Behavioral assays reveal mechanisms of supercolony formation in odorous house ants.

The formation of expansive multi-nest and multi-queen supercolonies is perhaps the most important factor responsible for the ecological success of invasive ants. The odorous house ant, Tapinoma sessile, is a widespread ant native to North America. T. sessile is a challenging urban pest, but also serves as an interesting system to study ant social organization and invasion biology. This is due to its remarkable dichotomy in colony social and spatial structure between natural and urban environments. Natural colonies typically consist of a small number of workers, inhabit a single nest, and are monogyne whereas urban colonies show extreme polygyny and polydomy and form large supercolonies. The current study examined the extent to which T. sessile colonies from different habitats (natural vs. urban) and social structures (monogynous vs. polygynous) exhibit aggression toward alien conspecifics. Additionally, interactions between mutually aggressive colonies were examined in colony fusion experiments to assess the potential role of colony fusion as a mechanism leading to supercolony formation. Aggression assays demonstrated high levels of aggression in pairings involving workers from different urban colonies and workers from different natural colonies, but low aggression in pairings involving queens from different urban colonies. Colony merging tests demonstrated that urban T. sessile colonies are highly aggressive to each other, but capable of fusing under laboratory conditions when competing for limited nesting and food resources. Despite highly aggressive interactions and relatively high worker and queen mortality, all colony pairs merged in 3-5 days. Fusion occurred after most workers died and the survivors merged. This result suggests that the success of T. sessile in urban areas may be driven, at least in part, by successful colony mergers of unrelated colonies which may be determined by ecological constraints such as seasonal shortages in nest and/or food availability. In summary, two independent factors including the growth of a single colony and/or the merger of multiple colonies may be responsible for the evolution of supercolonies in invasive ants. Both processes may be happening simultaneously and may act synergistically to produce supercolonies.

A Randomized Intervention of Supplemental Nutrition Assistance Program-Education Did Not Improve Dietary Outcomes Except for Vitamin D Among Lower-Income Women in Indiana.

BACKGROUND: The goal of US Department of Agriculture Supplemental Nutrition Assistance Program-Education (SNAP-Ed) is to improve the likelihood that those eligible for SNAP will make healthy choices aligned with the Dietary Guidelines for Americans, 2020-2025. OBJECTIVE: The objective of the study was to evaluate the long-term effects of a direct SNAP-Ed intervention in which participants actively engage in learning with educator instruction about dietary quality and usual intake of key nutrient and food groups among Indiana SNAP-Ed-eligible women participants as an example sample in the context of no similar existing evaluation. DESIGN: The study design was a parallel-arm, randomized controlled, nutrition education intervention, with follow-up at 1 year. PARTICIPANTS/SETTING: Participants (18 years and older; n = 97 women) eligible for SNAP-Ed and interested in receiving nutrition education lessons were recruited from 31 Indiana counties from August 2015 to May 2016 and randomized to an intervention (n = 53) or control (n = 44) group. INTERVENTION: The intervention comprised core lessons of Indiana SNAP-Ed delivered between 4 and 10 weeks after baseline assessment. Each participant completed a baseline and 1-year follow-up assessment. Dietary intake was assessed using repeated 24-hour dietary recalls (up to 2). MAIN OUTCOME MEASURES: Mean usual nutrient, food group intake, diet quality (ie, Healthy Eating Index-2010 scores), and proportion of intervention and control groups meeting Dietary Guidelines for Americans, 2020-2025 recommendations and Dietary Reference Intake indicators of requirement or adequacy, were determined using the National Cancer Institute method and the simple Healthy Eating Index-2010 scoring algorithm method. Dietary changes between intervention and control groups were examined over time using mixed linear models. STATISTICAL ANALYSES PERFORMED: Bonferroni-corrected significance levels were applied to the results of the mixed linear models for comparisons of usual intake of nutrients and foods. RESULTS: No differences in diet quality, intake of food group components, food group intake, or nutrients were observed at 1-year follow-up, except that vitamin D intake was higher among those who received SNAP-Ed compared with the control group. CONCLUSIONS: A direct SNAP-Ed intervention did not improve diet quality, food group intake, or key nutrient intake, except for vitamin D, among Indiana SNAP-Ed-eligible women up to 1 year after the nutrition education.

