Elderly Healthcare

Research Findings

Research Activities, August 2008:
Hospice care saves money for Medicare and Medicaid patients in nursing homes
Encouraging nursing home residents to participate in their care helps them maintain function and physical performance
Studies elaborate on the potential use of health information technology to improve care delivery

Research Activities, July 2008:
Studies examine racial/ethnic disparities and use patterns for nonsteroidal anti-inflammatory drugs
The Medicare Part D prescription drug benefit has modestly boosted drug use and reduced average out-of-pocket expenses
Hospitalizations for ischemic stroke drop by one-third
One in four disabled seniors use risky or ineffective medicines

Research Activities, June 2008:
Several factors can quickly identify mortality risk among frail elderly persons living in the community
Use of dementia treatments is similar in community and long-term care settings

Research Activities, May 2008:
Researchers examine the relationship of workarounds to technology implementation and medication safety in nursing homes
Staff education and performance feedback only slightly improve fracture prevention among nursing home residents
Physicians could improve end-of-life communication and decision-making for elderly patients with advanced heart failure
Health improves when previously uninsured adults become eligible for Medicare
Nursing home residents likely to receive diagnosis and pills for depression but not psychotherapy

Research Activities, April 2008:
Modest health care quality gains outpaced by spending
Physicians and terminal patients need to communicate better with each other about end-of-life care options
Certain interventions have the potential to reduce costly and risky hospitalizations of the frail elderly
Self-rated health may not be the best way to identify mortality risks among less-educated, black older persons
Quality of care for geriatric-prevalent conditions is worse than general care among the hospitalized frail elderly
Conference on assisted living reveals its evolution, dearth of research, and quality of life for residents
Poverty-related factors rather than frequency of primary care visits underlie racial disparities in preventive care

Research Activities, March 2008:
Few nursing home residents receive medications and supplements for osteoporosis
More than half a million patients visit the emergency department for severe sepsis each year

Research Activities, February 2008:
Age, gender, and location are keys to predicting patient fall injuries in hospitals
Staffing levels and turnover are influenced by nursing home expenditure patterns
Medicare drug plans cover a good selection of drugs for nursing home residents, but plan vigilance should continue
Financial incentives to physicians and long-term care facilities may foster adoption of computerized drug systems
Three-tier formularies increase cost sharing for retirees in generous plans, with little effect on continued drug use
Managed care helps the elderly avoid preventable hospitalizations more than traditional Medicare

Research Activities, January 2008:
AHRQ releases toolkits to help providers and patients implement safer health care practices
Some women with breast cancer do not receive adjuvant treatments recommended by guidelines
Elderly cancer patients who live in minority communities use hospice care less than their counterparts in white communities
The link between vitamin B levels and subsequent cognitive function remains unclear
Following recommended guidelines to manage cardiovascular disease improves patient outcomes
New studies reveal the impact of drug copayment and coinsurance policies on statin and beta-blocker therapy after heart attack

Research Activities, December 2007:
Common medications provide equal blood pressure control
Many seniors will pay double the monthly copay for angiotensin receptor blockers under the Medicare Part D drug plan compared with their previous plans
Prescribing antidepressants for elderly persons should not be affected by concern about drug-related pneumonia risk
A pharmacy alert system plus physician-pharmacist collaboration can reduce inappropriate drug prescribing among elderly outpatients

Research Activities, November 2007:
AHRQ expands therapeutics education and research centers and adds new topics: Health IT, economics, and formularies
Study documents the health costs of being a woman
Nursing home report cards have prompted many nursing homes to improve care, especially those with poor scores
Postdischarge care management that integrates medical and social care can improve outcomes of the low-income elderly
Black and white caregivers of rural patients with dementia have different characteristics and coping styles
Low income middle-aged Americans have higher 10-year death rates even after controlling for their worse health at baseline
Several factors prompt patients with HIV to voluntarily switch physicians
Late diagnosis of HIV is a problem for older patients, many of whom aren't diagnosed until they've already developed AIDS
End-of-life care expenditures and use among Medicare colorectal cancer patients differ more by age than gender
Palliative care study challenges assumptions about physician emotional involvement and communication with patients
Complications following heart valve replacements are prevalent and worsen patient outcomes
Diagnosing coronary heart disease prior to a heart attack improves the chance of lowering the risk of future coronary events
Adults who arrive at the emergency department with acute cough and vital sign abnormalities may have pneumonia
Patients who were uninsured use more medical services once they enroll in Medicare

