Building the Infrastructure to Integrate Social Care in a Safety Net Health System.

A recent National Academies report recommended that health systems invest in new infrastructure to integrate social and medical care. Although many health systems routinely screen patients for social concerns, few health systems achieve the recommended model of integration. In this critical case study in an urban safety net health system, we describe the human capital, operational redesign, and financial investment needed to implement the National Academy recommendations. Using data from this case study, we estimate that other health systems seeking to build and maintain this infrastructure would need to invest $1 million to $3 million per year. While health systems with robust existing resources may be able to bootstrap short-term funding to initiate this work, we conclude that long-term investments by insurers and other payers will be necessary for most health systems to achieve the recommended integration of medical and social care. Researchers seeking to test whether integrating social and medical care leads to better patient and population outcomes require access to health systems and communities who have already invested in this model infrastructure. (Am J Public Health. 2024;114(6):619-625. https://doi.org/10.2105/AJPH.2024.307602).

Complex Transitions from Skilled Nursing Facility to Home: Patient and Caregiver Perspectives.

BACKGROUND: Patients who undergo the complex series of transitions from the hospital to a skilled nursing facility (SNF) back to home represent a unique patient population with multiple comorbidities and impaired functional abilities. The needs and outcomes of patients who are discharged from the hospital to SNF before returning home are understudied in care transitions scholarship. OBJECTIVE: To study the patient and caregiver challenges and perspectives on transitions from the hospital to the SNF and back to home. DESIGN: Between 48 h and 1 week after discharge from the SNF, semi-structured interviews were performed with a convenience sample of patients and caregivers in their homes. Within 1 to 2 weeks after the baseline interview, follow-up interviews were performed over the phone. PARTICIPANTS: A total of 39 interviewees comprised older adults undergoing the series of transitions from hospital to skilled nursing facility to home and their informal caregivers. MAIN MEASURES: A constructionist, grounded-theory approach was used to code the interviews, identify major themes and subthemes, and develop a theoretical model explaining the outcomes of the SNF to home transition. KEY RESULTS: The mean age of the patients was 76.6 years and 64.8 years for the caregivers. Four major themes were identified: comforts of home, information needs, post-SNF care, and independence. Patients noted an extended time away from home and were motivated to return to and remain in the home. Information needs were variably met and affected post-SNF care, including medication management, appointments, and therapy gains and setbacks. Interviewees identified independent function at home as the most important outcome of the transition home. CONCLUSIONS: Post-SNF in home support is needed rapidly after discharge from the SNF to prevent adverse outcomes. In-home support needs to be highly individualized based on a patient's and caregiver's unique situation and needs.

Does targeted cognitive training reduce educational disparities in cognitive function among cognitively normal older adults?

OBJECTIVE: The aim of this study was to investigate educational differences in treatment responses to memory, reasoning, and speed of processing cognitive training relative to no-contact control. METHODS: Secondary analyses of the Advanced Cognitive Training for Independent and Vital Elderly trial were conducted. Two thousand eight hundred older adults were randomized to memory, reasoning, or speed of processing training or no-contact control. A repeated-measures mixed-effects model was used to investigate immediate post-training and 1-year outcomes with sensitivity analyses out to 10 years. Outcomes were as follows: (1) memory composite of Hopkins Verbal Learning Test, Rey Auditory Verbal Learning Test, and Rivermead Behavioral Memory Test; (2) reasoning composite of letter series, letter sets, and word series; and (3) speed of processing measured using three trials of useful field of view and the digit symbol substitution test. RESULTS: The effects of reasoning and memory training did not differ by educational attainment. The effect of speed of processing training did. Those with fewer than 12 years of education experienced a 50% greater effect on the useful field of view test compared with those with 16 or more years of education. The training advantage for those with fewer than 12 years of education was maintained to 3 years post-training. CONCLUSION: Older adults with less than a secondary education are at elevated risk of dementia, including Alzheimer's disease. The analyses here indicate that speed of processing training is effective in older adults with low educational attainment.

Sex and Race Differences in the Relationship between Obesity and C-Reactive Protein.

C-reactive protein (CRP) is a risk factor for cardiovascular disease and mortality; it is known to be positively associated with obesity but there is some evidence that this association differs by race or sex. We used nationally representative data of adults aged >50 years to investigate sex and race modifiers of the associations between obesity and CRP in non-Hispanic White males (n=3,517) and females (n=4,658), and non-Hispanic Black males (n=464) and females (n=826). Using multiple linear regression models with the natural logarithm of CRP as the dependent variable, we sequentially included body mass index (BMI), a body shape index (ABSI), and socioeconomic, health and health behavior covariates in the model. The association between BMI and CRP was significantly stronger in females than males. Obese White females had mean CRP values slightly above 3 mg/liter (vs 2 for White males) and Black females had mean CRP values >4 mg/liter (vs 3 for Black males). More than 50% of Black females in the United States have obesity. Continued research into racial and sex differences in the relationship between obesity, inflammation, and health risks may ultimately lead to more personalized weight loss recommendations.

