EAL

FNOA: Aging Programs (2012)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To analyze the reasons for elders' termination from a Meals on Wheels program and determinants of their length of stay in the program.

Inclusion Criteria:

Participation in a county-wide Meals on Meals program in western New York State between 1994 and 1996.

Exclusion Criteria:

Participants in the program who were non-elderly disabled.

Description of Study Protocol:

Recruitment

No recruitment was needed. Records were used as the basis of the study. A 33% systematic random sample of all persons who were receiving meals between 1994 and 1996 was selected.

Design

Retrospective Cohort Study. Records for 509 persons aged 60 and older were reviewed. The sources of data included initial social work, nutrition assessment, and periodic reassessment done by the program's social work and nutrition staff. In addition, included a summary log that contained dates of referral, intake and initial assessment, start of meal delivery, reassessment, and termination from the program.

Blinding used

Not applicable

Intervention

Participation in Meals on Wheels

Statistical Analysis

A bivariate analysis was conducted comparing racial and gender differences between those who remained in the program and those who terminated their Meals on Wheels participation
A Cox proportional hazard regression model was conducted for current and past participants to analyze predictors of length of stay.

Data Collection Summary:

Timing of Measurements

Data was collected between 1994 and 1996. The data analysis occurred in June of 1997.

Dependent Variables

Length of stay in Meals on Wheels program as measured in weeks. Data on length of stay was obtained from records.

Independent/Control Variables

All information obtained from participant records

Age
Gender
Race
Marital status
Health status at time of enrollment (self-reported prior hospitalizations)
Weight pattern in six months prior to enrollment (self-reported)
Appetite (self-reported)
Type of service received (number of days per week meals were received)
Whether the participant required a special diet
Economic status as measured by monthly amount of financial contribution the participant made to the program.

Description of Actual Data Sample:

Initial N: 545 persons were originally selected for the study, representing a 33% random sample of the participants in the Meals on Wheels program. 36 non-elderly disabled persons were eliminated, making the final n=509.
Attrition (final N): Final n=509
- Of the 509, 328 had terminated the program (64.3%)
- 181 (35.6%) were currently participating
Age: The average age of the sample was 78.4 years
Ethnicity:
- 76.2 percent of participants were white
- 12 percent were black
- 11.8 percent were other races, including Hispanic
Other relevant demographics:
- 64.8 percent were female and 35.2 percent male
- 57.4 percent were widowed, 22.3 percent married or in long-term relationships
- 20.3 were in other categories (never married, divorced, or separated)
- 43.2 percent of the sample had hypertension
- 25.4 percent had heart disease
- 24.6 percent had diabetes
- 18.8 percent had arthritis
- 13.6 percent had pulmonary disease
- 10.6 percent had had a stroke
Anthropometrics: Mean weights showed that blacks were significantly heavier than whites (163 vs. 139 pounds)
Location: Western New York State.

Summary of Results:

Of the 509 persons is the original sample, 328 (64%) were no longer participating in Meals on Wheels at the time of data collection. A major reason for termination included deteriorating health. A higher proportion of African Americans than white elders discontinued their participation due to dissatisfaction with the meals or their poor appetite.

A significantly lower percentage of black than white and "other" elders were discontinued due to their prolonged hospitalization, placement in a supervised facility, or improved health.

Racial and Gender Differences in Reasons for Termination from the Meals on Wheels Program (percent Terminated)

Variable	Race			Gender
	White	Black	Other	Male	Female
Improved health (able to prepare own meals)	15.8	5.1	21.3	9.3	18.8
Prolonged hospitalization	5.6	2.6	0	7.0	3.1
Placement in a supervised facility	19.9	10.3	36.2	17.1	23.3
Move to relative's home or someone else cooking	18.8	20.5	8.5	23.3	14.3
Relocation to a non-service area	10.2	10.3	4.3	10.0	8.9
Dissatisfaction with meals/food preferences/poor appetite	12.8	28.2	14.9	11.6	16.6
Death	13.9	15.4	12.8	18.6	11.2
Other	3.0	7.7	2.1	2.3	4.0

Results of the Cox Hazard Regression Model

Older ages, being white, and having a better appetite were negatively associated with the hazard of termination from the program.

Number of ADL's performed with difficulty was positively associated with the hazard of termination from the program. Elders who had more difficulty carrying out ADLs were likely to stay in the program for a shorter period.

Gender, marital status, race, recent hospitalization, weight-change pattern prior to enrollment, number of days the meals were delivered, and the amount of monetary contributions had no significant association with the hazard of termination from the program.

Author Conclusion:

The author concludes that reasons for termination in the Meals on Wheels program are largely associated with circumstances related to deteriorating health. Prolonged hospitalizations, placement in a supervised facility, moving in with a relative or caregiver or arranging for someone else to cook, and death were the primary reasons for termination. However, a higher proportion of African Americans discontinued participation due to their dissatisfaction with the quality of meals, different food preferences, or poor appetite.

Funding Source:

University/Hospital:

SUNY at Buffalo

Reviewer Comments:

Demographic information collected did not include whether participants lived alone or with someone else. This information would have been helpful when evaluating reasons for termination from the program.

Dissatisfaction with meal service and poor appetite were placed together as reasons for termination from the program. It is unclear to this reviewer if this category means dissatisfaction with the delivery process (ie, timing, etc), the food temperature, the quality of the meals (ie, inexpensive cuts of meat), or different food preferences. Additionally, poor intake could be a sign of deteriorating health, not just dissatisfaction with the meals, so placing it in this category may have skewed the results of the study.

Cox Proportional Data are based on n of 495 (both past and current participants) and n of 321 (past participants only). Those numbers are different than the original "n" quoted in the paper. The reviewer was unable to account for missing participants.

The sample size was only 12% African Americans. The most significant results in this study were drawn based on this small sample of the original n. When broken down by reasons for termination, the actual numbers of participants in each category was very small.

The author confounded the results of the study by including 24 current participants who had been terminated and then re-enrolled in the program. It is unclear to the reviewer why these participants were included in the study.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		???
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	N/A
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	No
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		???
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	???
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	N/A
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		N/A
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	N/A
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	Yes
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	N/A
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	N/A
	7.5.	Was the measurement of effect at an appropriate level of precision?	N/A
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes