Regional variation in financial hardship among US veterans during the COVID-19 pandemic.

Geographic variation in hardship, especially health-related hardship, was identified prior to and during the pandemic, but we do not know whether this variation is consistent among Veterans Health Administration (VHA)-enrolled veterans, who reported markedly high rates of financial hardship during the pandemic, despite general and veteran-specific federal policy efforts aimed at reducing hardship. In a nationwide, regionally stratified sample of VHA-enrolled veterans, we examined whether the prevalence of financial hardship during the pandemic varied by US Census region. We found veterans in the South, compared with those in other census regions, reported higher rates of severe-to-extreme financial strain, using up all or most of their savings, being unable to pay for necessities, being contacted by collections, and changing their employment due to the kind of work they could perform. Regional variation in veteran financial hardship demonstrates a need for further research about the role and interaction of federal and state financial-assistance policies in shaping risks for financial hardship as well as potential opportunities to mitigate risks among veterans and reduce variation across regions.

Comprehensive Medication Review Completion Rates and Disparities After Medicare Star Rating Measure.

Importance: Comprehensive medication reviews (CMRs) are offered to qualifying US Medicare beneficiaries annually to optimize medication regimens and therapeutic outcomes. In 2016, Medicare adopted CMR completion as a Star Rating quality measure to encourage the use of CMRs. Objective: To examine trends in CMR completion rates before and after 2016 and whether racial, ethnic, and socioeconomic disparities in CMR completion changed. Design, Setting, and Participants: This observational study using interrupted time-series analysis examined 2013 to 2020 annual cohorts of community-dwelling Medicare beneficiaries aged 66 years and older eligible for a CMR as determined by Part D plans and by objective minimum eligibility criteria. Data analysis was conducted from September 2022 to February 2024. Exposure: Adoption of CMR completion as a Star Rating quality measure in 2016. Main Outcome and Measures: CMR completion modeled via generalized estimating equations. Results: The study included a total of 561 950 eligible beneficiaries, with 253 561 in the 2013 to 2015 cohort (median [IQR] age, 75.8 [70.7-82.1] years; 90 778 male [35.8%]; 6795 Asian [2.7%]; 24 425 Black [9.6%]; 7674 Hispanic [3.0%]; 208 621 White [82.3%]) and 308 389 in the 2016 to 2020 cohort (median [IQR] age, 75.1 [70.4-80.9] years; 126 730 male [41.1%]; 8922 Asian [2.9%]; 27 915 Black [9.1%]; 7635 Hispanic [2.5%]; 252 781 White [82.0%]). The unadjusted CMR completion rate increased from 10.2% (7379 of 72 225 individuals) in 2013 to 15.6% (14 185 of 90 847 individuals) in 2015 and increased further to 35.8% (18 376 of 51 386 individuals) in 2020, in part because the population deemed by Part D plans to be MTM-eligible decreased by nearly half after 2015 (90 487 individuals in 2015 to 51 386 individuals in 2020). Among a simulated cohort based on Medicare minimum eligibility thresholds, the unadjusted CMR completion rate increased but to a lesser extent, from 4.4% in 2013 to 12.6% in 2020. Compared with White beneficiaries, Asian and Hispanic beneficiaries experienced greater increases in likelihood of CMR completion after 2016 but remained less likely to complete a CMR. Dual-Medicaid enrollees also experienced greater increases in likelihood of CMR completion as compared with those without either designation, but still remained less likely to complete CMR. Conclusion and Relevance: This study found that adoption of CMR completion as a Star Rating quality measure was associated with higher CMR completion rates. The increase in CMR completion rates was achieved partly because Part D plans used stricter eligibility criteria to define eligible patients. Reductions in disparities for eligible Asian, Hispanic, and dual-Medicaid enrollees were seen, but not eliminated. These findings suggest that quality measures can inform plan behavior and could be used to help address disparities.

Health Expenditures After Bariatric Surgery: A Retrospective Cohort Study.