Task-Oriented Exercise to Reduce Activities of Daily Living Disability in Vulnerable Older Adults: A Feasibility Study of the 3-Step Workout for Life.

The purpose of this feasibility study was to evaluate the 3-Step Workout for Life program, a 10-week exercise program that included moderate-intensity muscle strength training followed by task-oriented training. Fourteen participants completed the program (mean age = 73 years; SD = 6.83). The Box and Block test (Z = -2.24, p = .03) and the 30-s chair stand test (Z = -2.21, p = .03) indicate improved physical functioning of the upper and lower extremities. More importantly, results of the function component from the Late-Life Function and Disability Instrument (Z = -2.04, p = .04) and motor skills scale from the Assessment of Motor and Process Skills (Z = -2.97, p = .003) indicate subjective and objective improvements on performing activities of daily living. Supplementing moderate-intensity muscle strength exercise with task-oriented training components is feasible. Preliminary data support the effectiveness of 3-Step Workout for Life in reducing late-life disability.

Errors in self-reports of health services use: impact on alzheimer disease clinical trial designs.

BACKGROUND: Most Alzheimer disease clinical trials that compare the use of health services rely on reports of caregivers. The goal of this study was to assess the accuracy of self-reports among older adults with Alzheimer disease and their caregiver proxy respondents. This issue is particularly relevant to Alzheimer disease clinical trials because inaccuracy can lead both to loss of power and increased bias in study outcomes. METHODS: We compared respondent accuracy in reporting any use and in reporting the frequency of use with actual utilization data as documented in a comprehensive database. We next simulated the impact of underreporting and overreporting on sample size estimates and treatment effect bias for clinical trials comparing utilization between experimental groups. RESULTS: Respondents self-reports have a poor level of accuracy with κ-values often below 0.5. Respondents tend to underreport use even for rare events such as hospitalizations and nursing home stays. In analyses simulating underreporting and overreporting of varying magnitude, we found that errors in self-reports can increase the required sample size by 15% to 30%. In addition, bias in the reported treatment effect ranged from 3% to 18% due to both underreporting and overreporting errors. CONCLUSIONS: Use of self-report data in clinical trials of Alzheimer disease treatments may inflate sample size needs. Even when adequate power is achieved by increasing sample size, reporting errors can result in a biased estimate of the true effect size of the intervention.

Food resources and kitchen skills plus aerobic training (FoRKS+) for black adults with hypertension: A pilot trial protocol.

BACKGROUND: Midlife hypertension is associated with cognitive decline and Alzheimer's disease and related dementia (ADRD), suggesting that blood pressure control may be a therapeutic target for dementia prevention. Given excess hypertension in non-Hispanic Black (NHB) adults, blood pressure control may also reduce ADRD disparities. We describe a pilot randomized controlled trial (RCT) to evaluate the feasibility and preliminary efficacy of a multicomponent lifestyle-based intervention versus enhanced usual care on cognition among middle-aged NHB adults. METHODS AND STUDY DESIGN: The Food Resources and Kitchen Skills plus Aerobic Training (FoRKS+) study is a 2-arm, single-blinded trial that compares those receiving the FoRKS+ program (target N = 64) versus those receiving enhanced usual care (target N = 64) in local federally-qualified health centers. Key eligibility criteria include self-identified NHB adults between ages 35-75 with a mean systolic blood pressure ≥ 130 mm/Hg obtained from 24-h ambulatory blood pressure monitoring. The FoRKS+ program includes 5 weeks of hypertension self-management courses, 11 weeks of nutrition courses, and 12 weeks of aerobic training in dietitian and health coach-led virtual groups. We will collect data on primary cognitive outcomes, feasibility, hypothesized intervention mediators and moderators, and demographic and health covariates at baseline, near intervention weeks 16-, and 28 (primary outcome assessment), and week 52 follow-up. We will use mixed-effects modeling to examine intervention effects on cognition. DISCUSSION: This pilot RCT will examine the feasibility and preliminary effects of a multicomponent lifestyle intervention on cognitive function in NHB adults, which may have implications for reducing health disparities in ADRD.

Hospital and nursing home use from 2002 to 2008 among U.S. older adults with cognitive impairment, not dementia in 2002.