Research Activities, October 2007:
Health literacy is not associated with how minorities perceive their physical or mental health status
Researchers examine link between trauma and alcohol problems as well as cardiovascular risk factors among American Indians
Studies show lower colorectal cancer screening rates and access to surgery among the poor, minority, and uninsured
Elderly blacks' higher hospitalization rates for certain conditions suggest worse quality of outpatient care
Elderly women in the early stages of lung cancer live longer than elderly men, regardless of the type of treatment they receive
Low blood levels of omega-3 fatty acids predicts increased risk for acute coronary syndrome
Studies examine medication adherence and group medical visits among persons with high blood pressure
One-third of patients with acute coronary syndrome and diabetes do not have their blood sugar assessed before hospital discharge
Studies show shorter hospital stays for coronary bypass surgery reduce costs without harm to patients

Research Activities, September 2007:
Elderly black men are less likely than white men to seek and receive care for lower urinary tract symptoms
Women in Medicare and private managed care plans receive worse care than men for cardiovascular disease and diabetes
Home health care following hospitalization for hip fracture may provide an opportunity to limit osteoporosis progression
Nurses and physicians have different perspectives and roles in medical decisions affecting nursing home residents
Studies examine the safety of prescribing antipsychotics, acetylcholinesterase inhibitors, and beta-blockers to older adults
Medicare Part D provides coverage protection for mental health-related drugs, but certain drugs still may not be covered
Drug therapy has reduced hospitalization for HIV patients, but those hospitalized are getting older and sicker
Effectively treating other medical conditions in patients with HIV may reduce HIV's overall impact on functioning

Research Activities, August 2007:
Hospice care dramatically reduces end-of-life hospitalizations of nursing home residents
Early detection and aggressive treatment for prostate cancer is linked to more use of androgen-deprivation therapy for older men
Rates of inappropriate carotid endarterectomy surgery decreased after publication of the results from clinical trials
Medication therapy management programs varied widely after initial implementation of the Medicare Part D drug benefit
Socioeconomically disadvantaged patients with lupus have less access to and use of health care
Providing combination medication for elderly patients following a heart attack can save both lives and money
Education, income, and wealth all affect medical care expenditures among Medicare managed care members

Research Activities, July 2007:
Greater access to physician services may narrow mortality differences among the black and white elderly
Certain resident and facility characteristics and medications increase the risk of fractures among nursing home residents
Urinary incontinence is common among residents of Southeastern nursing homes, especially among black residents
One-third of Medicare patients say that the decision about where to undergo surgery was made mainly by their doctor
The Medicare short stay transfer policy reduced hospital incentives to discharge orthopedic surgery patients early
Patients suffering from arthritis or depression may have worse health-related quality of life than those with other chronic conditions
Total, partial, and revision hip replacement are associated with different rates of postoperative complications and readmissions

Research Activities, June 2007:
A fall management program in nursing homes improves care and reduces use of physical restraints

Research Activities, May 2007:
Older women who are depressed following breast cancer therapy are less likely to fully recover shoulder mobility
Elderly Medicare patients with low health literacy receive little tangible support for their health care needs
Growth hormone is not recommended as an antiaging therapy
Hip fracture patients with osteoarthritis have longer hospital stays, but similar functional gain as those without the condition

Research Activities, April 2007:
Medicare/Medicaid patients with unstable angina receive poorer quality of care than other Medicare patients
Rural nursing home residents with dementia are less likely than their urban counterparts to undergo intensive end-of-life care
Elderly people find international medical school graduates to lack in cultural competency and communication skills
Extending health insurance coverage to older working adults may substantially improve their health

Research Activities, March 2007:
Stimulation of the subthalamic nucleus of the brain improves quality of life for patients with advanced Parkinson's disease
Intimate partner abuse has no age limit
Older adults' psychological and health characteristics influence their use and timing of online health information searches
Use of the pain reliever propoxyphene is associated with a higher risk of hip fracture among the elderly

Research Activities, February 2007:
Shifting from a culture of blame to a culture of safety in nursing homes could help identify and prevent medical errors
Few patients seek compensation for medical injuries through New Zealand's no-fault medical malpractice system
Not adjusting for pre-existing health problems may have exaggerated the number of deaths due to medical injury
Computerized and age-specific drug alerts can reduce both inappropriate prescribing of drugs and unnecessary drug alerts
Followup care after total hip replacement could be improved
Advance care plans of nursing home residents vary by age, race/ethnicity, and income

Research Activities, January 2007:
Missed opportunities: Too few Americans are being screened or counseled to prevent colorectal cancer, obesity, and other conditions
A new classification scheme quantifies the risk of hemorrhage among atrial fibrillation patients taking anticoagulants
Medicare payment reforms sparked changes in use of home health care services among the elderly

Research Activities, December 2006:
Older American Indians often have a poorer view of their own health than their doctors
Functional outcomes may be good markers of quality of care for hip fracture surgery patients
Journal supplement reviews evidence for the efficacy of telemedicine and telecare
Racial differences in religiosity and religious coping styles are linked to use of health care services by low-income older women
The decision to hospitalize nursing home residents is driven primarily by residents' preference and quality of life
A pain medication appropriateness scale reveals that many nursing home residents suffer from poorly controlled pain
Studies examine factors influencing postoperative complications and functioning among patients undergoing hip fracture repair
People with low incomes are more likely to obtain dental care outside of private dental practices than those with higher incomes

Research Activities, November 2006:
Women's self-report of mammography use conflicts with verified reports using claims data
Increasing the time that nurses spend with nursing home residents is key to improving their job satisfaction
Computerized drug alerts when ordering medications reduce inappropriate prescribing for the elderly
Men, young children, and elderly people are most likely to sustain traumatic brain injury from blunt head trauma
HMOs do not appear to adversely affect the health of the near-elderly and may benefit those with chronic health conditions
Influenza is the most deadly illness for the very elderly

Research Activities, October 2006:
Teriparatide alone is less cost-effective than alendronate alone for the treatment of women with severe osteoporosis
Elderly patients whose physicians are white or have urban practices are more likely to use antidepressants
Severity of illness and rural location affect the willingness of elderly people to travel longer distances to the hospital
Prescription drug benefits limits for Medicare beneficiaries are associated with less use of prescription drugs, worse clinical outcomes, and higher hospitalization costs
Greater competition among health plans is linked to more advertising that targets healthier patients

Research Activities, August 2006:
Elderly women are more likely than men to die after coronary bypass surgery
Long work hours and family care-giving affect nurses' hospital performance
Studies highlight the value of the Medical Expenditure Panel Survey to inform trends in care costs, coverage, use, and access
Modifying unhealthy habits in middle age may reduce the likelihood of nursing home admissions later in life
Only half of older people with diabetes receive ACE inhibitors or angiotensin receptor blockers to prevent cardiac problems
Older veterans need to become more actively involved in hospital discharge planning for their post-hospital needs

Research Activities, July 2006:
Doctors often fail to order laboratory monitoring when elderly HMO outpatients begin cardiovascular medications
Greater use of agency nurses in nursing homes may lead to poorer quality of care
Patients with the poorest functioning after a stroke benefit the most from followup therapy
Some adults with diabetes face high health care expenditures

Research Activities, June 2006:
Adverse incident reporting system improves documentation of falls in nursing homes to guide prevention of future falls
Clinicians may need to balance recommendations with patient preferences for anticoagulant medication to treat atrial fibrillation

Research Activities, May 2006
Ethnicity, age, and living arrangements affect the use of assistive devices by people with impaired mobility
Researchers examine gender disparities in the quality of preventive care and management of heart disease and diabetes
Nursing homes that emphasize team effort and staff flexibility are more likely to sustain improvements in quality of care
Nursing home working conditions are linked to care performance
Greater Medicare HMO penetration is associated with a shift in elderly stroke deaths from hospital to non-hospital settings
Improved recognition and treatment of emotional problems may indirectly improve the elderly's use of preventive care
One-third of all patients admitted to the Nation's community hospitals are elderly

Research Activities, April 2006
Although inappropriate for use in older adults, propoxyphene was widely prescribed to elderly patients in the 1990s

Research Activities, March 2006
Fewer visits to the doctor contribute to the higher mortality rates among black Medicare patients in Tennessee
Women need information about alternatives, risks, and benefits of hormone therapy for osteoporosis to make an informed decision

