Mortality Following Widowhood: The Role of Prior Spousal Health Public
Heller, Debra Ann (2014)
Abstract
Previous studies have demonstrated that widowhood is associated with increased mortality risk. Although prior research suggests that the context of the predeceased spouse's death may affect this association, information is limited regarding how the rapidity of the decedent's health decline affects the survival of the bereaved spouse. The goal of this study was to combine two methods - group-based trajectory modeling and survival analysis - to identify decedents' end-of-life morbidity trajectories and to examine their association with post-widowhood survival in bereaved spouses.
Subjects included 9,967 married couples enrolled in the
Pennsylvania Pharmaceutical Assistance Contract for the Elderly
(PACE) Program. Using the predeceased spouse's death date as an
index date, predeceased and bereaved spouses' morbidity
trajectories in the prior year were evaluated for three morbidity
measures: the Combined Comorbidity Score, inpatient hospitalized
days, and ambulatory visits. Kaplan-Meier and Cox proportional
hazards models were used to evaluate associations between morbidity
patterns and post-widowhood survival over three years.
Multiple trajectories were identified for each predeceased
morbidity measure, including six patterns for Combined Comorbidity,
four for inpatient days, and six for ambulatory visits. Among
hospice users, stable low or late onset predeceased Combined
Comorbidity trajectories were associated with elevated mortality
rates in the bereaved, relative to chronic high morbidity (HR=1.47
and 1.62, respectively); no effect was apparent in non-hospice
users. Relative to stable medium ambulatory visits, chronic high
predeceased visits were associated with a lower mortality rate in
the bereaved (HR=0.67; 95% CI: 0.48, 0.92), while a stable zero
visit pattern was associated with a higher rate (HR=1.32; 95% CI:
1.14, 1.53). The effects of spousal morbidity on survival were
neither confounded with nor modified by age, sex, race, or place of
death. However, for Combined Comorbidity and ambulatory visits, the
predeceased morbidity trajectory was confounded with the widowed
subject's own morbidity trajectory.
These results demonstrate the utility of group-based trajectory
modeling for describing end-of-life health decline. However, the
impact of spousal morbidity trajectory on post-widowhood survival
was not consistent across measures, and was confounded with
subjects' own morbidity. More research is needed to examine the
complex pathways through which spousal illness trajectories affect
post-widowhood mortality.
Table of Contents
CHAPTER I: INTRODUCTION
Rationale (1)
Problem Statement (1)
Purpose Statement (5)
Research Questions (5)
Significance Statement (7)
Definition of Key Terms (8)
CHAPTER II: REVIEW OF THE LITERATURE
Introduction (10)
Marital Status and Mortality (10)
Bereavement and Mortality (14)
Early Cohort Studies
(14)
Gender, Age, and Duration of Bereavement (16)
Cause-Specific Mortality of Bereaved Spouses (19)
Studies Addressing Shared Environmental Effects (20)
Meta Analyses of Bereavement and Mortality (21)
Impact of Bereavement on Other Health Measures (22)
Context of the Predeceased Spouse's Death (25)
Health Conditions of
the Predeceased Spouse (25)
Expectedness of Death (29)
Caregiving Burden (31)
The Importance of Place of Death (34)
Use of Hospice Services (36)
End-of-Life Health Trajectories (36)
Summary of Current Problem and Study Relevance
(40)
CHAPTER III: METHODOLOGY
Introduction (41)
Population and Sample (42)
The PACE Program
(42)
Widowed Cohort (43)
Research Design (44)
Procedures (44)
Instruments (45)
Data Files (46)
Computed Measures (48)
Plans for Data Analysis (51)
Phase 1: Health
Trajectory Analysis (51)
Phase 2: Survival Analysis (58)
Study Limitations and Delimitations (66)
CHAPTER IV: RESULTS
Health Trajectory Analysis (70)
Combined Comorbidity
Score Trajectories (70)
Inpatient Hospitalization Days (75)
Ambulatory Visits (78)
Survival Analysis (81)
Collinearity
Assessment (81)
Crude Mortality Risks and Rates (82)
Comparison of Mortality Rates to Other PACE Data (84)
Kaplan-Meier Analysis Results (85)
Cox Proportional Hazards Modeling (86)
CHAPTER V: DISCUSSION
Introduction (92)
Summary of Study (93)
Rationale and
Significance (93)
Study Sample and Research Questions (95)
Methodology Used (96)
Conclusions, Implications, and Recommendations
(97)
TABLES (109)
FIGURES (144)
REFERENCES (179)
Appendix A: Emory University
Institutional Review Board Letter (191)
Appendix B: SAS Code (193)
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