OBJECTIVE: Bariatric surgery leads to substantial improvements in weight and weight-related conditions, but prior literature on post-surgical health expenditures is equivocal. In a retrospective cohort study, we compared expenditures between surgical and matched non-surgical patients. SUMMARY BACKGROUND DATA AND METHODS: In a retrospective study, total, outpatient, inpatient and medication expenditures 3 years before and 5.5 years after surgery were compared between 22,698 bariatric surgery (n=7,127 RYGB, 15,571 sleeve gastrectomy) patients from 2012-2019 and 66,769 matched non-surgical patients, using generalized estimating equations. We also compared expenditures between patients receiving the two leading surgical procedures in weighted analyses. RESULTS: Surgical and non-surgical cohorts were well matched, 80-81% female, with mean body mass index (BMI) of 44, and mean age of 47 (RYGB) and 44 (SG) years. Estimated total expenditures were similar between surgical and non-surgical groups 3 years before surgery ($27 difference, 95% confidence interval (CI): -42, 102)), increased 6 months prior to surgery for surgical patients, and decreased below pre-period levels for both groups after 3-5.5 years to become similar (difference at 5.5 y=-$61, 95% CI: -166, 52). Long-term outpatient expenditures were similar between groups. Surgical patients' lower long-term medication expenditures ($314 lower at 5.5 y, 95% CI: -419, -208) were offset by a higher risk of hospitalization. Total expenditures were similar between RYGB and SG patients 3.5 to 5.5 years after surgery. CONCLUSIONS: Bariatric surgery translated into lower medication expenditures than matched controls, but not lower overall long-term expenditures. Expenditure trends appear similar for the two leading bariatric operations.

Differences in healthcare costs over 10 years following discharge from military service by weight trajectory.

The prevalence of overweight and obesity among military personnel has increased substantially in the past two decades. Following military discharge many personnel can receive integrated health care from the Veterans Health Administration. Prior research related to the economic impacts of obesity has not examined health care costs following the transition into civilian life following military discharge. To address this evidence gap, this study sought to compare longitudinal costs over 10 years across weight categories among VA enrollees recently discharged from the military.

Risk of Potentially Preventable Hospitalizations After SARS-CoV-2 Infection.

Importance: Research demonstrates that SARS-CoV-2 infection is associated with increased risk of all-cause hospitalization. However, no prior studies have assessed the association between SARS-CoV-2 and potentially preventable hospitalizations-that is, hospitalizations for conditions that can usually be effectively managed in ambulatory care settings. Objective: To examine whether SARS-CoV-2 is associated with potentially preventable hospitalization in a nationwide cohort of US veterans. Design, Setting, and Participants: This cohort study used an emulated target randomized trial design with monthly sequential trials to compare risk of a potentially preventable hospitalization among veterans with SARS-CoV-2 and matched comparators without SARS-CoV-2. A total of 189 136 US veterans enrolled in the Veterans Health Administration (VHA) who were diagnosed with SARS-CoV-2 between March 1, 2020, and April 30, 2021, and 943 084 matched comparators were included in the analysis. Data were analyzed from May 10, 2023, to January 26, 2024. Exposure: SARS-CoV-2 infection. Main Outcomes and Measures: The primary outcome was a first potentially preventable hospitalization in VHA facilities, VHA-purchased community care, or Medicare fee-for-service care. Extended Cox models were used to examine adjusted hazard ratios (AHRs) of potentially preventable hospitalization among veterans with SARS-CoV-2 and comparators during follow-up periods of 0 to 30, 0 to 90, 0 to 180, and 0 to 365 days. The start of follow-up was defined as the date of each veteran's first positive SARS-CoV-2 diagnosis, with the same index date applied to their matched comparators. Results: The 1 132 220 participants were predominantly men (89.06%), with a mean (SD) age of 60.3 (16.4) years. Most veterans were of Black (23.44%) or White (69.37%) race. Veterans with SARS-CoV-2 and comparators were well-balanced (standardized mean differences, all <0.100) on observable baseline clinical and sociodemographic characteristics. Overall, 3.10% of veterans (3.81% of those with SARS-CoV-2 and 2.96% of comparators) had a potentially preventable hospitalization during 1-year follow-up. Risk of a potentially preventable hospitalization was greater among veterans with SARS-CoV-2 than comparators in 4 follow-up periods: 0- to 30-day AHR of 3.26 (95% CI, 3.06-3.46); 0- to 90-day AHR of 2.12 (95% CI, 2.03-2.21); 0- to 180-day AHR of 1.69 (95% CI, 1.63-1.75); and 0- to 365-day AHR of 1.44 (95% CI, 1.40-1.48). Conclusions and Relevance: In this cohort study, an increased risk of preventable hospitalization in veterans with SARS-CoV-2, which persisted for at least 1 year after initial infection, highlights the need for research on ways in which SARS-CoV-2 shapes postinfection care needs and engagement with the health system. Solutions are needed to mitigate preventable hospitalization after SARS-CoV-2.

