Use of health care utilization as a metric of intervention success may perpetuate racial disparities: An outcome evaluation of a homeless transitional care program.

OBJECTIVE: This study explored race-based differences in disease burden, health care utilization, and mortality for Black and White persons experiencing homelessness (PEH) who were referred to a transitional care program, and health care utilization and program outcomes for program participants. DESIGN: This was a quantitative program evaluation. SAMPLE: Black and White PEH referred to a transitional care program (n = 450). We also analyzed data from the subgroup of program participants (N = 122). Of the 450 referrals, 122 participants enrolled in the program. MEASURES: We included chronic disease burden, mental illness, substance use, health care utilization, and mortality rates for all PEH referred. For program participants, we added 6-month pre/post health care utilization and program outcomes. All results were dichotomized by race. RESULTS: Black PEH who were referred to the program had higher rates of hypertension, diabetes, renal failure, and HIV and similar post-referral mortality rates compared to White PEH. Black and White PEH exhibited similar program outcomes; however, Black PEH revisited the emergency department (ED) less frequently than White PEH at 30 and 90 days after participating in the program. CONCLUSIONS: Health care utilization may be a misleading indicator of medical complexity and morbidity among Black PEH. Interventions that rely on health care utilization as an outcome measure may unintentionally contribute to racial disparities.

Cost-Effectiveness of a Homeless Care Transition Program: Durham Homeless Care Transitions.

BACKGROUND Transitional care and medical respite programs provide assistance to people experiencing homelessness as they move from acute care into community settings. These programs can address issues that may fall outside the reach of traditional medical care yet have a profound impact on the health of vulnerable populations. This article focuses on the cost-effectiveness of the Durham Homeless Care Transitions (DHCT) program.METHOD This intervention study of the DHCT program uses a comparison group of people experiencing homelessness who were referred but did not participate. Encounter-level data, aggregated by quarterly segments of charges and reimbursements, were abstracted for all persons referred. Descriptive statistics were computed and models of charges and reimbursements were created using ordinary least squares (OLS) regression to compare utilization for 12 months pre- and post-referral.RESULTS Patients referred to the DHCT program (N = 485) were primarily non-Hispanic Black (62.5%), male (68.4%), uninsured (35.5%), and had an average of 5.3 chronic conditions and an average age of 50.0 years (SD = 11.3). There was variability among charges and reimbursement based on health care visit type but a negative association between treatment and charges, indicating that being part of the DHCT program led to lower charges post-referral.LIMITATIONS The study is limited by lack of access to line-item details of charges, reimbursement, and payer mix.CONCLUSION There is evidence of benefit to patients from transitional care and medical respite programs that does not substantially increase the overall societal cost of care; however, health systems commonly require evidence of cost savings and benefit as a return on investment.

Bach to the Basics: Implementation and Impact of a Postoperative, Inpatient Personalized Music Program for Older Adults.

PURPOSE: Music as an intervention to mitigate pain and anxiety has been well studied in the perioperative period. We present a quality improvement (QI) report describing implementation and evaluation of a postoperative, inpatient personalized music program for older adults undergoing elective surgeries. DESIGN: We embedded this program in an existing interdisciplinary perioperative care program, with an outpatient and an inpatient component, at an academic institution. METHODS: We describe our initial QI steps, highlight critical lessons learned from this behavioral intervention, and discuss high yield areas to focus on future implementation efforts. FINDINGS: Rapid cycle improvement was an effective method to monitor QI measures. Participants in our program perceived improved mood and pain control, were satisfied with their experience, and had lower rates of incident delirium. CONCLUSIONS: This program offers perioperative teams, especially frontline nursing staff, an inexpensive, patient-centered tool to optimize postoperative pain and anxiety. We believe that it can be easily replicated at a variety of hospital systems.

Negative Temperature Differential in Preterm Infants Less Than 29 Weeks Gestational Age: Associations With Infection and Maternal Smoking.

