Changes in the burden of medications that may impair driving among older adults before and after a motor vehicle crash.

BACKGROUND: Medications are one of the most easily modifiable risk factors for motor vehicle crashes (MVCs) among older adults, yet limited information exists on how the use of potentially driver-impairing (PDI) medications changes following an MVC. Therefore, we examined the number and types of PDI medication classes dispensed before and after an MVC. METHODS: This observational study included Medicare fee-for-service beneficiaries aged ≥67 years who were involved in a police-reported MVC in New Jersey as a driver between 2008 and 2017. Analyses were conducted at the "person-crash" level because participants could be involved in more than one MVC. We examined the use of 36 PDI medication classes in the 120 days before and 120 days after MVC. We described the number and prevalence of PDI medication classes in the pre-MVC and post-MVC periods as well as the most common PDI medication classes started and stopped following the MVC. RESULTS: Among 124,954 person-crashes, the mean (SD) age was 76.0 (6.5) years, 51.3% were female, and 83.9% were non-Hispanic White. The median (Q1 , Q3 ) number of PDI medication classes was 2 (1, 4) in both the pre-MVC and post-MVC periods. Overall, 20.3% had a net increase, 15.9% had a net decrease, and 63.8% had no net change in the number of PDI medication classes after MVC. Opioids, antihistamines, and thiazide diuretics were the top PDI medication classes stopped following MVC, at incidences of 6.2%, 2.1%, and 1.7%, respectively. The top medication classes started were opioids (8.3%), skeletal muscle relaxants (2.2%), and benzodiazepines (2.1%). CONCLUSIONS: A majority of crash-involved older adults were exposed to multiple PDI medications before and after MVC. A greater proportion of person-crashes were associated with an increased rather than decreased number of PDI medications. The reasons why clinicians refrain from stopping PDI medications following an MVC remain to be elucidated.

Assessing the representativeness of cluster randomized trials: Evidence from two large pragmatic trials in United States nursing homes.

BACKGROUND/AIMS: When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We used data from two large nursing home-based pragmatic cluster randomized trials to compare nursing home and resident characteristics in randomized facilities to eligible non-randomized and ineligible facilities. METHODS: We linked data from the high-dose influenza vaccine trial and the Music & Memory Pragmatic TRIal for Nursing Home Residents with ALzheimer's Disease (METRICaL) to nursing home assessments and Medicare fee-for-service claims. The target population for the high-dose trial comprised Medicare-certified nursing homes; the target population for the METRICaL trial comprised nursing homes in one of four US-based nursing home chains. We used standardized mean differences to compare facility and individual characteristics across the three groups and logistic regression to model the probability of nursing home trial participation. RESULTS: In the high-dose trial, 4476 (29%) of the 15,502 nursing homes in the target population were eligible for the trial, of which 818 (18%) were randomized. Of the 1,361,122 residents, 91,179 (6.7%) were residents of randomized facilities, 463,703 (34.0%) of eligible non-randomized facilities, and 806,205 (59.3%) of ineligible facilities. In the METRICaL trial, 160 (59%) of the 270 nursing homes in the target population were eligible for the trial, of which 80 (50%) were randomized. Of the 20,262 residents, 973 (34.4%) were residents of randomized facilities, 7431 (36.7%) of eligible non-randomized facilities, and 5858 (28.9%) of ineligible facilities. In the high-dose trial, randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (132.5 vs 145.9 and 91.9, respectively), for-profit status (91.8% vs 66.8% and 68.8%), belonging to a nursing home chain (85.8% vs 49.9% and 54.7%), and presence of a special care unit (19.8% vs 25.9% and 14.4%). In the METRICaL trial randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (103.7 vs 110.5 and 67.0), resource-poor status (4.6% vs 10.0% and 18.8%), and presence of a special care unit (26.3% vs 33.8% and 10.9%). In both trials, the characteristics of residents in randomized facilities were similar across the three groups. CONCLUSION: In both trials, facility-level characteristics of randomized nursing homes differed considerably from those of eligible non-randomized and ineligible facilities, while there was little difference in resident-level characteristics across the three groups. Investigators should assess the characteristics of clusters that participate in cluster randomized trials, not just the individuals within the clusters, when examining the applicability of trial results beyond participating clusters.