Association Between a National Behavioral Weight Management Program and Veterans Affairs Health Expenditures.

OBJECTIVE: The association between participation in a behavioral weight intervention and health expenditures has not been well characterized. We compared Veterans Affairs (VA) expenditures of individuals participating in MOVE!, a VA behavioral weight loss program, and matched comparators 2 years before and 2 years after MOVE! initiation. METHODS: Retrospective cohort study of Veterans who had one or more MOVE! visits in 2008-2017 who were matched contemporaneously to up to 3 comparators with overweight or obesity through sequential stratification on an array of patient characteristics, including sex. Baseline patient characteristics were compared between the two cohorts through standardized mean differences. VA expenditures in the 2 years before MOVE! initiation and 2 years after initiation were modeled using generalized estimating equations with a log link and distribution with variance proportional to the standard deviation (gamma). RESULTS: MOVE! participants (n=499,696) and comparators (n=1,336,172) were well-matched, with an average age of 56, average body mass index of 35, and similar total VA expenditures in the fiscal year before MOVE! initiation ($9662 for MOVE! participants and $10,072 for comparators, standardized mean difference=-0.019). MOVE! participants had total expenditures that were statistically lower than matched comparators in the 6 months after initiation but modestly higher in the 6 months to 2 years after initiation, though differences were small in magnitude (1.0%-1.6% differences). CONCLUSIONS: The VA's system-wide behavioral weight intervention did not realize meaningful short-term health care cost savings for participants.

Changes in Outpatient Health Care Use After COVID-19 Infection Among Veterans.

Importance: The association of COVID-19 infection with outpatient care utilization is unclear. Many studies reported population surveillance studies rather than comparing outpatient health care use between COVID-19-infected and uninfected cohorts. Objective: To compare outpatient health care use across 6 categories of care (primary care, specialty care, surgery care, mental health, emergency care, and diagnostic and/or other care) between veterans with or without COVID-19 infection. Design, Setting, and Participants: In a retrospective cohort study of Veterans Affairs primary care patients, veterans with COVID-19 infection were matched to a cohort of uninfected veterans. Data were obtained from the Veterans Affairs Corporate Data Warehouse and the Centers for Medicare & Medicaid Services Fee-for-Service Carrier/Physician Supplier file from January 2019 through December 2022. Data analysis was performed from September 2022 to April 2023. Exposure: COVID-19 infection. Main Outcomes and Measures: The primary outcome was the count of outpatient visits after COVID-19 infection. Negative binomial regression models compared outpatient use over a 1-year preinfection period, and peri-infection (0-30 days), intermediate (31-183 days), and long-term (184-365 days) postinfection periods. Results: The infected (202 803 veterans; mean [SD] age, 60.5 [16.2] years; 178 624 men [88.1%]) and uninfected (202 803 veterans; mean [SD] age, 60.4 [16.5] years; 178 624 men [88.1%]) cohorts were well matched across all covariates. Outpatient use in all categories (except surgical care) was significantly elevated during the peri-infection period for veterans with COVID-19 infection compared with the uninfected cohort, with an increase in all visits of 5.12 visits per 30 days (95% CI, 5.09-5.16 visits per 30 days), predominantly owing to primary care visits (increase of 1.86 visits per 30 days; 95% CI, 1.85-1.87 visits per 30 days). Differences in outpatient use attenuated over time but remained statistically significantly higher at 184 to 365 days after infection (increase of 0.25 visit per 30 days; 95% CI, 0.23-0.27 visit per 30 days). One-half of the increased outpatient visits were delivered via telehealth. The utilization increase was greatest for veterans aged 85 years and older (6.1 visits, 95% CI, 5.9-6.3 visits) vs those aged 20 to 44 years (4.8 visits, 95% CI, 4.7-4.8 visits) and unvaccinated veterans (4.5 visits, 95% CI, 4.3-4.6 visits) vs vaccinated veterans (3.2 visits; 95% CI, 3.4-4.8 visits). Conclusions and Relevance: This study found that outpatient use increased significantly in the month after infection, then attenuated but remained greater than the uninfected cohorts' use through 12 months, which suggests that there are sustained impacts of COVID-19 infection.

Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients.

