Using Pain Medication Intensity to Stratify Back Pain Among Older Adults.

OBJECTIVE: To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions. METHODS: A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models. RESULTS: About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures. CONCLUSIONS: New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.

The impact of mobility limitations on health outcomes among older adults.

The purpose of this study was to stratify an older adult population for subsequent interventions based on functional ability, and to estimate prevalence, characteristics and impact of mobility limitations on health outcomes. In 2016, surveys were sent to a stratified random sample of AARP® Medicare Supplement insureds; mobility limitations were defined using two screening questions. Responses were stratified to three mobility limitation levels. Multivariate regression models determined characteristics and impact on health outcomes. Among weighted survey respondents (N = 15,989), severe, moderate and no limitation levels were 21.4%, 18.4% and 60.3%, respectively. The strongest predictors of increased limitations included pain and poor health. Individuals with more severe limitations had increased falls, decreased preventive services compliance and increased healthcare utilization and expenditures. Utilizing two screening questions stratified this population to three meaningful mobility limitation levels. Higher levels of mobility limitations were strongly associated with negative health outcomes. Mobility-enhancing interventions could promote successful aging.

The growing need for resources to help older adults manage their financial and healthcare choices.

BACKGROUND: Both financial literacy (managing personal finances) and health literacy (managing personal health) become increasingly important for older adults, potentially impacting their quality of life. Resources in these constructs of literacy tend to be distinct, although the skills and decision-making involved overlap as financial issues impact healthcare choices. Thus the primary purpose of this commentary is to propose a new area of research focus that defines the intersection of financial and health literacy (i.e., financial health literacy). METHODS: We conducted a limited literature review related to financial, health, and health insurance literacy to demonstrate gaps in the literature and support our position. Online search engines were utilized to identify research in our primary areas of interest. RESULTS: We define the intersection of financial and health literacy as an area of need labeled financial health literacy, with a focus on four domains. These include: 1) the ability to manage healthcare expenses; 2) pay medical bills; 3) determine health needs and understand treatment options; and 4) make sound healthcare decisions with financial resources available. Despite some overlap with health insurance literacy, financial health literacy would define an area of need encompassing health management choices and health plan selections integrated with other financial management issues including living arrangements, financial planning, and retirement planning. CONCLUSIONS: Potential initiatives should be considered to help at-risk older adults find resources to improve their financial health literacy, which in turn will enhance their abilities to manage medical choices in the environment of an increasingly complex healthcare system.

Caregivers for older adults: Prevalence, characteristics, and health care utilization and expenditures.

The purpose of this study was to provide an overview of caregiver prevalence and characteristics and to estimate the impact of caregiving on health care utilization and expenditures among AARP® Medicare Supplement insureds to inform caregiver intervention strategies. A subgroup with live-in partners was used to investigate the additional effect of live-in health status on caregiver health. Multivariate regression models were utilized to determine caregivers' characteristics and associated impacts on their health care utilization and expenditures. Among respondents (n = 18,928), 14.9% self-identified as caregivers. The strongest characteristics included being younger, healthier, but reporting depression or loneliness. Caregivers of sicker live-ins were female, older and indicated moderate loneliness; caregivers of healthier live-ins were younger, healthier, but reported severe loneliness. Caregivers had significantly lower inpatient admissions and medical and prescription drug expenditures. These results indicated an adverse impact on psychological health associated with caregiving but no evidence of a negative impact on physical health.

A qualitative study to examine older adults' perceptions of health: Keys to aging successfully.

Older adult health is often defined in clinical terms. Research has demonstrated that many older adults self-report aging successfully regardless of clinical health status. This qualitative study used claims data to identify older adults on three levels of health status: healthy and active, managing diseases, or very sick, to better understand how health is defined and maintained. In total, 32 participants from two cities were interviewed. Interviews were audio- and video-recorded and then transcribed. Thematic analysis identified five themes: disconnectedness between objective and subjective health; health defined to include psychological and social components; resilience and coping mechanisms indicative of successful aging; social support systems integral to health; and the goal of maintaining functioning. These results indicate the importance of individual perceptions of health rather than just counts of chronic diseases. Health management programs should provide holistic approaches to maximize health outcomes and to promote successful aging.

The impact of inadequate health literacy on patient satisfaction, healthcare utilization, and expenditures among older adults.