Evaluating a Food Pantry-Based Intervention to Improve Food Security, Dietary Intake, and Quality in Midwestern Food Pantries.

BACKGROUND: Voices for Food was a longitudinal community, food pantry-based intervention informed by the social ecological model, and designed to improve food security, dietary intake, and quality among clients, which was carried out in 24 rural food pantries across 6 Midwestern states. OBJECTIVE: Our objective was to evaluate changes in adult food security, dietary intake, and quality from baseline (2014) to follow-up (2016), and to assess the role of adult food security on dietary outcomes. DESIGN: A multistate, longitudinal, quasi-experimental intervention with matched treatment and comparison design was used to evaluate treatment vs comparison group changes over time and changes in both groups over time. PARTICIPANTS/SETTING: Adult food pantry clients (n = 617) completed a demographic food security survey, and up to three 24-hour dietary recalls at baseline (n = 590) and follow-up (n = 160). INTERVENTION: Community coaching served as the experimental component, which only "treatment" communities received, and a food council guide and food pantry toolkit were provided to both "treatment" and matched "comparison" communities. MAIN OUTCOME MEASURES: Change in adult food security status, mean usual intakes of nutrients and food groups, and Healthy Eating Index-2010 scores were the main outcome measures. STATISTICAL ANALYSES PERFORMED: Linear mixed models estimated changes in outcomes by intervention group and by adult food security status over time. RESULTS: Improvements in adult food security score (-0.7 ± 0.3; P = .01), Healthy Eating Index-2010 total score (4.2 ± 1.1; P < .0001), and empty calories component score (3.4 ± 0.5; P <.0001) from baseline to follow-up were observed in treatment and comparison groups, but no statistically significant changes were found for adult food security status, dietary quality, and usual intakes of nutrients and food groups between the 2 groups over time. The intervention effect on dietary quality and usual intake changes over time by adult food security status were also not observed. CONCLUSIONS: Food pantry clients in treatment and comparison groups had higher food security and dietary quality at the follow-up evaluation of the Voices for Food intervention trial compared with baseline, despite the lack of difference among the groups as a result of the experimental coaching component.

Nutritional contributions of food pantries and other sources to the diets of rural, Midwestern food pantry users in the USA.

Food pantries provide free food to individuals at nutritional risk given lack of available foods. Frequent use of food pantries is associated with higher dietary quality; however, neither the nutrient contributions of food pantries to participant diets nor their relationship with household food security are known. This cross-sectional analysis used secondary data from rural food pantry participants, including sociodemographic characteristics, household food security and 24-h recalls. Mean intakes of selected food groups and nutrients from food pantries, supermarkets, other stores and restaurants, and other were compared by one-way ANCOVA. Interaction effects of household food security with food sources were evaluated by two-way ANCOVA. About 40 % of participants' dietary intake came from food pantries. Mean intakes of fibre (P < 0·0001), Na (P < 0·0001), fruit (P < 0·0001), grains (P < 0·0001) and oils (P < 0·0001) were higher from food pantries compared with all other sources, as were Ca (P = 0·004), vitamin D (P < 0·0001) and K (P < 0·0001) from food pantries compared with two other sources. Percentage total energy intake (%TEI) from added sugars (P < 0·0001) and saturated fat (P < 0·0001) was higher from supermarkets than most other sources. Significant interaction effects were observed between food sources and household food security for vegetables (P = 0·01), Na (P = 0·01) and %TEI from saturated fat (P = 0·004), with food-insecure participants having significantly higher intakes from food pantries and/or supermarkets compared with all other sources. Future interventions may incorporate these findings by providing education on purchasing and preparing healthy meals on limited budgets, to complement foods received from pantries, and by reducing Na in pantry environments.