Research Activities, February 2006:
Asking terminally ill patients why they want to hasten their death may provide opportunities to improve their situation
Varied use of physical therapists by people with back and neck pain suggests overuse by some patients and underuse by others
Both aspirin and extended release dipyridamole/aspirin are cost-effective anticoagulant agents to prevent second strokes

Research Activities, January 2006:
Individual characteristics, complications, and treatments influence quality of life among adults with diabetes

Research Activities, December 2005:
Anemia increases a patient's risk of dying after hospitalization for unstable angina or heart attack
Study examines factors that predict influenza vaccination status in older adults
Donepezil has a small effect in the treatment of dementia from Parkinson's disease

Research Activities, November 2005:
Diagnosing dementia is difficult and expensive for primary care practices
Very elderly patients are more likely to need skilled nursing care after coronary bypass surgery
Educating patients with asthma on avoiding allergens is suboptimal
Studies examine rates of morbid obesity and bariatric surgery and risk of death after the surgery
Studies detail the impact of costs on drug and health care use

Research Activities, October 2005:
Osteoarthritis impairs recovery from stroke
Older and minority elderly are less willing to travel to distant hospitals for care
Psychotherapy is not commonly used to treat older adults with depression
Medicare expenditures among residents of assisted living facilities are similar to those of community-dwelling elderly

Research Activities, September 2005:
Elderly people commonly use herbs or vitamin-mineral supplements, but use varies by ethnicity
Hospitalization rates vary for nursing home residents with suspected pneumonia
Increased use of ACE inhibitors for elderly people with diabetes could improve outcomes and save money
Computerized guidelines for psychotropic drug use can improve prescribing and reduce falls among hospitalized elderly patients
At least one-fourth of older adults will be uninsured at some point during the years preceding eligibility for Medicare

Research Activities, August 2005:
Medical disparities for elderly Medicare beneficiaries are narrowing
Traditional values underlie older Korean Americans' preference for informal over formal long-term care arrangements
Elderly individuals with financial problems face more disability and risk of death after hospital discharge
Patients most likely to benefit from stroke rehabilitation are least likely to be selected
Diagnostic test information often reassures patients who have chest pain suggestive of coronary artery disease
Study calls for reform of policies that reject candidates for cardiac transplantation due to lack of insurance or finances

Research Activities, July 2005:
Nursing homes vary widely in their hospitalization of residents, particularly those with Alzheimer's disease
Older people in HMOs and PPOs use more outpatient and preventive services than those in fee-for-service plans
Study questions whether competition among HMOs will inherently improve care quality

Research Activities, June 2005:
Three clinical factors can determine the likelihood of cervical spine fractures in elderly victims of blunt trauma
Advance care planning standards could be improved by giving patients more flexibility in conveying their wishes to others
Nurses tend to use individual behavioral and visual cues to assess pain in nursing home residents
Resident and facility characteristics affect the amount of direct care time received by elders in supportive housing
Publishing report cards about a surgeon's quality influences consumer selection of surgeons
Nursing home complaints, taken together with other measures, can be used to assess nursing home quality of care

Research Activities, May 2005:
A delay of 2 or more days in surgical repair of hip fracture substantially increases mortality rates
Rates of coronary angiography are inappropriately low in older cardiac patients who have chronic kidney disease
Even seemingly mild complications after surgery may radically alter an elderly person's risk of dying
Use of potentially inappropriate medications in patients aged 65 and older continues to be widespread
Study cites several barriers to adoption of guideline-recommended osteoporosis care for frail nursing home residents
Informal care of elderly parents by adult children limits use of nursing home and other formal care and shortens hospital stays

Research Activities, April 2005:
Study documents the prescribing of potentially harmful drugs to elderly outpatients prescribed multiple drugs
Postoperative functioning, age, obesity, and social support influence where patients go after total hip replacement
Informal caregiver characteristics influence the hospitalization and discharge of elderly women
Sociodemographic factors affect receipt of preventive care services among women aged 65 and older
Pain management is often inadequate for elderly patients hospitalized for surgery
Nursing home quality of care may suffer if budget shortfalls force States to freeze or reduce Medicaid rates
Algorithms can enhance communication between pharmacists and physicians about medications prescribed for elderly patients