OBJECTIVE: Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN: Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models. PRINCIPAL FINDINGS: Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures. CONCLUSIONS: In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.

Association between results of an amyloid PET scan and healthcare utilization in individuals with cognitive impairment.

BACKGROUND: The Imaging Dementia Evidence for Amyloid Scanning (IDEAS) study reports that amyloid PET scans help providers diagnose and manage Alzheimer's disease and related dementias (ADRD). Using CARE-IDEAS, an IDEAS supplemental study, we examined the association between amyloid PET scan result (elevated or non-elevated amyloid), patient characteristics, and participant healthcare utilization. METHODS: We linked respondents in CARE-IDEAS study to their Medicare fee-for-service records (n = 1333). We examined participants' cognitive impairment-related, outpatient, emergency department (ED), and inpatient encounters in the year before compared with the 2 years after the amyloid PET scan. RESULTS: Individuals with a non-elevated amyloid scan had more healthcare encounters throughout the overall study period than those with an elevated amyloid scan. Regardless of the amyloid scan result, cognitive impairment-related and outpatient encounters overall decreased, but ED and inpatient encounters increased in the 2 years after the scan compared with the year prior. There was minimal evidence of differences in healthcare utilization between participants with an elevated and non-elevated amyloid scan. CONCLUSIONS: There is no difference in change in healthcare utilization between people with scans showing elevated and non-elevated beta-amyloid.

Economic costs of family caregiving for persons with advanced stage cancer: a longitudinal cohort study.

PURPOSE: To form a multifaceted picture of family caregiver economic costs in advanced cancer. METHODS: A multi-site cohort study collected prospective longitudinal data from caregivers of patients with advanced solid tumor cancers. Caregiver survey and out-of-pocket (OOP) receipt data were collected biweekly in-person for up to 24 weeks. Economic cost measures attributed to caregiving were as follows: amount of OOP costs, debt accrual, perceived economic situation, and working for pay. Descriptive analysis illustrates economic outcomes over time. Generalized linear mixed effects models asses the association of objective burden and economic outcomes, controlling for subjective burden and other factors. Objective burden is number of activities and instrumental activities of daily living (ADL/IADL) tasks, all caregiving tasks, and amount of time spent caregiving over 24 h. RESULTS: One hundred ninety-eight caregivers, 41% identifying as Black, were followed for a mean period of 16 weeks. Median 2-week out-of-pocket costs were $111. One-third of caregivers incurred debt to care for the patient and 24% reported being in an adverse economic situation. Whereas 49.5% reported working at study visit 1, 28.6% of caregivers at the last study visit reported working. In adjusted analysis, a higher number of caregiving tasks overall and ADL/IADL tasks specifically were associated with lower out-of-pocket expenses, a lower likelihood of working, and a higher likelihood of incurring debt and reporting an adverse economic situation. CONCLUSIONS: Most caregivers of cancer patients with advanced stage disease experienced direct and indirect economic costs. IMPLICATIONS FOR CANCER SURVIVORS: Results support the need to find solutions to lessen economic costs for caregivers of persons with advanced cancer.

Informing a home time measure reflective of quality of life: A data driven investigation of time frames and settings of health care utilization.

OBJECTIVE: To evaluate short- and long-term measures of health care utilization-days in the emergency department (ED), inpatient (IP) care, and rehabilitation in a post-acute care (PAC) facility-to understand how home time (i.e., days alive and not in an acute or PAC setting) corresponds to quality of life (QoL). DATA SOURCES: Survey data on community-residing veterans combined with multipayer administrative data on health care utilization. STUDY DESIGN: VA or Medicare health care utilization, quantified as days of care received in the ED, IP, and PAC in the 6 and 18 months preceding survey completion, were used to predict seven QoL-related measures collected during the survey. Elastic net machine learning was used to construct models, with resulting regression coefficients used to develop a weighted utilization variable. This was then compared with an unweighted count of days with any utilization. PRINCIPAL FINDINGS: In the short term (6 months), PAC utilization emerged as the most salient predictor of decreased QoL, whereas no setting predominated in the long term (18 months). Results varied by outcome and time frame, with some protective effects observed. In the 6-month time frame, each weighted day of utilization was associated with a greater likelihood of activity of daily living deficits (0.5%, 95% CI: 0.1%-0.9%), as was the case with each unweighted day of utilization (0.6%, 95% CI: 0.3%-1.0%). The same was true in the 18-month time frame (for both weighted and unweighted, 0.1%, 95% CI: 0.0%-0.3%). Days of utilization were also significantly associated with greater rates of instrumental ADL deficits and fair/poor health, albeit not consistently across all models. Neither measure outperformed the other in direct comparisons. CONCLUSIONS: These results can provide guidance on how to measure home time using multipayer administrative data. While no setting predominated in the long term, all settings were significant predictors of QoL measures.