Diet Quality and Associations with Food Security among Women Eligible for Indiana Supplemental Nutrition Assistance Program-Education.

BACKGROUND: The diet quality among adults receiving nutrition education lessons through Supplemental Nutrition Assistance Program-Education (SNAP-Ed) is currently unknown. OBJECTIVES: The objectives of this study were to characterize the diet quality of Indiana SNAP-Ed-eligible women; estimate their mean usual intake of fruits, vegetables, dairy, and whole grains compared to Dietary Guidelines for Americans (DGA) recommendations; and determine if these dietary outcomes differed by food security status. METHODS: SNAP-Ed paraprofessionals recruited participants from August 2015 to May 2016 for this secondary analysis of cross-sectional data collected as the baseline assessment for a randomized controlled trial. Participants were SNAP-Ed-eligible women aged ≥18 y interested in nutrition education lessons. Dietary outcomes were assessed by one or two 24-h dietary recalls. The Healthy Eating Index (HEI)-2010 was used to characterize diet quality. Mean usual intake of food groups was estimated using the National Cancer Institute Method. Food security status was classified using the US Household Food Security Survey Module. Data were analyzed in October 2019. RESULTS: Mean ± SEM HEI-2010 total score was 42 ± 0.9 for the study sample. Mean ± SE usual intake of servings of fruits (0.61 ± 0.08 cups [144.32 ± 18.93 mL]), vegetables [1.4 ± 0.10 cups (331.2 ± 23.66 mL)], dairy [1.5 ± 0.11 cups (354.88 ± 26.02 mL)], and whole grains [0.48 ± 0.06 ounces (13.61 ± 1.70 g)] did not differ by food security subgroup. Mean HEI-2010 total score was significantly higher by 4.8 ± 2.0 points for the food-secure than for the food-insecure subgroup (P = 0.01). Mean HEI-2010 component scores were 1.1 ± 0.5 points higher for whole grain (P = 0.01) and 1.0 ± 0.5 points higher for dairy (P = 0.05) in the food-secure than in the food-insecure subgroup. The proportions of the study sample not meeting the DGA recommendations for food group intake were ≥85% for both food-secure and -insecure subgroups. CONCLUSIONS: Indiana SNAP-Ed-eligible women reported poor diet quality, highlighting their need for nutrition interventions aiming to improve food security and diet as per DGA recommendations in low-income populations.

Daily Dietary Intake Patterns Improve after Visiting a Food Pantry among Food-Insecure Rural Midwestern Adults.

Emergency food pantries provide food at no cost to low-resource populations. The purpose of this study was to evaluate single-day dietary intake patterns before and after visiting a food pantry among food-secure and food-insecure pantry clients. This observational cohort study comprised a paired, before-and-after design with a pantry visit as the intervention. Participants (n = 455) completed a demographic and food security assessment, and two 24-h dietary recalls. Adult food security was measured using the U.S. Household Food Security Survey Module. Dietary intake patterns were assessed using Automated Self-Administered 24-h Recall data and classified by Healthy Eating Index (HEI-2010) scores, dietary variety, number of eating occasions, and energy intake. Paired t-tests and Wilcoxon signed-rank tests compared outcomes before and after a pantry visit. Mean dietary variety increased after the pantry visit among both food-secure (p = 0.02) and food-insecure (p < 0.0001) pantry clients. Mean energy intake (p = 0.0003), number of eating occasions (p = 0.004), and HEI-2010 component scores for total fruit (p < 0.001) and whole fruit (p < 0.0003) increased among food-insecure pantry clients only. A pantry visit may improve dietary intake patterns, especially among food-insecure pantry clients.

Pre- and Post-Activity Stretching Practices of Collegiate Athletic Trainers in the United States.