Little is known about health care use in the cognitive impairment, not dementia (CIND) subpopulation. Using a cohort of 7130 persons aged 71 years or over from the Health and Retirement Survey, we compared mean and total health care use from 2002 to 2008 for those with no cognitive impairment, CIND, or dementia in 2002. Cognitive status was determined using a validated method based on self or proxy interview measures. Health care use was also based on self or proxy reports. On the basis of the Health and Retirement Survey, the CIND subpopulation in 2002 was 5.3 million or 23% of the total population 71 years of age or over. Mean hospital nights was similar and mean nursing home nights was less in persons with CIND compared with persons with dementia. The CIND subpopulation, however, had more total hospital and nursing home nights--71,000 total hospital nights and 223,000 total nursing home nights versus 32,000 hospital nights and 138,000 nursing home nights in the dementia subpopulation. A relatively large population and high health care use result in a large health care impact of the CIND subpopulation.

Delivering Food Resources and Kitchen Skills (FoRKS) to Adults with Food Insecurity and Hypertension: A Pilot Study.

Food insecurity affects nearly 50 million Americans and is linked to cardiovascular disease risk factors and health disparities. The purpose of this single-arm pilot study was to determine the feasibility of a 16-week dietitian-led lifestyle intervention to concurrently address food access, nutrition literacy, cooking skills, and hypertension among safety-net primary care adult patients. The Food Resources and Kitchen Skills (FoRKS) intervention provided nutrition education and support for hypertension self-management, group kitchen skills and cooking classes from a health center teaching kitchen, medically tailored home-delivered meals and meal kits, and a kitchen toolkit. Feasibility and process measures included class attendance rates and satisfaction and social support and self-efficacy toward healthy food behaviors. Outcome measures included food security, blood pressure, diet quality, and weight. Participants (n = 13) were on average {mean (SD)} aged 58.9 ± 4.5 years, 10 were female, and 12 were Black or African American. Attendance averaged 19 of 22 (87.1%) classes and satisfaction was rated as high. Food self-efficacy and food security improved, and blood pressure and weight declined. FoRKS is a promising intervention that warrants further evaluation for its potential to reduce cardiovascular disease risk factors among adults with food insecurity and hypertension.

Design and baseline characteristics of the Cognitive and Aerobic Resilience for the Brain (CARB) study.

BACKGROUND: Treatments that delay progression of cognitive impairment in older adults are of great public health significance. This manuscript outlines the protocol, recruitment, baseline characteristics, and retention for a randomized controlled trial of cognitive and aerobic physical training to improve cognition in individuals with subjective cognitive dysfunction, the "Cognitive and Aerobic Resilience for the Brain" (CARB) study. METHODS: Community-dwelling, older adults with self-reported memory loss were randomly assigned to receive either computer-based cognitive training, aerobic physical training, combined cognitive and physical training, or education control. Treatment was delivered 2- to 3-times per week in 45- to 90-min sessions for 12 weeks by trained facilitators videoconferencing into subject's home. Outcome assessments of were taken at the baseline, immediately following training, and 3-months after training. RESULTS: 191 subjects were randomized into the trial (mean age, 75.5 years; 68% female; 20% non-white; mean education, 15.1 years; 30% with 1+ APOE e4 allele). The sample was generally obese, hypertensive, and many were diabetic, while cognition, self-reported mood, and activities of daily living were in the normal range. There was excellent retention throughout the trial. Interventions were completed at high rates, participants found the treatments acceptable and enjoyable, and outcome assessments were completed at high rates. CONCLUSIONS: This study was designed to determine the feasibility of recruiting, intervening, and documenting response to treatment in a population at risk for progressive cognitive decline. Older adults with self-reported memory loss were enrolled in high numbers and were well engaged with the intervention and outcome assessments.

Continuous Glucose Monitoring and Other Wearable Devices to Assess Hypoglycemia among Older Adult Outpatients with Diabetes Mellitus.