BACKGROUND: Hypothermia is related to increased morbidity and mortality in very preterm infants; continuous temperature monitoring is necessary. Thermoregulation is limited in preterm infants. OBJECTIVES: The purpose of the research was to assess and describe negative temperature differential (NTD) and assess the associations of NTD with infant demographic characteristics, medical history, and clinical events. METHODS: An exploratory, case study design was used. Abdominal and foot temperature was measured every minute over the first 2 weeks of life in 22 preterm infants at less than 29 weeks gestational age. RESULTS: All infants experienced NTD. Daily NTD in all infants across all study days ranged from 0 to 70.7%; 2-week mean NTD over all infants ranged from 7.3% to 38.5%. Four infants treated for late onset of infection had a higher NTD than 18 infants without infection (M = 27.8%, SD = 9.52 vs. M = 16.4%, SD = 5.34, p < .05). Although not statistically significant, higher mean percentage of NTD was noted in infants having early onset infection (24.1% vs. 16.4%), African American race (20.0% vs. 15.3%), and/or being born to a mother who smoked during pregnancy (26.6% vs. 16.7%). DISCUSSION: A larger study is needed to examine associations between NTD and race, maternal smoking history, and infection. NTD might be used as a biomarker to guide acute clinical care and identify infants at risk for acute and chronic morbidity.

Factors Associated with COVID-19 Vaccination Promptness after Eligibility in a North Carolina Longitudinal Cohort Study.

Many studies identified factors associated with vaccination intention and hesitancy, but factors associated with vaccination promptness and the effect of vaccination intention on vaccination promptness are unknown. This study identified factors associated with COVID-19 vaccination promptness and evaluated the role of vaccination intention on vaccination promptness in 1223 participants in a community-based longitudinal cohort study (June 2020 to December 2021). Participants answered questions regarding COVID-19 vaccination intention, vaccination status, and reasons for not receiving a vaccine. The association of baseline vaccine hesitancy with vaccination was assessed by the Kaplan-Meier survival analysis. Follow-up analyses tested the importance of other variables predicting vaccination using the Cox proportional hazards model. Older age was associated with shorter time to vaccination (HR = 1.76 [1.37-2.25] 85-year-old versus 65-year-old). Lower education levels (HR = 0.80 [0.69-0.92]), household incomes (HR = 0.84 [0.72-0.98]), and baseline vaccination intention of 'No' (HR = 0.16 [0.11-0.23]) were associated with longer times to vaccination. The most common reasons for not being vaccinated (N = 58) were vaccine safety concerns (n = 33), side effects (n = 28), and vaccine effectiveness (n = 25). Vaccination campaigns that target populations prone to hesitancy and address vaccine safety and effectiveness could be helpful in future vaccination rollouts.

Retention of older veterans with serious mental illness in a clinical exercise program.

Older adults with serious mental illness (SMI) have compromised physical function that could be improved with exercise; however, retention in exercise programs is a challenge. This study was a retrospective analysis of retention for the 150 older veterans with SMI that enrolled in Gerofit, a clinical exercise program offered in the Veterans Health Administration. Chi-square and t-tests were conducted to evaluate baseline differences between those that were and were not retained at six and 12 months. Retention was 33% and better health-related quality of life and endurance were related to retention. Future work is needed to improve exercise program retention in this population.

Program Outcomes and Health Care Utilization of People Experiencing Homelessness and Substance Use Disorder after Transitional Care Program Engagement.

People experiencing homelessness (PEH) have a high prevalence of mental illness and substance use disorder (SUD) and substantial acute and chronic disease burden. Transitional care and medical respite programs facilitate a safe transfer for PEH from the acute care to community setting. Many medical respite programs practice harm reduction strategies that can increase the opportunity for positive program outcomes for PEH with SUD. This transitional care and medical respite program evaluation explored program outcomes, health care utilization patterns, and comorbid conditions of persons with and without SUD. People experiencing homelessness with SUD had similar program outcomes and both groups had decreased acute care utilization after program engagement. A high prevalence of trimorbidity, which is associated with early mortality, was noted. Opportunities for harm reduction strategies to promote both social and clinical outcomes are offered.

Differences in Clinical Outcomes of Adults Referred to a Homeless Transitional Care Program Based on Multimorbid Health Profiles: A Latent Class Analysis.

Background: People experiencing homelessness face significant medical and psychiatric illness, yet few studies have characterized the effects of multimorbidity within this population. This study aimed to (a) delineate unique groups of individuals based on medical, psychiatric, and substance use disorder profiles, and (b) compare clinical outcomes across groups. Methods: We extracted administrative data from a health system electronic health record for adults referred to the Durham Homeless Care Transitions program from July 2016 to June 2020. We used latent class analysis to estimate classes in this cohort based on clinically important medical, psychiatric and substance use disorder diagnoses and compared health care utilization, overdose, and mortality at 12 months after referral. Results: We included 497 patients in the study and found 5 distinct groups: "low morbidity" (referent), "high comorbidity," "high tri-morbidity," "high alcohol use," and "high medical illness." All groups had greater number of admissions, longer mean duration of admissions, and more ED visits in the 12 months after referral compared to the "low morbidity" group. The "high medical illness" group had greater mortality 12 months after referral compared to the "low morbidity" group (OR, 2.53, 1.03-6.16; 95% CI, 1.03-6.16; p = 0.04). The "high comorbidity" group (OR, 5.23; 95% CI, 1.57-17.39; p < 0.007) and "high tri-morbidity" group (OR, 4.20; 95% CI, 1.26-14.01; p < 0.02) had greater 12-month drug overdose risk after referral compared to the referent group. Conclusions: These data suggest that distinct groups of people experiencing homelessness are affected differently by comorbidities, thus health care programs for this population should address their risk factors accordingly.