Popp, JK, Bellar, DM, Hoover, DL, Craig, BW, Leitzelar, BN, Wanless, EA, and Judge, LW. Pre- and post-activity stretching practices of collegiate athletic trainers in the United States. J Strength Cond Res 31(9): 2347-2354, 2017-The aim of the study was to investigate the knowledge and practices of collegiate-certified athletic trainers (ATs) in the United States. Participants (n = 521) were provided an overview of the study and a hyperlink to a web-based survey. The "pre- and post-activity practices in athletic training questionnaire" consisted of demographic items and elements to measure knowledge and practices related to pre- and post-activity stretching routines. In previous studies, the survey demonstrated construct validity, α = 0.722. Pearson chi-square test was used to evaluate goodness of fit, and kappa was calculated to measure agreement between items. Only 32.2% of ATs recommended dynamic stretching (DS) to be performed pre-activity, whereas a larger percentage (42.2%) recommended a combination of static stretching (SS) and DS. Athletic trainers reported that only 28.0% of athletes are performing DS before activity. Conversely, 60.6% of collegiate ATs recommended SS postexercise, and 61.0% of athletes agree and perform after workout SS (κ = 0.761, p < 0.001). Collegiate ATs seem to underuse the current research evidence, which indicates that DS is more beneficial than SS when used pre-activity, and ATs continue to regularly incorporate SS in their pre-activity routines. However, there is evidence that collegiate ATs in the United States emphasize SS postactivity in a manner consistent with current research.

Unmet Need for Help With Activities of Daily Living Disabilities and Emergency Department Admissions Among Older Medicare Recipients.

Purpose of the Study: This study determined whether self-reports of unmet need for help with activities of daily living (ADL) disabilities are prognostic of emergency department (ED) utilization. Design and Methods: This prospective cohort study of 2,194 community-living, ADL-disabled subjects combined 2004 National Long-Term Care Survey responses with linked Medicare data through 2005. A negative binomial count model was computed to assess the association between unmet ADL need and number of subsequent ED admissions while statistically adjusting for predisposing, enabling, and need characteristics associated with ED admissions among older adults. Results: The adjusted annual incidence rate (IR) for ED admissions was 19% higher for unmet versus met need (IR = 1.19; 95% confidence interval [CI] = 1.00-1.40; p = .047). The IR for ED admissions for falls and injuries was higher for those with unmet ADL versus met ADL need (IR = 1.43; 95% CI = 1.10-1.86), and trended toward significance for ED admissions for skin breakdown (IR = 2.02; 95% CI = 0.97-2.88), but was not significant for ED admissions for dehydration (IR = 1.13; 95% CI= 0.79-1.63). Implications: Unmet ADL need is prognostic of ED admissions, especially for falls and injuries. Future research is needed to determine whether resolution of unmet ADL need reduces ED utilization.

SNAP-Ed (Supplemental Nutrition Assistance Program-Education) Increases Long-Term Food Security among Indiana Households with Children in a Randomized Controlled Study.

BACKGROUND: Food insecurity is negatively associated with US children's dietary intake and health. The Supplemental Nutrition Assistance Program-Education (SNAP-Ed) aims to alleviate food insecurity by offering nutrition, budgeting, and healthy lifestyle education to low-income individuals and families. OBJECTIVE: The objective of this study was to evaluate the long-term impact of the Indiana SNAP-Ed on food security among households with children. METHODS: A randomized, controlled, parallel study design with SNAP-Ed as an intervention was carried out during a 4- to 10-wk intervention period. Intervention group participants received the first 4 Indiana SNAP-Ed curriculum lessons. Study participants (n = 575) were adults aged ≥18 y from low-income Indiana households with ≥1 child living in the household. Both treatment groups completed an assessment before and after the intervention period and 1 y after recruitment. The 18-item US Household Food Security Survey Module was used to classify the primary outcomes of food security for the household and adults and children in the household. A linear mixed model was used to compare intervention with control group effects over time on food security. RESULTS: Mean ± SEM changes in household food security score and food security score among household adults from baseline to 1-y follow-up were 1.2 ± 0.4 and 0.9 ± 0.3 units lower, respectively, in the intervention group than in the control group (P < 0.01). The mean change in food security score from baseline to 1-y follow-up among household children was not significantly different in the intervention group compared with the control group. CONCLUSIONS: SNAP-Ed improved food security over a longitudinal time frame among low-income Indiana households with children in this study. SNAP-Ed may be a successful intervention to improve food security.