BACKGROUND: Hypoglycemia (HG) causes symptoms that can be fatal, and confers risk of dementia. Wearable devices can improve measurement and feedback to patients and clinicians about HG events and risk. OBJECTIVES: The aim of the study is to determine whether vulnerable older adults could use wearables, and explore HG frequency over 2 weeks. METHODS: First, 10 participants with diabetes mellitus piloted a continuous glucometer, physical activity monitor, electronic medication bottles, and smartphones facilitating prompts about medications, behaviors, and symptoms. They reviewed graphs of glucose values, and were asked about the monitoring experience. Next, a larger sample (N = 70) wore glucometers and activity monitors, and used the smartphone and bottles, for 2 weeks. Participants provided feedback about the devices. Descriptive statistics summarized demographics, baseline experiences, behaviors, and HG. RESULTS: In the initial pilot, 10 patients aged 50 to 85 participated. Problems addressed included failure of the glucometer adhesive. Patients sought understanding of graphs, often requiring some assistance with interpretation. Among 70 patients in subsequent testing, 67% were African-American, 59% were women. Nearly one-fourth (23%) indicated that they never check their blood sugars. Previous HG was reported by 67%. In 2 weeks of monitoring, 73% had HG (glucose ≤70 mg/dL), and 42% had serious, clinically significant HG (glucose under 54 mg/dL). Eight patients with HG also had HG by home-based blood glucometry. Nearly a third of daytime prompts were unanswered. In 24% of participants, continuous glucometers became detached. CONCLUSION: Continuous glucometry occurred for 2 weeks in an older vulnerable population, but devices posed wearability challenges. Most patients experienced HG, often serious in magnitude. This suggests important opportunities to improve wearability and decrease HG frequency among this population.

A comparison and cross-validation of models to predict basic activity of daily living dependency in older adults.

BACKGROUND: A simple method of identifying elders at high risk for activity of daily living (ADL) dependence could facilitate essential research and implementation of cost-effective clinical care programs. OBJECTIVE: We used a nationally representative sample of 9446 older adults free from ADL dependence in 2006 to develop simple models for predicting ADL dependence at 2008 follow-up and to compare the models to the most predictive published model. Candidate predictor variables were those of published models that could be obtained from interview or medical record data. METHODS: Variable selection was performed using logistic regression with backward elimination in a two-third random sample (n = 6233) and validated in a one-third random sample (n = 3213). Model fit was determined using the c-statistic and evaluated vis-a-vis our replication of a published model. RESULTS: At 2-year follow-up, 8.0% and 7.3% of initially independent persons were ADL dependent in the development and validation samples, respectively. The best fitting, simple model consisted of age and number of hospitalizations in past 2 years, plus diagnoses of diabetes, chronic lung disease, congestive heart failure, stroke, and arthritis. This model had a c-statistic of 0.74 in the validation sample. A model of just age and number of hospitalizations achieved a c-statistic of 0.71. These compared with a c-statistic of 0.79 for the published model. Sensitivity analyses demonstrated model robustness. CONCLUSIONS: Models based on a widely available data achieve very good validity for predicting ADL dependence. Future work will assess the validity of these models using medical record data.

Environments and situations as correlates of eating and drinking among women living with obesity and urban poverty.

Objective: One path to improving weight management may be to lessen the self-control burden of physical activity and healthier food choices. Opportunities to lessen the self-control burden might be uncovered by assessing the spatiotemporal experiences of individuals in daily context. This report aims to describe the time, place, and social context of eating and drinking and 6-month weight change among 209 midlife women (n = 113 African-American) with obesity receiving safety-net primary care. Methods: Participants completed baseline and 6-month weight measures, observations and interviews regarding obesogenic cues in the home environment, and up to 12 ecological momentary assessments (EMA) per day for 30 days inquiring about location, social context, and eating and drinking. Results: Home was the most common location (62%) at times of EMA notifications. Participants reported "yes" to eating or drinking at the time of nearly one in three (31.1% ± 13.2%) EMA notifications. Regarding social situations, being alone was significantly associated with less frequent eating and drinking (OR = 0.75) unless at work in which case being alone was significantly associated with a greater frequency of eating or drinking (OR = 1.43). At work, eating was most common late at night, whereas at home eating was most frequent in the afternoon and evening hours. However, eating and drinking frequency was not associated with 6-month weight change. Conclusions: Home and work locations, time of day, and whether alone may be important dimensions to consider in the pursuit of more effective weight loss interventions. Opportunities to personalize weight management interventions, whether digital or human, and lessen in-the-moment self-control burden might lie in identifying times and locations most associated with caloric consumption.Clinical trial registration: NCT03083964 in clinicaltrials.gov.

Improving Care for People Living With Dementia and Diabetes: Applying the Human-Centered Design Process to Continuous Glucose Monitoring.

People with Alzheimer's disease or related dementias and diabetes mellitus (ADRD-DM) are at high risk for hypoglycemic events. Their cognitive impairment and psychosocial situation often hinder detection of hypoglycemia. Extending use and benefits of continuous glucose monitoring (CGM) to people with ADRD-DM could improve hypoglycemia detection, inform care, and reduce adverse events. However, cognitive impairment associated with ADRD presents unique challenges for CGM use. This commentary proposes applying the human-centered design process to CGM, investigating design solutions or interventions needed to integrate CGM into the health care of patients with ADRD-DM. With this process, we can identify and inform CGM designs for people with ADRD-DM, broadening CGM access, increasing detection and treatment of the silent threat posed by hypoglycemia.