Research Activities, March 2005:
Androgen-deprivation therapy for prostate cancer increases the risk of fracture among elderly men
Use of certain antidepressants may increase risk of hip fractures among older patients
Studies of COX-2 inhibitors have ramifications for other drugs and pharmaceutical policies
Primary care providers miss opportunities during office visits for adult preventive care
Women 65 and older used more medications and spent more for them than same-age men during the period 1999 to 2001

Research Activities, February 2005:
Task Force recommends screening for abdominal aortic aneurysm for male smokers and former smokers ages 65 to 75
Adding a breakfast portion to home-delivered meals can improve the lives of frail, homebound older adults

Research Activities, January 2005:
Improving access to coronary angioplasty in hospitals without CABG surgery programs is risky
Study finds declining quality of primary care for elderly Medicare patients
Researchers find potentially inappropriate drug use in nursing homes associated with deaths of elderly residents
Study suggests that use of lifesaving beta-blockers for heart attack patients is increasing at community hospitals
Elderly people who lack prescription drug coverage may not get needed medications for chronic conditions
Nursing homes that employ physician extenders and provide training for nurses' aides have fewer hospitalizations
Medicaid may be an important key to linking older individuals in rural areas with formal home health care
Medicare managed care enrollees make significant use of home health benefits, but low education limits use of medical equipment

Research Activities, December 2004:
Patients with Alzheimer's disease and their caregivers need a comprehensive care program that addresses problem behaviors
Nursing home treatment for lower respiratory infection is safe and less costly than hospitalization for some residents
Improved health insurance coverage may enhance access to care among rural Hispanic elders

Research Activities, November 2004:
Prehypertension is a considerable health risk, particularly in people aged 45 and older
Falls among hospitalized patients of all ages are a persistent problem
Among elderly patients with dementia, blacks and Latinos are more likely than whites to show dementia-related behaviors
Structured health programs can greatly help frail older adults and their family caregivers
Knowledge of pain medication and its management could be improved among nursing home staff
Volume and intensity of physicians' services used by FFS Medicare enrollees jumped over 30 percent in the mid-1990s

Research Activities, October 2004:
Potentially inappropriate drugs are commonly prescribed for elderly outpatients
More effective and convenient medications for osteoporosis have increased recognition and treatment of the disease
Use of mechanical ventilation in adult noncardiac surgery patients increased in Ontario during the 1990s
Daily visit volume is similar for dying patients receiving hospice care in nursing homes and in the community
Cognitive testing can indicate when patients with Alzheimer's disease may lose the ability to make medical decisions
Over the period 1963-2000, per person spending on health care grew most rapidly among those aged 65 and older
Medicare drug benefits with high out-of-pocket costs might not be effective for low-income beneficiaries with chronic diseases

Research Activities, September 2004:
Many chronically ill patients don't tell their doctors that they limit use of prescription drugs because of cost
Clopidogrel is a cost-effective medication for patients with a recent stroke or peripheral arterial disease
Use of rofecoxib at 50 mg for more than 5 days for osteoarthritis should be discouraged due to dose-related problems
Lack of insurance coverage is not the only barrier to medication access among older Americans with chronic conditions
Interference of diabetes with social activities may be an early warning sign of subsequent disability
Osteoarthritis patients have less pain and better functioning after joint replacement surgery, but they need support at 1 month
Problems with mobility make it hard for people with Parkinson's disease to express their personality
Communication problems often contribute to untimely care of acute infections in nursing homes
Researchers compare treatment of U.S. and Dutch nursing home residents with dementia who develop lower respiratory infections
Despite overall national improvement in beta-blocker use after heart attack, the rate of improvement varies across hospitals
In-hospital mortality is similar for cardiac surgery patients treated at either medium- or high-volume hospitals

Research Activities, August 2004:
One-third of heart failure patients stop taking their prescribed medication within a year of hospital discharge
Residents are more likely to transfer out of nursing homes with low quality of care
Researchers examine factors affecting the quality of end-of-life care
Obese older adults tend to have lower quality of life than those who are normal weight or overweight
Incontinence alone does not increase risk of death or nursing home admission but is probably a marker of frailty
Outcomes usually are poor among patients receiving home enteral nutrition from informal caregivers
Researchers examine decision aids for prostate cancer screening and patients' attitudes toward screening and treatment