The current state of NCAA Division I collegiate strength facilities: size, equipment, budget, staffing, and football status.

Strength and conditioning training programs are essential components of athletic performance, and the effectiveness of these programs can be linked to the strength and conditioning facilities (SCFs) used by athletes. The primary purpose of this study was to provide a statistical overview of National Collegiate Athletic Association (NCAA) Division I SCFs, equipment and maintenance budget, and the relationship between SCF budget and staffing space, and equipment. The secondary purpose was to note differences in SCFs between those schools with and without football programs. An 84-item online survey instrument, developed with expert input from certified strength professionals, was used to collect data regarding the SCFs in NCAA Division I universities. A total of 110 valid and complete surveys were returned for a response rate of 38.6%. Results of Pearson's χ2 analysis demonstrated that the larger reported annual equipment budgets were associated with larger SCFs (χ2 = 451.4, p ≤ 0.001), greater maximum safe capacity of athletes using the facility (χ2 = 366.9, p ≤ 0.001), increased numbers of full-time coaches (χ2 = 224.2, p ≤ 0.001), and increased number of graduate assistant or intern coaches (χ2 = 102.9, p ≤ 0.001). Based on these data, it can be suggested to athletic administrators and strength and conditioning professionals at the collegiate level that budgets need to be re-evaluated as the number of personnel available to monitor student-athletes and the size and safe capacity of the facility are related to the ability of the strength and conditioning staff to safely and adequately perform their duties.

Bayesian reconstruction of P(r) directly from two-dimensional detector images via a Markov chain Monte Carlo method.

The interatomic distance distribution, P(r), is a valuable tool for evaluating the structure of a molecule in solution and represents the maximum structural information that can be derived from solution scattering data without further assumptions. Most current instrumentation for scattering experiments (typically CCD detectors) generates a finely pixelated two-dimensional image. In contin-uation of the standard practice with earlier one-dimensional detectors, these images are typically reduced to a one-dimensional profile of scattering inten-sities, I(q), by circular averaging of the two-dimensional image. Indirect Fourier transformation methods are then used to reconstruct P(r) from I(q). Substantial advantages in data analysis, however, could be achieved by directly estimating the P(r) curve from the two-dimensional images. This article describes a Bayesian framework, using a Markov chain Monte Carlo method, for estimating the parameters of the indirect transform, and thus P(r), directly from the two-dimensional images. Using simulated detector images, it is demonstrated that this method yields P(r) curves nearly identical to the reference P(r). Furthermore, an approach for evaluating spatially correlated errors (such as those that arise from a detector point spread function) is evaluated. Accounting for these errors further improves the precision of the P(r) estimation. Experimental scattering data, where no ground truth reference P(r) is available, are used to demonstrate that this method yields a scattering and detector model that more closely reflects the two-dimensional data, as judged by smaller residuals in cross-validation, than P(r) obtained by indirect transformation of a one-dimensional profile. Finally, the method allows concurrent estimation of the beam center and Dmax, the longest interatomic distance in P(r), as part of the Bayesian Markov chain Monte Carlo method, reducing experimental effort and providing a well defined protocol for these parameters while also allowing estimation of the covariance among all parameters. This method provides parameter estimates of greater precision from the experimental data. The observed improvement in precision for the traditionally problematic Dmax is particularly noticeable.

Hospital readmission among older adults who return home with unmet need for ADL disability.