Design and analysis of outcomes following SARS-CoV-2 infection in veterans.

BACKGROUND: Understanding how SARS-CoV-2 infection impacts long-term patient outcomes requires identification of comparable persons with and without infection. We report the design and implementation of a matching strategy employed by the Department of Veterans Affairs' (VA) COVID-19 Observational Research Collaboratory (CORC) to develop comparable cohorts of SARS-CoV-2 infected and uninfected persons for the purpose of inferring potential causative long-term adverse effects of SARS-CoV-2 infection in the Veteran population. METHODS: In a retrospective cohort study, we identified VA health care system patients who were and were not infected with SARS-CoV-2 on a rolling monthly basis. We generated matched cohorts within each month utilizing a combination of exact and time-varying propensity score matching based on electronic health record (EHR)-derived covariates that can be confounders or risk factors across a range of outcomes. RESULTS: From an initial pool of 126,689,864 person-months of observation, we generated final matched cohorts of 208,536 Veterans infected between March 2020-April 2021 and 3,014,091 uninfected Veterans. Matched cohorts were well-balanced on all 39 covariates used in matching after excluding patients for: no VA health care utilization; implausible age, weight, or height; living outside of the 50 states or Washington, D.C.; prior SARS-CoV-2 diagnosis per Medicare claims; or lack of a suitable match. Most Veterans in the matched cohort were male (88.3%), non-Hispanic (87.1%), white (67.2%), and living in urban areas (71.5%), with a mean age of 60.6, BMI of 31.3, Gagne comorbidity score of 1.4 and a mean of 2.3 CDC high-risk conditions. The most common diagnoses were hypertension (61.4%), diabetes (34.3%), major depression (32.2%), coronary heart disease (28.5%), PTSD (25.5%), anxiety (22.5%), and chronic kidney disease (22.5%). CONCLUSION: This successful creation of matched SARS-CoV-2 infected and uninfected patient cohorts from the largest integrated health system in the United States will support cohort studies of outcomes derived from EHRs and sample selection for qualitative interviews and patient surveys. These studies will increase our understanding of the long-term outcomes of Veterans who were infected with SARS-CoV-2.

Association between patient-reported social, behavioral, and health factors and emergency department visits in high-risk VA patients.

RESEARCH OBJECTIVE: To identify patient-reported social risk, behavioral, and health factors associated with emergency department (ED) utilization in high-risk Veterans Affairs (VA) patients. DATA SOURCES: Patient survey, VA, Medicare data. STUDY DESIGN: Prospective cohort study using multivariable logistic regression to identify patient-reported factors associated with all-cause and ambulatory care sensitive condition (ACSC)-related ED visits among VA patients at high risk for hospitalization or death. DATA EXTRACTION METHODS: Patient-reported measures derived from a 2018 survey sent to 10,000 VA patients; clinical and demographic characteristics derived from VA data; ED visits derived from VA and Medicare claims. PRINCIPAL FINDINGS: Among 4680 survey respondents, 52.5% and 16.3% experienced an all-cause or ACSC-related ED visit in the following year, respectively. An ED visit was more likely among individuals with functional status limitations (6.0% points (Confidence Interval [CI] 0.017-0.103)) and transportation barriers (5.2% points [CI 0.005-0.099]). An ACSC-related ED visit was more likely among individuals with functional status limitations (3.2% points [CI 0.003-0.062]) and self-rated poorer health (7.4% points (CI 0.030-0.119) poor; 6.2% points (CI 0.029-0.096) fair; 4.1% points (CI 0.009-0.073) good; compared with excellent/very good). CONCLUSIONS: Patient-reported factors not present in most electronic health records were significantly associated with future ED visits in high-risk VA patients.

Racial inequality in functional trajectories between Black and White U.S. veterans.