Persistence of High-Need Status Over Time Among Fee-for-Service Medicare Beneficiaries.

Although administrative claims data can be used to identify high-need (HN) Medicare beneficiaries, persistence in HN status among beneficiaries and subsequent variation in outcomes are unknown. We use national-level claims data to classify Fee-for-Service (FFS) Medicare beneficiaries as HN annually among beneficiaries continuously enrolled between 2013 and 2015. To examine persistence of HN status over time, we categorize longitudinal patterns in HN status into being never, newly, transiently, and persistently HN and examine differences in patients' demographic characteristics and outcomes. Among survivors, 23% of beneficiaries were HN at any time-4% persistently HN, 13% transiently HN, and 6% newly HN. While beneficiaries who were persistently HN had higher mortality, utilization, and expenditures, classification as HN at any time was associated with poor outcomes. These findings demonstrate longitudinal variability of HN status among FFS beneficiaries and reveal the pervasiveness of poor outcomes associated with even transitory HN status over time.

Individual and Geographic Variation in Driver's License Suspensions: Evidence of Disparities by Race, Ethnicity and Income.

INTRODUCTION: Although access to a motor vehicle is essential for pursuing social and economic opportunity and ensuring health and well-being, states have increasingly used driver's license suspensions as a means of compelling compliance with a variety of laws and regulations unrelated to driving, including failure to pay a fine or appear in court. Little known about the population of suspended drivers and what geographic resources may be available to them to help mitigate the impact of a suspension. METHODS: Using data from the New Jersey Safety Health Outcomes (NJ-SHO) data warehouse 2004-2018, we compared characteristics of suspended drivers, their residential census tract, as well as access to public transportation and jobs, by reason for the suspension (driving or non-driving related). In addition, we examined trends in the incidence and prevalence of driving- and non-driving-related suspensions by sub-type over time. RESULTS: We found that the vast majority (91%) of license suspensions were for non-driving-related events, with the most common reason for a suspension being failure to pay a fine. Compared to drivers with a driving-related suspension or no suspension, non-driving-related suspended drivers lived in census tracts with a lower household median income, higher proportion of black and Hispanic residents and higher unemployment rates, but also better walkability scores and better access to public transportation and jobs. CONCLUSIONS: Our study contributes to a growing literature that shows, despite public perception that they are meant to address traffic safety, the majority of suspensions are for non-driving-related events. Further, these non-driving-related suspensions are most common in low-income communities and communities with a high-proportion of black and Hispanic residents. Although non-driving-related suspensions are also concentrated in communities with better access to public transportation and nearby jobs, additional work is needed to determine what effect this has for the social and economic well-being of suspended drivers.

Characteristics of Top-Performing Hospitals Caring for High-Need Medicare Beneficiaries.

A small proportion of high-need (HN) Medicare beneficiaries account for a large share of medical expenditures in the United States. Identifying hospitals with the best outcomes for HN patients is central to identifying and spreading evidence-based practices to improve care for this population. The objective of this study was to identify and characterize top-performing hospitals for HN patients. Administrative claims data from 2013-2014 were used to identify HN beneficiaries and their treating hospital; hospitals were ranked based on their HN beneficiaries' outcomes in 2015. Hospitalization, mortality, and days spent in community were assessed, and all outcomes were risk standardized for age, sex, dual eligibility, and hospital referral region. American Hospital Association and aggregated inpatient claims data characterized hospitals. Logistic regression models estimated the odds of ranking in the top 20% on all outcomes. Of 2253 hospitals with at least 500 HN patients in the United States, 92 (4.1%) ranked in the top 20% across all outcomes. No hospital characteristics were associated with being top performing across all outcomes, but urban hospitals were significantly less likely to perform well on hospitalization and private, for-profit hospitals performed better on mortality. Small hospitals, Accountable Care Organization providers, and those providing palliative care services were more likely to rank highly on days spent in the community. Top-performing hospitals served fewer minority, dual eligible, and HN patients, suggesting that case mix may explain some of the differences in performance, and that additional work is needed to examine programs and practices at outstanding hospitals.

High-Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes.

OBJECTIVES: High-need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes. DESIGN: Latent class analysis was used to identify phenotypes within a sample of HN fee-for-service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post-acute assessment data. SETTING: Not applicable. PARTICIPANTS: Two cross-sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643). MEASUREMENTS: The following variables were used to identify phenotypes: acute and post-acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes. RESULTS: Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4. CONCLUSIONS: Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70-77, 2019.