Inadequate health literacy (HL) is associated with impaired healthcare choices leading to poor quality-of-care. Our primary purpose was to estimate the prevalence of inadequate HL among two populations of AARP® Medicare Supplement insureds: sicker and healthier populations; to identify characteristics of inadequate HL; and to describe the impact on patient satisfaction, preventive services, healthcare utilization, and expenditures. Surveys were mailed to insureds in 10 states. Multivariate regression models were used to identify characteristics and adjust outcomes. Among respondents (N = 7334), 23% and 16% of sicker and healthier insureds, respectively, indicated inadequate HL. Characteristics of inadequate HL included male gender, older age, more comorbidities, and lower education. Inadequate HL was associated with lower patient satisfaction, lower preventive service compliance, higher healthcare utilization and expenditures. Inadequate HL is more common among older adults in poorer health, further compromising their health outcomes; thus they may benefit from expanded educational or additional care coordination interventions.

The impact of resilience among older adults.

The purpose of this literature review was to provide an overview of resilience for the purpose of informing potential intervention designs that may benefit older adults. While numerous reviews have focused on various specific aspects of resilience, none have provided the necessary information required to design an effective resilience intervention. Research examining resilience suggests that older adults are capable of high resilience despite socioeconomic backgrounds, personal experiences, and declining health. Thus opportunities to inform interventions in this area exist. Research studies have identified the common mental, social, and physical characteristics associated with resilience. High resilience has also been significantly associated with positive outcomes, including successful aging, lower depression, and longevity. Interventions to enhance resilience within this population are warranted, but little evidence of success exists. Thus this review provides an overview of resilience that may aid in the design of resilience interventions for the often underserved population of older adults.

A polymorphic pseudoautosomal boundary in the Carica papaya sex chromosomes.

Sex chromosomes are defined by a non-recombining sex-determining region (SDR) flanked by one or two pseudoautosomal regions (PARs). The genetic composition and evolutionary dynamics of the PAR is also influenced by its linkage to the differentiated non-recombining SDR; however, understanding the effects of this linkage requires a precise definition of the PAR boundary. Here, we took a molecular population genetic approach to further refine the location of the PAR boundary of the evolutionary young sex chromosomes of the tropical plant, Carica papaya. We were able to map the position of the papaya PAR boundary A to a 100-kb region between two genetic loci approximately 2 Mb upstream of the previously genetically identified PAR boundary. Furthermore, this boundary is polymorphic within natural populations of papaya, with an approximately 100-130 kb expansion of the non-recombining SDR found in 16 % of individuals surveyed. The expansion of the PAR boundary in one Y haplotype includes at least one additional gene. Homologs of this gene are involved in male gametophyte and pollen development in other plant species.

Pharmaceutical Cost-Saving Strategies and their Association with Medication Adherence in a Medicare Supplement Population.

BACKGROUND: On average, Medicare Supplement insureds take about seven unique prescription medications each year, resulting in substantial out-of-pocket drug copayments, in addition to Medicare Supplement and Part D premiums. To help alleviate this financial burden, many individuals resort to cost-saving strategies that are not trackable by Part D insurance plans, likely resulting in an underestimation of medication adherence rates. OBJECTIVE: We aimed to estimate utilization rates of cost-saving strategies, measure member characteristics associated with these strategies and estimate if these strategies are associated with medication adherence. DESIGN: This was a cross-sectional analysis of a 2012-2013 survey of AARP® Medicare Supplement plan insureds with Part D pharmaceutical coverage. PARTICIPANTS: The study included 5,784 community-dwelling survey respondents ≥ 65 years of age, living in ten states and with self-reported use of prescription medications. MAIN MEASURES: Self-reported use of cost-saving strategies included: obtaining free samples from physicians, splitting pills so medications lasted longer, purchasing medications from other countries and/or over the internet, or purchasing medications through the Veterans Administration. Propensity weighted multivariate regressions were utilized to determine characteristics associated with the use of such strategies and the association with medication adherence as measured from Medicare Part D claims. KEY RESULTS: Among those taking medications, 39.6% used cost-saving strategies. Those using these strategies were significantly (p < 0.05) more likely to be male, non-minority, have more comorbid conditions, have more disabilities and use more medications. Few variables were significantly related to pharmaceutical nonadherence, but those who were nonadherent were significantly more likely to use more medications, split pills, obtain free samples from their physicians and be male. CONCLUSION: Cost-saving strategies are used extensively as a means to augment Medicare Part D coverage. These strategies are associated with measured medication nonadherence and likely result in underreporting of medication adherence rates. Pharmacy management programs should consider these additional medication sources in assisting plan members to problem solve cost-related medication management issues.