BACKGROUND: Racial inequality in functional trajectories has been well documented in the U.S. civilian population but has not been explored among Veterans. Our objectives were to: (1) assess how functional trajectories differed for Black and White Veterans aged ≥50 and (2) explore how socioeconomic, psychosocial, and health-related factors altered the relationship between race and function. METHODS: We conducted a prospective, longitudinal analysis using the 2006-2016 Health and Retirement Study. The study cohort included 3700 Veterans who self-identified as Black or White, responded to baseline psychosocial questionnaires, and were community-dwelling on first observation. We used stepwise and stratified linear mixed effects models of biannually assessed functional limitations. The outcome measure was as a count of functional limitations. Race was measured as respondent self-identification as Black or White. Demographic measures included gender and age. Socioeconomic resources included partnership status, education, income, and wealth. Psychosocial stressors included exposure to day-to-day and major discrimination, traumatic life events, stressful life events, and financial strain. Health measures included chronic and mental health diagnoses, smoking, rurality, and use of Veterans Affairs services. RESULTS: Black Veterans developed functional limitations at earlier ages and experienced faster functional decline than White Veterans between the ages of 50 and 70, with convergence occurring at age 85. Once we accounted for economic resources and psychosocial stressors in multivariable analyses, the association between race and the number of functional limitations was no longer statistically significant. Lower wealth, greater financial strain, and traumatic life events were significantly associated with functional decline. CONCLUSIONS: Health systems should consider how to track Veterans' function earlier in the life course to ensure that Black Veterans are able to get timely access to services that may slow premature functional decline. Providers may benefit from training about the role of economic resources and psychosocial stressors in physical health outcomes.

Short-term effects of comprehensive caregiver supports on caregiver outcomes.

OBJECTIVE: To estimate the association of the Veterans Health Administration (VHA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) implemented in 2011 with caregiver health and health care use. DATA SOURCES: VHA claims and electronic health records from May 2009 to May 2018. STUDY DESIGN: Using a retrospective, pre-post study design with inverse probability of treatment weights to address selection into treatment, we examine the association of PCAFC on caregivers who are veterans: (1) outpatient primary, specialty, and mental health care visits; (2) probability of uncontrolled hypertension and anxiety/depression; and (3) VHA health care costs. We compare outcomes for caregivers approved for PCAFC (treatment) to caregivers denied PCAFC (comparison). DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: In the year pre-application, we observe similar probabilities of having any VHA primary care (~36%), VHA specialty care (~24%), and VHA or VHA-purchased mental health care (~22%) for treatment and comparison caregivers. In the year post-application, treated caregivers had a 5.89 percentage point larger probability of any outpatient VHA primary care (p = 0.002) and 4.34 percentage points larger probability of any outpatient mental health care use (p = 0.014). Post-application, probabilities of having uncontrolled hypertension or diagnosed anxiety/depression were higher for both treated and comparison groups. In the second year post-application, treated caregivers had a 1.88 percentage point larger probability of uncontrolled hypertension (p = 0.019) and 4.68 percentage points larger probability of diagnosed anxiety/depression (predicted probabilities: treated = 0.30; comparison = 0.25; p = 0.005). We find no evidence of differences in VHA total costs by PCAFC status. CONCLUSIONS: Our findings that PCAFC enrollment is associated with increased health care diagnosis and service use may reflect improved access for previously unmet needs in the population of veteran caregivers for veterans in PCAFC. The costs and value of these increases can be weighed against other effects of the program to inform national policies supporting caregivers.

Amyloid-ß PET Scan Results Disclosure and Care-Partner Emotional Well-Being Over Time.

BACKGROUND: Diagnostic tests, such as amyloid-ß positron emission tomography (PET) scans, can increase appropriate therapeutic management for the underlying causes of cognitive decline. To evaluate the full utility of this diagnostic tool, information is needed on whether results from amyloid-ß PET scans influence care-partner outcomes. OBJECTIVE: This study examines the extent to which previous disclosure of elevated amyloid (suggestive of Alzheimer's disease (AD) etiology) versus not-elevated amyloid (not suggestive of AD etiology) is associated with changes in care-partner wellbeing. METHODS: The study used data derived from a national longitudinal survey of Medicare beneficiaries (n = 921) with mild cognitive impairment (MCI) or dementia and their care-partners. Care-partner wellbeing outcomes included depressive symptoms (PHQ-8), subjective burden (4-item Zarit burden score), and a 3-item measure of loneliness. Change was measured between 4 (Time 1) and 18 (Time 2) months after receiving the scan results. Adjusted linear regression models regressed change (Time 2-Time 1) in each outcome on scan result. RESULTS: Care-partners were primarily white, non-Hispanic, college-educated, and married to the care recipient. Elevated amyloid was not associated with statistically significant Time 1 differences in outcomes or with statistically significant changes in depressive symptoms 0.22 (-0.18, 0.61), subjective burden 0.36 (-0.01, 0.73), or loneliness 0.15 (-0.01, 0.32) for care-partners from one time point to another. CONCLUSION: Given advances in AD biomarker testing, future research in more diverse samples is needed to understand the influence of scan results on care-partner wellbeing across populations.