The burden of respiratory infections among older adults in long-term care: a systematic review.

BACKGROUND: Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature. METHODS: We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively. RESULTS: A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%. CONCLUSIONS: The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts.

Cost sharing for antiepileptic drugs: medication utilization and health plan costs.

OBJECTIVES: To examine the association between health plan out-of-pocket (OOP) costs for antiepileptic drugs and healthcare utilization (HCU) and overall plan spending among US-based commercial health plan beneficiaries with epilepsy. STUDY DESIGN: Retrospective cohort. METHODS: The Truven MarketScan Commercial Claims database for January 1, 2009, to June 30, 2015, was used. Patients 65 years or younger with epilepsy and at least 12 months of continuous enrollment before index (date meeting first epilepsy diagnostic criteria) were included. Analyses were adjusted for age group, gender, beneficiary relationship, insurance plan type, and Charlson Comorbidity Index score. Primary outcomes included proportion of days covered (PDC), HCU, and healthcare spending in 90-day postindex periods. Associations between OOP costs and mean PDC, HCU, and plan healthcare spending per 90-day period were estimated. RESULTS: Across 5159 plans, 187,241 beneficiaries met eligibility criteria; 54.3% were female, 41.7% were aged 45 to 65 years, and 62.4% were in preferred provider organization plans. Across postindex 90-day periods, mean (SD) PDC, epilepsy-specific hospitalizations, outpatient visits, and emergency department visits were 0.85 (0.26), 0.02 (0.13), 0.34 (0.47), and 0.05 (0.22), respectively. Median (interquartile range) spending per 90-day period was $1488 ($459-$4705); median epilepsy-specific spending was $139 ($18-$623). Multivariable linear regression without health plan fixed effects revealed that higher OOP spending was associated with a decrease in PDC (coefficient, -0.008; 95% CI, -0.009 to -0.006; P <.001) and an increase in overall spending (218.6; 95% CI, 47.9-389.2; P = .012). Health plan fixed effects model estimates were similar, except for epilepsy-specific spending, which was significant (120.6; 95% CI, 29.2-211.9; P = .010). CONCLUSIONS: Increases in beneficiaries' OOP costs led to higher overall spending and lower PDC.

The Impact of Dementia Special Care Units on Quality of Care: An Instrumental Variables Analysis.

OBJECTIVE: To compare the quality of care following admission to a nursing home (NH) with and without a dementia special care unit (SCU) for residents with dementia. DATA SOURCES/STUDY SETTING: National resident-level minimum dataset assessments (MDS) 2005-2010 merged with Medicare claims and provider-level data from the Online Survey, Certification, and Reporting database. STUDY DESIGN: We employ an instrumental variable approach to address the endogeneity of selection into an SCU facility controlling for a range of individual-level covariates. We use "differential distance" to a nursing home with and without an SCU as our instrument. DATA COLLECTION/EXTRACTION METHODS: Minimum dataset assessments performed at NH admission and every quarter thereafter. PRINCIPAL FINDINGS: Admission to a facility with an SCU led to a reduction in inappropriate antipsychotics (-9.7 percent), physical restraints (-9.6 percent), pressure ulcers (-3.3 percent), feeding tubes (-8.3 percent), and hospitalizations (-14.7 percent). We found no impact on the use of indwelling urinary catheters. Results held in sensitivity analyses that accounted for the share of SCU beds and the facilities' overall quality. CONCLUSIONS: Facilities with an SCU provide better quality of care as measured by several validated quality indicators. Given the aging population, policies to promote the expansion and use of dementia SCUs may be warranted.

The Alternative Quality Contract: Impact on Service Use and Spending for Children With ADHD.

In 2009, Blue Cross-Blue Shield of Massachusetts (BCBSMA) implemented the alternative quality contract (AQC), which pays provider organizations a global payment for all services used by enrollees. BCBSMA claims for 2006-2011 were used to compare youths enrolled in provider organizations participating in the AQC (7,407 person-years [PYs]) with those not participating (45,398 PYs). Difference-in-differences models estimated changes in mental health and substance abuse treatment service utilization and spending attributable to the AQC. The AQC was associated with small increases in the probability of any outpatient visits and in the probability and number of medication management visits among children with attention-deficit hyperactivity disorder (ADHD). Spending did not change, and there was no evidence of reductions in service utilization or spending for children with ADHD in the first three years of AQC implementation.