PURPOSE: This study determined whether returning to the community from a recent hospitalization with unmet activities of daily living (ADL) need was associated with probability of readmission. METHODS: A total of 584 respondents to the 1994, 1999, and/or 2004 National Long-Term Care Surveys (NLTCS) who were hospitalized within 90 days prior to the interview and reported ADL disability at the time of the interview were considered for analysis. Medicare claims linked to the NLTCS provided information about hospital episodes, so those enrolled in Health Maintenance Organizations or Veterans Affairs Medical Centers were not included (n = 62), resulting in a total sample size of 522. ADL disability was defined as needing human help or equipment to complete the task. Unmet ADL need was defined as receiving inadequate or no help for one or more ADL disabilities. Disability that began within 90 days of the interview was considered new disability. RESULTS: After adjusting for demographic, health, and functioning characteristics, unmet ADL need was associated with increased risk for hospital readmission (HR: 1.37, 95% CI: 1.03-1.82). Risk of readmission was greater for those with unmet need for new disabilities than those with unmet need for disabilities that were present before the index hospitalization (HR: 1.66, 95% CI: 1.01-2.73). IMPLICATIONS: Many older patients are discharged from the hospital with ADL disability. Those who report unmet need for new ADL disabilities after they return home from the hospital are particularly vulnerable to readmission. Patients' functional needs after discharge should be carefully evaluated and addressed.

Joint modeling of medical cost and survival in complex sample surveys.

Medical cost data are typically highly skewed to the right with a large proportion of zero costs. It is also common for these data to be censored because of incomplete follow-up and death. In the case of censoring due to death, it is important to consider the potential dependence between cost and survival. This association can occur because patients who incur a greater amount of medical cost tend to be frailer and hence are more likely to die. To handle this informative censoring issue, joint modeling of cost and survival with shared random effects has been proposed. In this paper, we extend this joint modeling approach to handle a final feature of many medical cost data sets, i.e., Specifically, the fact that data were obtained via a complex survey design. Specifically, we extend the joint model by incorporating the sample weights when estimating the parameters and using the Taylor series linearization approach when calculating the standard errors. We use a simulation study to compare the joint modeling approach with and without these adjustments. The simulation study shows that parameter estimates can be seriously biased when information about the complex survey design is ignored. It also shows that standard errors based on the Taylor series linearization approach provide satisfactory confidence interval coverage. The proposed joint model is applied to monthly hospital costs obtained from the 2004 National Long Term Care Survey.

Evaluating accuracy of diagnostic tests with intermediate results in the absence of a gold standard.

Intermediate test results often occur with diagnostic tests. When assessing diagnostic accuracy, it is important to properly report and account for these results. In the literature, these results are commonly discarded prior to analysis or treated as either a positive or a negative result. Although such adjustments allow sensitivity and specificity to be computed in the standard way, these forced decisions limit the interpretability and usefulness of the results. Estimation of diagnostic accuracy is further complicated when tests are evaluated without a gold standard. Although traditional latent class modeling can be readily applied to analyze these data and account for intermediate results, these models assume that tests are independent conditional on the true disease status, which is rarely valid in practice. We extend both the log-linear latent class model and the probit latent class model to accommodate the conditional dependence among tests while taking the intermediate results into consideration. We illustrate our methods using a simulation study and a published medical study on the detection of epileptiform activity in the brain.

Assessment of physician practices in adult attention-deficit/hyperactivity disorder.

OBJECTIVE: Adult attention-deficit/hyperactivity disorder (ADHD) is a common neuropsychiatric disorder, yet only 1 in 10 affected adults receives treatment. The study objective was to assess gaps in knowledge and describe current practice patterns of primary care physicians and psychiatrists in the United States in the management of adult patients with ADHD. METHOD: Primary care physicians and psychiatrists completed an Internet survey as a needs assessment of customary care related to management of adults with ADHD. Adult clinical case vignettes were followed by practice, confidence, and barrier questions. Survey data were collected from April 15, 2010, to August 22, 2010, and were deidentified and analyzed in aggregate to maintain confidentiality. χ(2) and t tests were used to compare responses of primary care physicians with those of psychiatrists. RESULTS: The survey was completed by 1,924 physicians: 1,216 primary care physicians and 708 psychiatrists. Fewer primary care physicians than psychiatrists were "extremely confident" in diagnosis (8% vs 28%, respectively, P < .001) and treatment (8% vs 27%, respectively, P < .001). Limited experience with ADHD diagnosis was more of a barrier in primary care than in psychiatry (44% vs 19%, respectively, P < .001). Mean scores on 12 evidence-based questions were lower for primary care physicians than for psychiatrists (6.1 vs 6.8 correct, respectively, P < .001). Awareness of adult ADHD prevalence was lower among primary care physicians than among psychiatrists (32% vs 47% correct, respectively, P < .001). Fewer primary care physicians than psychiatrists recognized comorbid substance use disorder (76% vs 82%, respectively, P = .002), but more primary care physicians than psychiatrists recognized eating disorders (35% vs 21%, respectively, P < .001). CONCLUSIONS: The self-assessment survey results indicate physician practices in primary care and psychiatry differ and show areas in which further education will be useful to improve care for adults with ADHD.