Making the Informal Formal: Discussing and Completing Advance Care Plans in Care Dyads with Cognitive Impairment.

Background: Discussing advance care planning (ACP) with care partners may be a steppingstone to the completion of advance directives (ADs) for persons with cognitive impairment (PwCIs). Objectives: To examine whether PwCI-reported occurrence of and PwCI-care partner agreement about ACP discussions are associated with completion of ADs. Design and Subjects: We conducted a secondary, cross-sectional analysis of data from 1672 PwCI-care partner dyads in the BLINDED study. PwCIs were Medicare beneficiaries in the US, aged >65 years, and diagnosed with mild cognitive impairment or dementia. Care partners were identified by PwCIs as being most involved in their health care. Measurements: PwCIs' completion of ADs was determined by 1 or more affirmative responses to dichotomous indicators for formalizing a living will, medical directive, or durable power of attorney for health care. Discussion occurrence was based on PwCI reports and agreement between PwCI and care partner reports of prior conversations about PwCIs' ACP preferences between PwCIs and care partners. Results: In logistic regression models adjusted for PwCI and care partner characteristics, PwCIs who had (vs. had not) discussed ACP were 10% more likely to complete ADs. PwCIs from dyads agreeing (vs. disagreeing) a discussion occurred were 7% more likely to complete ADs. PwCIs from care dyads in agreement (vs. disagreement) about non-discussion were 11% less likely to formalize ADs. Conclusions: Discussing ACP with care partners plays a direct, positive role in completing ADs among PwCIs. Health care providers who approach ACP as a dyadic, communicative decision-making process from the outset may facilitate PwCIs' uptake of ADs.

Disparities in Chronic Kidney Disease Progression by Medicare Advantage Enrollees.

INTRODUCTION: The prevalence of chronic kidney disease (CKD) in Medicare beneficiaries has quadrupled in the past 2 decades, but little is known about risk factors affecting the progression of CKD. This study aims to understand the progression in Medicare Advantage enrollees and whether it differs by provider recognition of CKD, race and ethnicity, or geographic location. In a large cohort of Medicare Advantage (MA) enrollees, we examined whether CKD progression, up to 5 years after study entry, differed by demographic and clinical factors and identified additional risk factors of CKD progression. METHODS: In a cohort of 1,002,388 MA enrollees with CKD stages 1-4 based on 2013-2018 labs, progression was estimated using a mixed-effects model that adjusted for demographics, geographic location, comorbidity, urine albumin-to-creatinine ratio, clinical recognition via diagnosed CKD, and time-fixed effects. Race and ethnicity, geographic location, and clinical recognition of CKD were interacted with time in 3 separate regression models. RESULTS: Mean (median) follow-up was 3.1 (3.0) years. Black and Hispanic MA enrollees had greater kidney function at study entry than other beneficiaries, but their kidney function declined faster. MA enrollees with clinically recognized CKD had estimated glomerular filtration rate levels that were 18.6 units (95% confidence interval [CI]: 18.5-18.7) lower than levels of unrecognized patients, but kidney function declined more slowly in enrollees with clinical recognition. There were no differences in CKD progression by geography. After removal of the race coefficient from the eGFR equation in a sensitivity analysis, kidney function was much lower in all years among Black MA enrollees, but patterns of progression remained the same. DISCUSSION/CONCLUSIONS: These results suggest that patients with clinically recognized CKD and racial and ethnic minorities merit closer surveillance and management to reduce their risk of faster progression.

Annual wellness visits and care management before and after dialysis initiation.

INTRODUCTION: Demands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis. METHODS: We used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014-2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation. RESULTS: In the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6-9 (odds ratio (OR) = 0.59, 95 % CI: 0.37-0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01-2.52) or a PCP (OR = 15.65, 95 % CI: 9.26-26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39-0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07-2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88-6.34). CONCLUSIONS: AWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.