Homebound older adults: Prevalence, characteristics, health care utilization and quality of care.

The purpose of this study was to estimate prevalence rates of homebound older adults, their characteristics and the impact of homebound status on health care utilization, expenditures and quality of medical care measures. Surveys were sent to new enrollees (n = 25,725) in AARP(®) Medicare Supplement plans (insured through UnitedHealthcare) to screen for serious chronic conditions, ambulatory disabilities and eligibility for care coordination programs. Health care utilization and expenditures were determined from paid claims. Member-level quality measures considered compliance with medication adherence and care patterns. Among survey respondents, 19.6% were classified as being homebound. The strongest predictors of being homebound included serious memory loss, being older, having more chronic conditions, taking more prescription medications and having multiple hospitalizations. Homebound had significantly higher health care utilization and expenditures. Homebound were more likely to be noncompliant with medication adherence and care pattern rules. Ongoing screening and subsequent interventions for new enrollees classified as homebound may be warranted.

Obese older adults report high satisfaction and positive experiences with care.

BACKGROUND: Obese, older adults often have multiple chronic conditions resulting in multiple health care encounters. However, their satisfaction and experiences with care are not well understood. The objective of this study was to examine the independent impact of obesity on patient satisfaction and experiences with care in adults 65 years of age and older with Medigap insurance. METHODS: Surveys were mailed to 53,286 randomly chosen adults with an AARP® Medicare Supplement Insurance Plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York) in 10 states. Following adjustment for non-response bias, multivariate regression modeling was used to adjust for demographic, socioeconomic and health status differences to estimate the independent impact of weight on satisfaction and experiences with care. Outcome variables included four global and four composite measures of satisfaction and experiences with care. RESULTS: 21.4% of the respondents were obese. Relative to normal weight, obesity was significantly associated with higher patient satisfaction and better experiences with care in seven of the eight ratings measured. CONCLUSIONS: Obese individuals were more satisfied and had better experiences with care. Obese individuals had more office visits and discussions about nutrition, exercise and medical checks. This may have led to increased attentiveness to care, explaining the increase in satisfaction and better experiences with care. Given the high level of satisfaction and experiences with care in older, obese adults, opportunities exist for clinicians to address weight concerns in this population.

Listening to the nurse pays off: an integrated Nurse HealthLine programme was associated with significant cost savings.

AIM: To estimate the relationship between adherence to nurse recommendations about where to seek care and expenditures for health-care services received by callers to a Nurse HealthLine telephone-based triage programme. METHODS: Health-care utilization and claims data from callers to the Nurse HealthLine were included. Adherent callers were those who followed the nurse recommendations, while those who did not were classified as non-adherent. Programme-related savings were estimated using differences in downstream health-care expenditures between adherent and non-adherent callers after using multivariate modelling to adjust for between-group differences. RESULTS: Fifty-five per cent of callers were adherent. Nurses were over three times as likely (41% vs. 13%) to recommend seeking a higher level of care (e.g. emergency room vs. urgent care). Regression analyses showed that the impact of getting members to the appropriate place of care was associated with significant annual savings of $13.8 million (P < 0.05), attributable mostly to Medicare, generating a positive return on investment of $1.59. CONCLUSIONS: This is the first known Nurse HealthLine triage programme exclusively for Medicare beneficiaries with supplemental coverage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should consider promoting telephone-based triage programmes as complementary to clinical nursing, which has a direct impact on health-care utilization and costs.

Barriers to managing coronary artery disease among older women.

Numerous barriers to managing coronary artery disease (CAD) among older women are reported in the literature; however, few studies adjust for demographic and health status differences. A survey assessing barriers and other factors was distributed to a stratified random sampling of older women with CAD. Factor analysis and multiple logistic regression procedures were used to estimate the impact of these issues on receiving a CAD-related office visit. The most problematic barriers included denial and low health literacy. Efforts to promote patient awareness of heart health and better communication between patients and clinicians may alleviate these barriers.

The impact of pain on physical and mental quality of life in adults 65 and older.