Incremental dementia-related expenditures in a medicaid population.

OBJECTIVES: With the growing number of older adults, understanding expenditures associated with treating medical conditions that are more prevalent among older adults is increasingly important. The objectives of this research were to estimate incremental medical encounters and incremental Medicaid expenditures associated with dementia among Indiana Medicaid recipients 40 years or older in 2004. METHODS: A retrospective cohort design analyzing Indiana Medicaid administrative claims files was used. Individuals at least 40 years of age with Indiana Medicaid eligibility during 2004 were included. Patients with dementia were identified via diagnosis codes in claims files between July 2001 and December 2004. Adjusted annual incremental medical encounters and expenditures associated with dementia in 2004 were estimated using negative binomial regression and zero-inflated negative binomial regression models. RESULTS: A total of 18,950 individuals (13%) with dementia were identified from 145,684 who were 40 years or older. The unadjusted mean total annualized Medicaid expenditures for the cohort with dementia ($28,758) were significantly higher than the mean expenditures for the cohort without dementia ($14,609). After adjusting for covariates, Indiana Medicaid incurred annualized incremental expenditures of $9,829 per recipient with dementia. Much of the annual incremental expenditure associated with dementia was driven by the higher number of days in nursing homes and resulting nursing-home expenditures. Drug expenditures accounted for the second largest component of the incremental expenditures. On the basis of disease prevalence and per recipient annualized incremental expenditures, projected incremental annualized Indiana Medicaid spending associated with dementia for persons 40 or more years of age was $186 million. CONCLUSIONS: Dementia is associated with significant expenditures among Medicaid recipients. Disease management initiatives designed to reduce nursing-home use among recipients with dementia may have much potential to decrease Medicaid expenditures associated with dementia.

Volume of home- and community-based services and time to nursing-home placement.

OBJECTIVE: The purpose of this study was to determine whether the volume of Home- and Community-Based Services (HCBS) that target Activities of Daily Living disabilities, such as attendant care, homemaking services, and home-delivered meals, increases recipients' risk of transitioning from long-term care provided through HCBS to long-term care provided in a nursing home. DATA SOURCES: Data are from the Indiana Medicaid enrollment, claims, and Insite databases. Insite is the software system that was developed for collecting and reporting data for In-Home Service Programs. STUDY DESIGN: Enrollees in Indiana Medicaid's Aged and Disabled Waiver program were followed forward from time of enrollment to assess the association between the volume of attendant care, homemaking services, home-delivered meals, and related covariates, and the risk for nursing-home placement. An extension of the Cox proportional hazard model was computed to determine the cumulative hazard of nursing-home placement in the presence of death as a competing risk. PRINCIPAL FINDINGS: Of the 1354 Medicaid HCBS recipients followed in this study, 17% did not receive any attendant care, homemaking services, or home-delivered meals. Among recipients who survived through 24 months after enrollment, one in five transitioned from HCBS to a nursing-home. Risk for nursing-home placement was significantly lower for each five-hour increment in personal care (HR=0.95, 95% CI=0.92-0.98) and homemaking services (HR=0.87, 95% CI=0.77-0.99). CONCLUSIONS: Future policies and practices that are focused on optimizing long-term care outcomes should consider that a greater volume of HCBS for an individual is associated with reduced risk of nursing-home placement.