Research Activities, July 2004:
Younger women with heart failure have worse quality of life than older women and men, but they also tend to improve more over time
Higher income and coverage for dental care increase use of dental services among older adults
Disparities in use of preventive care may be reduced by requiring Medicare HMO enrollees to select a primary care doctor
Medicare managed care is better at delivering preventive services, but traditional Medicare is better in other areas

Research Activities, June 2004:
Shorter hospital length of stay not associated with worse outcomes for patients without DNR orders
Physician prescribing preference plays a greater role than patient risk factors in prescribing COX-2 inhibitors
Screening sigmoidoscopy may be less effective for detecting colorectal cancer in women and older people
Doctors can use proactive office systems and patient education to persuade more elderly patients to get flu shots
Fewer Medicare patients die in the hospital than in the past, but those who do receive more intensive and expensive treatment
Nursing homes generally respect residents' do-not-hospitalize orders, but not always
Researchers examine Medicare costs and use of hospice care
Nursing home staffing and quality improved after passage of the Nursing Home Reform Act
Primary care of adults with chronic acid-related disorders could be improved if more doctors followed treatment guidelines
Patient age has more influence on Medicare costs for end-of-life care than race, income, or sex

Research Activities, May 2004:
Less than half of older women who have suffered fractures due to osteoporosis are treated properly to prevent further fractures
Better monitoring of the cardiac drug amiodarone among outpatients could improve its safety
Early surgery reduces hip fracture pain
Practices that allot more time for acute care visits and promote immunization have higher adult vaccination rates
Doctors should target chronic disease and functioning among frail older patients to lower the risk of hospitalization
More than half of assisted living facilities will not admit individuals who have moderate cognitive impairment or behavioral problems or need assistance with transfer
Increased State Medicaid reimbursement for nursing home care reduces residents' risk of being hospitalized
State governments assumed an increasing role in funding home care after passage of the 1997 Balanced Budget Act
Use of medical care in the Nation is greatest among the wealthy, and income-related inequality in use is highest among seniors
Young and healthy individuals fare better than moderately sick individuals with consumer-directed health benefits

Research Activities, April 2004:
Diagnosis and treatment of depression in the elderly increased in the 1990s, but racial and other disparities persist
Problems in self-management of congestive heart failure may contribute to ER visits and poor prognosis
Hip fracture patients function better after hip repair surgery if they receive transfusions for anemia while in the hospital
Many medications are effective in managing atrial fibrillation
Studies focus on care for respiratory tract infections in the elderly
Medicare drug benefit bill will increase physicians' exposure to drug formularies
Medicare enrollees in for-profit plans are no less likely to receive high-cost procedures than those in non-profit plans

Research Activities, March 2004:
Renal disease progression is not slower among women than men, and it may even be faster
EXCEED projects focus on prevention and treatment of cardiovascular disease
Certain oral blood-sugar-lowering drugs may increase the risk of heart failure in patients with type 2 diabetes
Screening relatively healthy elderly women for breast cancer every 2 years is cost effective
Inconsistent use of medications by elderly Mexican Americans with diabetes may explain their greater risk of some complications
Only about half of stroke survivors living in nursing homes receive medicine to prevent another stroke
Hospital costs are higher for elderly Medicare patients with low functional status
Medicare's role in financing nursing home care has greatly expanded
State shifting of Medicaid home care costs to Medicare greatly increases Medicare expenditures for home care
Higher RN staffing is associated with fewer deaths among elderly Medicare patients hospitalized for heart attack

Research Activities, February 2004:
New study estimates potential savings gained by expanding use of beta-blockers in heart failure patients
Complications from prostate cancer treatment vary according to pretreatment function and choice of treatment

Research Activities, January 2004:
Few postmenopausal women who have suffered a fracture receive drug treatment to prevent further fractures
Transfusion after hip fracture surgery reduces the risk of rehospitalization for older patients with significant anemia
Age alone should not be a deterrent for recommending coronary bypass surgery
Elderly, low-income black women need more education about the importance of breast cancer screening
Residents of assisted living facilities with a full-time RN are less likely to leave the facility for a nursing home
Providing rehabilitation to newly admitted nursing home residents increases the likelihood of community discharge and lengthens survival
Researchers examine factors affecting diagnosis of acute illness and mental health conditions among nursing home residents
Recent HCSUS studies focus on HIV infection in older individuals and women, use of complementary and alternative therapies, and insurance status