Pain is a frequent and debilitating problem among older adults, decreasing quality of life (QOL) both physically and mentally. The burden of arthritis, sciatica, and back pain on QOL was estimated using ordinary least squares regression techniques to estimate the impact of each of these types of pain on QOL, controlling for patient demographic, socioeconomic, and health status characteristics. For individuals with arthritis, sciatica, and back pain, the adjusted average physical component scores were 4.19, 1.39, and 6.75 points lower, respectively (all p < 0.0001), than those without pain. Adjusted average mental component scores were 1.33, 0.47, and 2.93 points lower (all p < 0.01) for individuals with arthritis, sciatica, and back pain, respectively. The impact of pain on QOL was greater than that for many other commonly treated medical conditions. Clinicians should discuss pain with their patients to maximize their QOL.

The burden of depressive symptoms and various chronic conditions and health concerns on the quality of life among those with Medicare Supplement Insurance.

OBJECTIVE: This study aims to estimate the burden of currently having depressive symptoms on quality of life independently and in combination with various chronic conditions/health concerns among adults with Medicare Supplement Insurance (i.e., Medigap) coverage. METHODS: Data were obtained from the Health Update Survey (HUS). The HUS contains questions on demographics, comorbid conditions, and all of the questions on the Veterans RAND 12-item (VR-12) health status/quality of life survey. The survey was mailed to a random sample of 30,000 insureds from 10 states between 2008 and 2009. On the basis of relevant questions from the survey, respondents were categorized into two groups: those currently suffering from current depressive symptoms (N = 2283) and those who never had depressive symptoms (N = 7058). Multiple regression modeling was used to test the impact on quality of life of depressive symptoms independently or as an interaction of depressive symptoms with various chronic conditions/health concerns. RESULTS: Depressive symptoms were common, with an estimated prevalence of 24.4%. The greatest impact of depressive symptoms in combination with various chronic conditions/health concerns on quality of life was on the ability to handle emotional roles, bodily pain, social functioning, and ability to handle physical roles. Most of the significant interactions between depressive symptoms and various chronic conditions/health concerns were demonstrated for those chronic conditions contributing to functional impairment (e.g., difficulty walking, falls, chronic pain, and diabetes). CONCLUSIONS: Although depressive symptoms independently reduced quality of life, having depressive symptoms in addition to other chronic conditions/health concerns had a greater impact on quality of life.

The prevalence of hearing impairment and its burden on the quality of life among adults with Medicare Supplement Insurance.

PURPOSE: To estimate the impact of hearing impairment on quality of life from a physical and mental standpoint. METHODS: Data were obtained from the Health Update Survey, which contains questions on demographics, comorbid conditions, and the Veterans RAND 12-item health status/quality of life survey. It was fielded on a random sample of 15,000 adults with an AARP(®) Medicare Supplement plan, insured by UnitedHealthcare. Respondents were divided into those with hearing impairments and others, based on their response to a survey question. Univariate and multivariate analyses were conducted to estimate the likelihood of hearing impairment and its impact on quality of life while controlling for respondent demographics and comorbid conditions. RESULTS: Of the 5,515 eligible respondents, 10.4% reported having hearing impairments. The strongest predictor of hearing impairment was older age, while those with 4 years of college or more were least likely to have hearing impairments. Those with hearing impairments averaged significantly lower physical component and mental component scores, exceeding those of numerous other chronic conditions. CONCLUSIONS: This is the first known study of hearing impairment among those with Medigap coverage. Hearing impairment was strongly associated with lower quality of life from both a physical and mental health standpoint.

The prevalence of urinary incontinence and its burden on the quality of life among older adults with medicare supplement insurance.

PURPOSE: Estimate the prevalence and burden of urinary incontinence (UI) on the quality of life (QOL) among adults (65 or older) with Medigap insurance. METHODS: Data were obtained from the health update survey (HUS), which contains questions on demographics, comorbid conditions, and the Veteran's RAND 12-item health status survey. The mail survey was fielded on a random sample of 15,000 insureds from 10 states in 2008. Respondents were divided into those with UI and others, based on their response to a question about leaking urine during the last six months. Univariate and multivariate analyses were conducted to estimate the likelihood of UI and its impact on QOL while controlling for respondent demographics and comorbid conditions. RESULTS: Of the 5,530 eligible respondents, 37.5% reported having UI. The strongest predictors of UI were female gender, advancing age, and obesity. All the QOL estimates were significantly lower for those with UI (P < 0.001). Further, UI had a stronger influence on QOL than did diabetes, cancer, and arthritis, particularly from a mental health standpoint. CONCLUSIONS: Consistent with other Medicare populations (e.g. Medicare managed care), UI was common in Medigap insureds, strongly associated with lower QOL affecting mental, physical, and social well-being, and is often untreated.