Medicare Beneficiaries With Advanced Lung Cancer Experience Diverse Patterns Of Care From Diagnosis To Death.

Characterizations of average end-of-life care for people with cancer can obscure important differences in patients' experiences. Using Medicare claims data for 14,257 patients diagnosed with extensive-stage small-cell lung cancer in the period 1995-2009, we used latent class analysis to identify classes of people with different care patterns. We characterized care trajectories from diagnosis to death using time spent in five care settings-home, hospital inpatient unit (acute), hospital intensive care unit (ICU), postacute skilled nursing facility, and hospice-and transitions across these settings. We identified four classes of patients: 66 percent spent the time primarily at home, 11 percent were primarily in hospice, 17 percent were largely in an acute setting, and 6 percent were largely in an ICU. Patients in these classes differed significantly in terms of baseline clinical characteristics, survival length, time spent in hospice, site of death, and spending. The findings show substantial heterogeneity in patterns of care for patients with advanced cancer, which should be accounted for in efforts to improve end-of-life care.

Passive Enrollment Of Dual-Eligible Beneficiaries Into Medicare And Medicaid Managed Care Has Not Met Expectations.

The Centers for Medicare and Medicaid Services Financial Alignment Initiative represents the largest effort to date to move beneficiaries who are eligible for both Medicare and Medicaid-known as dual eligibles-into a coordinated care model by the use of passive (automatic) enrollment. Thirteen states are testing integrated payment and delivery demonstration programs in which an estimated 1.3 million dual eligibles are qualified to participate. As of October 2016, passive enrollment had brought over 300,000 dual eligibles into nine capitated programs in eight states. However, program participation levels remained relatively low. Across the eight states, only 26.7 percent of dual eligibles who were qualified to participate were enrolled, ranging from 5.3 percent for the two New York programs together to 62.4 percent in Ohio. Although the exact causes of the high rates of opting out and disenrolling that we observed among passively enrolled dual eligibles are unknown, experience to date suggests that administrative challenges were combined with demand- and supply-side barriers to enrollment. These early findings draw into question whether passive enrollment can encourage dual eligibles to participate in integrated care models.

Effect of Clostridium difficile Prevalence in Hospitals and Nursing Homes on Risk of Infection.

OBJECTIVES: To assess the effect of facility Clostridium difficile infection (CDI) prevalence on risk of healthcare facility (HFC) acquired CDI. DESIGN: Retrospective cohort study. SETTING: Medicare fee-for-service (FFS) claims and skilled nursing facility (SNF) Minimum Data Set 3.0 assessments. PARTICIPANTS: Medicare beneficiaries with 90 days or more of no contact with a HCF before a hospital admission without a CDI diagnosis. Participants were separated into two cohorts: discharged to the community and discharged to a SNF. MEASUREMENTS: Risk of HCF-acquired CDI associated with CDI prevalence at the index facility measured according to 30-day rehospitalization with a discharge diagnosis of CDI or diagnosis in the SNF after admission. Hospital and SNF CDI prevalence were categorized into three groups: 0% and above and below the median value for facilities with greater than 0% prevalence. RESULTS: Of 817,900 eligible individuals, there were 553,423 admissions in the first cohort (discharged to the community) and 315,109 in the second (discharged to a SNF). In the first cohort, the risk of HCF-acquired CDI was higher for individuals admitted to hospitals with CDI prevalence less than the median (relative risk (RR) = 1.58, 95% confidence interval (CI) = 1.18-2.12) and greater than the median (RR = 2.56, 95% CI = 1.91-3.45) than for those with no CDI. In the second cohort, the risk of HCF-acquired CDI was greater for individuals admitted to a hospital (RR = 1.89, 95% CI = 1.49-2.39) and a SNF (RR = 1.48, 95% CI = 1.31-1.67) with CDI prevalence greater than the median. CONCLUSION: The risk of HCF-acquired CDI is greater for noninfected individuals admitted to hospitals and SNFs with a high prevalence of CDI.