Modeling correlated healthcare costs.

Accurate estimation and prediction of healthcare costs play crucial roles in decisions made by healthcare agencies on policy and resource allocation. Development of a cost model allows these decision-makers the opportunity to investigate the impact of different policies and/or allocations of resources. With increased subject-specific information, longitudinal studies and the breakdown of total costs into categories comes the need for healthcare cost models to account for correlation. In this article, we review the statistical models used to fit joint costs, emphasizing the use of copulas as a flexible and relatively straightforward approach to move from marginal to joint modeling.

Incident use and outcomes associated with potentially inappropriate medication use in older adults.

BACKGROUND: Most studies of potentially inappropriate medication (PIM) use among older adults have focused on prevalence rather than incidence. OBJECTIVES: The goals of this study were to determine the 1-year incidence of PIM use among elderly Indiana Medicaid residents of nursing homes and to examine associations between incident PIM use and hospitalization and mortality. METHODS: A retrospective analysis was conducted using Indiana Medicaid enrollment and administrative claims files. Individuals were included if they were Medicaid eligible and aged ≥65 years as of January 2003 and received nursing home services in each month of 2003 or until death in 2003. Individuals also had to receive nursing home services from October 2002 through December 2002 for inclusion in the sample. To focus analysis on incident PIM use, individuals who received any PIM prescription medication from October 2002 through December 2002 were excluded from the sample, as were those not prescribed any new medication in 2003. PIMs were identified using the 2003 Beers criteria. Associations between incident PIM use and hospitalization and mortality were assessed using logistic regression models after controlling for other risk factors. Potential selection bias was examined using bivariate probit models. RESULTS: The study sample consisted of 7594 individuals (mean age, 83.07 years). A majority of the sample was female (76.5%), white (89.7%), and widowed (58.8%). Most individuals received care in nursing homes located in urban areas (5306 [69.9%]) and in the central region of Indiana (2838 [37.4%]). One-year incidence of PIM use was 42.1%. Incident PIM users were more likely to be hospitalized (odds ratio [OR] = 1.27; 95% CI, 1.10-C1.46) and more likely to die (OR = 1.46; 95% CI, 1.31-C1.62) in the 12 months after first receiving a PIM than nonusers, even after adjusting for demographic and clinical risk factors. CONCLUSIONS: Incident PIM use was high among these elderly Indiana Medicaid residents of nursing homes. Individuals who began use of a PIM were at a higher risk of hospitalization and of dying.

Volume of home- and community-based Medicaid waiver services and risk of hospital admissions.

OBJECTIVES: To evaluate whether type and volume of Medicaid Home- and Community-Based Services (HCBS) waiver program are associated with risk of hospitalization and whether this association changes over time. DESIGN: Prospective. SETTING: Indiana Medicaid claims data from June 2001 to December 2004. PARTICIPANTS: Medicaid recipients (N=1,354) who enrolled in the Aged and Disabled waiver program between January 2002 and June 2004. MEASUREMENTS: Time to hospital admission since enrollment in the HCBS waiver program, adjusted for demographics, comorbidities, prior use of health services, and volume of HCBS received, including attendant care, homemaking, and home-delivered meals. RESULTS: A greater volume of attendant care, homemaking services, and home-delivered meals was associated with a lower risk of hospitalization. This effect diminished over time for attendant care and homemaking. The risk of hospitalization for subjects receiving 5 hours of attendant care per month was 54% (hazard ratio (HR)=0.46, 95% confidence interval (CI)=0.38-0.57) lower during the first month of enrollment and 20% lower by Month 10 (HR=0.80, 95% CI=0.73-0.88) than for those receiving no attendant care. CONCLUSION: Greater volume of HCBS services was associated with lower risk of hospitalization. The findings highlight the potential importance of assessing and monitoring the volume of HCBS patients receive.