The burden of falling on the quality of life of adults with Medicare supplement insurance.

To study the impact of falling or risk of falling on quality of life (QOL) outcomes, a survey was mailed to a random sample of 15,000 adults with an AARP® Medicare Supplement plan insured by UnitedHealthcare from 10 states in 2008. Approximately 21% had fallen in the past year; 17% did not fall but reported balance or walking problems (i.e., at high risk of falling); and 62% were in the low-risk, no-falls comparison group. Multiple regression analyses showed the strongest predictors of falling or being at high risk of falling were advancing age, female gender, heart conditions, stroke, digestive disorders, arthritis, sciatica, diabetes, and hearing problems. Average physical and mental component scores were significantly lower for both those who fell and those at risk of falling than the comparison group, indicating that falling or being at risk of falling had a stronger negative influence on QOL than most of the comorbidities measured. Clinicians, patients, and families should be aware of the potential negative impact of falling and fear of falling on the QOL of older adults.

Design of a new magnesium-based anterior cruciate ligament interference screw using finite element analysis.

BACKGROUND/OBJECTIVE: In anterior cruciate ligament â€‹reconstruction, a tendon graft, anchored by interference screws (IFSs), is frequently used as a replacement for the damaged ligament. Generally, IFSs are classified as being either metallic or polymeric. Metallic screws have sharp threads that lacerate the graft, preventing solid fixation. These constructs are difficult to image â€‹and can limit bone--screw integration because of the higher stiffness of the screw. Polymeric materials are often a better match to bone's material properties, but lack the strength needed to hold grafts in place. Magnesium (Mg) is a material of great promise for orthopaedic applications. Mg has mechanical properties similar to bone, ability to be seen on magnetic resonance imagings, and promotes bone healing. However, questions still remain regarding the strength of Mg-based screws. Previous ex vivo â€‹animal experiments found stripping of the screw drive when the full torque was applied to Mg screws during surgery, preventing full insertion and poor graft fixation. The similar design of the Mg screw led to questions regarding the relationship between material properties and design, and the ultimate impact on mechanical behaviour. Thus, the objective of this study was to analyze the stresses in the screw head, a key factor in the stripping mechanism of IFS, then use that information to improve screw design, for this material. METHODS: Using finite element analysis, a comparison study of six drive designs (hexagonal, quadrangle, torx, trigonal, trilobe, and turbine) was performed. This was followed by a parametric analysis to determine appropriate drive depth and drive width. RESULTS: It was observed that with a typical torque (2 â€‹Nm) used for screw insertion during anterior cruciate ligament reconstruction, the maximum von Mises and shear stress values were concentrated in the corners or turns of the drive, which could lead to stripping if the values were greater than the yield stress of Mg (193 â€‹MPa). With a four-time â€‹increase in drive depth to be fully driven and a 30% greater drive width, these maximum stress values were significantly decreased by more than 75%. CONCLUSION: It was concluded that improving the design of a Mg-based screw may increase surgical success rates, by decreasing device failure at insertion. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: The results of this work have the potential to improve designs of degradable IFSs, allowing for greater torque to be applied and thus greater screw fixation between host bone and the graft. Such a fixation will allow greater integration, better patient healing, and ultimately improved patient outcomes.

The Impact of a Heart Failure Management Program in a Medicare Advantage Population.

Heart failure (HF) is currently among the most prevalent and costly chronic diseases among older adults, who are at increased risk because of other chronic conditions and the aging process. HF has a significant impact on the health care system, patient outcomes, and the unsustainable rising costs of care. The primary objectives were to: (1) determine cost savings differences in medical expenditures between engaged and non-engaged members referred to a HF management program; (2) examine differences in length of stay and time to first post-engagement acute inpatient admission; and (3) examine the impact of using a remote weight monitoring scale on medical expenditures and inpatient admissions. Generalized linear modeling was used to compare key outcomes among individuals who engaged in the program and a propensity-matched cohort of those who were eligible but did not engage. Key outcomes included post-engagement acute inpatient medical service utilization, all-cause per-member-per-month medical expenses, and acute inpatient length of stay. When paired with regular use of a remote weight monitoring scale, engagement in this HF management program appears to be associated with decreased risk for acute inpatient admission and lower all-cause medical expenditures. Participation in a clinically based HF management program may improve health-related and financial outcomes among older individuals. However, further development and evaluation of disease management programs could help to improve their effectiveness and thus patient outcomes.