Patterns and predictors of medication adherence to lipid-lowering therapy in children aged 8 to 20 years.

BACKGROUND: The American Academy of Pediatrics recommends lipid-lowering therapy (LLT) for children at high risk of cardiovascular disease. However, the use of LLT in children is rare, and rates of nonadherence are unknown. OBJECTIVE: To identify patterns of use and predictors of nonadherence to LLT in children aged 8 to 20 years and the subgroup with dyslipidemia. METHODS: Commercially insured patients with a new dispensing for an LLT were included. Nonadherence was defined as a gap of >90 days between the last dispensing plus the medication days supply and the next dispensing or censoring. Descriptive statistics characterize the patterns of LLT adherence and class-specific drug switching. Kaplan-Meier curves and multivariable Cox proportional hazard models identified time to, and predictors of, nonadherence for the cohort and the dyslipidemia subgroup. RESULTS: Of the 8710 patients meeting inclusion criteria, 87% were nonadherent. Statins were the most common index prescription, and patients with an index statin dispensing were more likely to have multiple comorbidities and other prescription drug use. In multivariable analyses, nonadherence was inversely associated with dyslipidemia (hazard ratio [HR] = 0.61, 95% confidence interval [CI] = 0.57-0.65), chronic kidney disease (HR = 0.69, 95% CI = 0.54-0.88), higher outpatient (HR = 0.87, 95% CI = 0.77-0.98), and inpatient (HR = 0.83, 95% CI = 0.70-0.97) use. When limited to patients with dyslipidemia, nonadherence was related to age (HR = 1.21, 95% CI = 1.07-1.38) and obesity (HR = 1.23, 95% CI = 1.02-1.49). CONCLUSIONS: Despite recommendations to begin continuous treatment early for high-risk children, nonadherence to LLT is frequent in this population, with modestly higher adherence in children with dyslipidemia.

Demographics and care-seeking behaviors of sexual violence survivors in South Kivu province, Democratic Republic of Congo.

OBJECTIVES: One of the most striking features of the ongoing conflict in the Democratic Republic of Congo (DRC) is the use of sexual violence. In spite of the brutality of these crimes, the experiences of women affected by sexual violence in Eastern DRC remain poorly characterized. This analysis aimed to (1) provide detailed demographics of sexual violence survivors presenting to Panzi Hospital; (2) examine how demographic factors might impact patterns of sexual violence; and (3) describe care-seeking behavior among sexual violence survivors. METHODS: The demographics and care-seeking behavior of sexual violence survivors in South Kivu Province were described from a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital (2004-2008). RESULTS: A total of 4311 records were reviewed. The mean age of survivors was 35 years. Most women (53%) were married, self-identified with the Bashi tribe (65%), and reported agriculture as their livelihood (74%). The mean time delay between sexual assault and seeking care was 10.4 months. Five reasons were identified to help explain the lengthy delays to seeking care: waiting for physical symptoms to develop or worsen before seeking medical attention, lack of means to access medical care, concerns that family would find out about the sexual assault, stigma surrounding sexual violence, and being abducted into sexual slavery for prolonged periods of time. CONCLUSIONS: Many sexual assault survivors have very delayed presentations to medical attention. Promoting timely access of medical care may best be facilitated by reducing stigma and by educating women about the benefits of early medical care, even in the absence of injuries or symptoms.

Public health education for emergency medicine residents.

Emergency medicine (EM) has an important role in public health, but the ideal approach for teaching public health to EM residents is unclear. As part of the national Regional Public Health-Medicine Education Centers-Graduate Medical Education initiative from the CDC and the American Association of Medical Colleges, three EM programs received funding to create public health curricula for EM residents. Curricula approaches varied by residency. One program used a modular, integrative approach to combine public health and EM clinical topics during usual residency didactics, one partnered with local public health organizations to provide real-world experiences for residents, and one drew on existing national as well as departmental resources to seamlessly integrate more public health-oriented educational activities within the existing residency curriculum. The modular and integrative approaches appeared to have a positive impact on resident attitudes toward public health, and a majority of EM residents at that program believed public health training is important. Reliance on pre-existing community partnerships facilitated development of public health rotations for residents. External funding for these efforts was critical to their success, given the time and financial restraints on residency programs. The optimal approach for public health education for EM residents has not been defined.