likelihood for ADL improvement was greater in the intervention group compared with controls at 12 months (adjusted hazard ratio, 1.84; 95% confidence interval, 1.05 to 3.22; p ¼ .020). Cumulative worsening of ADL function was slightly lower in the intervention group at 12 months (18.6% vs 26.5%, p ¼ .237). Intervention participants tended to be at lower risk for ADL worsening (adjusted hazard ratio, 0.71; 95% confidence interval, 0.38 to 1.30; p ¼ .266) compared with control participants. Conclusion. The Health Enhancement Program intervention led to improved ADL functioning in those who were disabled initially and thereby offers a promising strategy for limiting or reversing functional decline in disabled elderly persons.

Journal of General Internal Medicine, 2000

OBJECTIVE: Women's health centers have been increasing in number but remain relatively unstudied.... more OBJECTIVE: Women's health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women's health center compared with those at a general medicine clinic. DESIGN: Cross-sectional survey. SETTING: University hospital-affiliated women's health and general internal medicine clinics. PARTICIPANTS: An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic. MEASUREMENTS AND MAIN RESULTS: Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women's health center. Women's health center users (n ‫؍‬ 357) were more likely than general medicine clinic users (n ‫؍‬ 349) to prefer a female provider (57% vs 32%, p ‫؍‬ .0001) and to have sought care at the clinic because of its focus on women's health (49% vs 17%, p ‫؍‬ .0001). After adjusting for age and self-assessed health status, women's health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2.6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction. CONCLUSIONS: These results suggest that, at least in this setting, women's health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women's health centers, the quality of general preventive care may be better in general medical clinics.