Reach out to ENhancE Wellness in Older Cancer Survivors (RENEW): design, methods and recruitment challenges of a home-based exercise and diet intervention to improve physical function among long-term survivors of breast, prostate, and colorectal cancer.

OBJECTIVE: Cure rates for cancer are increasing, especially for breast, prostate, and colorectal cancer. Despite positive trends in survivorship, a cancer diagnosis can trigger accelerated functional decline that can threaten independence, reduce quality-of-life and increase healthcare costs, especially among the elderly who comprise the majority of survivors. Lifestyle interventions may hold promise in reorienting functional decline in older cancer survivors, but few studies have been conducted. METHODS: We describe the design and methods of a randomized controlled trial, RENEW (Reach out to ENhancE Wellness), that tests whether a home-based multi-behavior intervention focused on exercise, and including a low saturated fat, plant-based diet, would improve physical functioning among 641 older, long-term (>or=5 years post-diagnosis) survivors of breast, prostate, or colorectal cancer. Challenges to recruitment are examined. RESULTS: Twenty thousand and fifteen cases were approached, and screened using a two-step screening process to assure eligibility. This population of long-term, elderly cancer survivors had lower rates of response (approximately 11%) and higher rates of ineligibility (approximately 70%) than our previous intervention studies conducted on adults with newly diagnosed cancer. Significantly higher response rates were noted among survivors who were White, younger, and more proximal to diagnosis and breast cancer survivors (p-values<0.001). CONCLUSION: Older cancer survivors represent a vulnerable population for whom lifestyle interventions may hold promise. RENEW may provide guidance in allocating limited resources in order to maximize recruitment efforts aimed at this needy, but hard-to-reach population.

The Diet Quality Index-Revised: a tool to promote and evaluate dietary change among older cancer survivors enrolled in a home-based intervention trial.

OBJECTIVE: To utilize the Diet Quality Index-Revised (DQI-R) as a framework for delivering and evaluating an intervention to improve overall diet quality among older cancer survivors. DESIGN: As part of a randomized controlled trial to improve lifestyle behaviors among older cancer survivors, we sought a dietary measure that could serve as both an intervention framework and a means to evaluate global dietary quality. The DQI-R measures overall diet quality by summing 10 subscales that relate to national guidelines. At baseline, DQI-R scores were generated from three multi-pass 24-hour dietary recalls. The 6-month intervention delivered tailored feedback on individual DQI-R subscales. Dietary recalls were repeated at 6 and 12 months. SUBJECTS: Elderly (aged >or=65 years) individuals within 18 months of diagnosis of breast or prostate cancer (n=182) were randomized postbaseline measures to intervention vs attention control arms. RESULTS: Significant differences in overall diet quality were observed between arms at 6 months, with the intervention arm improving (67.6+/-12.2 to 69.8+/-13.9), and controls declining (67.5+/-12.5 to 64.6+/-14.7) (P=0.003). Significant differences were observed between arms over time in dietary diversity subscale scores: baseline and 6-month follow-up means among intervention and control arms were 4.8+/-1.3 to 4.8+/-1.4, and 4.7+/-1.2 to 4.1+/-1.1, respectively (P=0.001). CONCLUSIONS: The DQI-R served as an effective guide and evaluation tool for this diet-related randomized controlled trial. Like many interventions, our effect diminished after the intervention was complete. Future research should consider testing interventions that use the DQI-R, or other global diet-related indexes, as guides and evaluation tools over longer study periods, as well as in other populations.

Promoting healthy lifestyles in older cancer survivors to improve health and preserve function.

Currently, there are about 7 million cancer survivors in this country aged 65 and older, and this number is expected to increase rapidly, given trends toward aging and improvements in early detection and treatment. Unfortunately, cancer survivors are at risk for several comorbid conditions and accelerated functional decline. A previous cross-sectional study of 688 older breast and prostate cancer survivors found significant associations between lifestyle practices and levels of physical functioning, with positive associations noted for physical activity and fruit and vegetable consumption and negative associations observed for dietary fat. In a more-recent cross-sectional study of 753 older survivors of breast, prostate, and colorectal cancer, significant associations were also observed between physical function, and physical activity (rho=0.22, P<.001) and diet quality (rho=0.07, P=.046), and a significant negative association was also found between physical function and body mass index (rho=-0.29, P<.001). Therefore, lifestyle interventions may be helpful in positively reorienting the trajectory of functional decline in this vulnerable population, although there are substantial barriers, such as travel, that must be overcome in delivering behavioral interventions to older cancer survivors. Previously reported results from the Pepper Center-funded Leading the Way in Exercise and Diet Project intervention development study suggested that an exercise and diet intervention delivered using telephone counseling and mailed materials was readily accepted and appeared to be of benefit. Larger trials, such as Reach-out to ENhancE Wellness in Older Survivors, have recently produced compelling data.

Emergency department discharge diagnosis and adverse health outcomes in older adults.

OBJECTIVES: To determine the relationship between the reason for an emergency department (ED) visit and subsequent risk of adverse health outcomes in older adults discharged from the ED. DESIGN: Secondary analysis of data from the Medicare Current Beneficiary Survey. SETTING: ED. PARTICIPANTS: One thousand eight hundred fifty-one community-dwelling Medicare fee-for-service enrollees aged 65 and older discharged from the ED between January 2000 and September 2002. MEASUREMENTS: Independent variables were ED discharge diagnosis groups: injury or musculoskeletal (MSK) (e.g., fracture, open wound), chronic condition (e.g., chronic obstructive pulmonary disorder, heart failure), infection, non-MSK symptom (e.g., chest pain, abdominal pain), and unclassified. Adverse health outcomes were hospitalization or death within 30 days of the index ED visit. RESULTS: Injury or MSK was the largest ED diagnosis group (31.4%), followed by non-MSK symptom (22.2%), chronic condition (20.9%), and infection (7.8%); 338 (17.8%) had ED discharge diagnoses that were unclassified. In adjusted analyses, a discharge diagnosis of injury or MSK condition was associated with lower risk of subsequent adverse health outcomes (hazard ratio (HR)=0.69, 95% confidence interval (CI)=0.50-0.96) than for all other diagnosis groups. Patients seen in the ED for chronic conditions were at greater risk of adverse outcomes (HR=1.86, 95% CI=1.37-2.52) than all others. There were no significant differences in risk between patients with infections, those with non-MSK symptoms, and the unclassified group. CONCLUSION: Adverse health outcomes were common in older patients with an ED discharge diagnosis classified as a chronic condition. ED discharge diagnosis may improve risk assessment and inform the development of targeted interventions to reduce adverse health outcomes in older adults discharged from the ED.

The Veterans Learning to Improve Fitness and Function in Elders Study: a randomized trial of primary care-based physical activity counseling for older men.

OBJECTIVES: To determine the effects of primary care-based, multicomponent physical activity counseling (PAC) promoting physical activity (PA) guidelines on gait speed and related measures of PA and function in older veterans. DESIGN: Randomized controlled trial. SETTING: Veterans Affairs Medical Center of Durham, North Carolina. PARTICIPANTS: Three hundred ninety-eight male veterans aged 70 and older. INTERVENTION: Twelve months of usual care (UC) or multicomponent PAC consisting of baseline in-person and every other week and then monthly telephone counseling by a lifestyle counselor, one-time clinical endorsement of PA, monthly automated telephone messaging from the primary care provider, and quarterly tailored mailings of progress in PA. MEASUREMENTS: Gait speed (usual and rapid), self-reported PA, function, and disability at baseline and 3, 6, and 12 months. RESULTS: Although no between-group differences were noted for usual gait speed, rapid gait speed improved significantly more for the PAC group (1.56 +/- 0.41 m/s to 1.68 +/- 0.44 m/s) than with UC (1.57 +/- 0.40 m/sec to 1.59 +/- 0.42 m/sec, P=.04). Minutes of moderate/vigorous PA increased significantly in the PAC group (from 57.1 +/- 99.3 to 126.6 +/- 142.9 min/wk) but not in the UC group (from 60.2 +/- 116.1 to 69.6 +/- 116.1 min/wk, P<.001). Changes in other functional/disability outcomes were small. CONCLUSION: In this group of older male veterans, multicomponent PA significantly improved rapid gait and PA. Translation from increased PA to overall functioning was not observed. Integration with primary care was successful.