Multicomponent behavioral intervention to reduce exposure to anticholinergics in primary care older adults.

OBJECTIVE: To test the impact of a multicomponent behavioral intervention to reduce the use of high-risk anticholinergic medications in primary care older adults. DESIGN: Cluster-randomized controlled trial. SETTING AND PARTICIPANTS: Ten primary care clinics within Eskenazi Health in Indianapolis. INTERVENTION: The multicomponent intervention included provider- and patient-focused components. The provider-focused component was computerized decision support alerting of the presence of a high-risk anticholinergic and offering dose- and indication-specific alternatives. The patient-focused component was a story-based video providing education and modeling an interaction with a healthcare provider resulting in a medication change. Alerts within the medical record triggered staff to play the video for a patient. Our design intended for parallel, independent priming of both providers and patients immediately before an outpatient face-to-face interaction. MEASUREMENT: Medication orders were extracted from the electronic medical record system to evaluate the prescribing behavior and population prevalence of anticholinergic users. The intervention was introduced April 1, 2019, through March 31, 2020, and a preintervention observational period of April 1, 2018, through March 31, 2019, facilitated difference in difference comparisons. RESULTS: A total of 552 older adults had visits at primary care sites during the study period, with mean age of 72.1 (SD 6.4) years and 45.3% African American. Of the 259 provider-focused alerts, only three (1.2%) led to a medication change. Of the 276 staff alerts, 4.7% were confirmed to activate the patient-focused intervention. The intervention resulted in no significant differences in either the number of discontinue orders for anticholinergics (intervention: two additional orders; control: five fewer orders, p = 0.7334) or proportion of the population using anticholinergics following the intervention (preintervention: 6.2% and postintervention: 5.1%, p = 0.6326). CONCLUSION: This multicomponent intervention did not reduce the use of high-risk anticholinergics in older adults receiving primary care. Improving nudges or a policy-focused component may be necessary to reduce use of high-risk medications.

Reducing anticholinergic medication exposure among older adults using consumer technology: Protocol for a randomized clinical trial.

INTRODUCTION: A growing body of scientific evidence points to the potentially harmful cognitive effects of anticholinergic medications among older adults. Most interventions designed to promote deprescribing of anticholinergics have directly targeted healthcare professionals and have had mixed results. Consumer-facing technologies may provide a unique benefit by empowering patients and can complement existing healthcare professional-centric efforts. METHODS: We initiated a randomized clinical trial to evaluate the effectiveness of a patient-facing mobile application (Brain Safe app) compared to an attention control medication list app in reducing anticholinergic exposure among community-dwelling older adults. Study participants are adults aged 60 years and above, currently using at least one prescribed strong anticholinergic, and receiving primary care. The trial plans to enroll a total of 700 participants, randomly allocated in 1:1 proportion to the two study arms. Participants will have the Brain Safe app (intervention arm) or attention control medication list app (control arm) loaded onto a smartphone (study provided or personal device). All participants will be followed for 12 months and will have data collected at baseline, at 6 months, and 12 months by blinded outcome assessors. The primary outcome of the study is anticholinergic exposure measured as total standard daily dose (TSDD) computed from medication prescription electronic records. Secondary outcomes of the study are cognitive function and health-related quality of life. DISCUSSION: A consumer-facing intervention to promote deprescribing of potentially high-risk medications can be part of a multi-pronged approach to reduce inappropriate medication use among older adult patients. Delivering a deprescribing intervention via a mobile app is a novel approach and may hold great promise to accelerate deployment of medication safety initiatives across diverse patient populations. CLINICAL TRIAL REGISTRATION: Registered at ClinicalTrials.gov on October 10, 2019. Identifier number: NCT04121858.

Life-cycle nitrogen trifluoride emissions from photovoltaics.

Amorphous- and nanocrystalline-silicon thin-film photovoltaic modules are made in high-throughput manufacturing lines that necessitate quickly cleaning the reactor. Using NF3, a potent greenhouse gas, as the cleaning agent triggered concerns as recent reports reveal that the atmospheric concentrations of this gas have increased significantly. We quantified the life-cycle emissions of NF3 in photovoltaic (PV) manufacturing, on the basis of actual measurements at the facilities of a major producer of NF3 and of a manufacturer of PV end-use equipment. From these, we defined the best practices and technologies that are the most likely to keep worldwide atmospheric concentrations of NF3 at very low radiative forcing levels. For the average U.S. insolation and electricity-grid conditions, the greenhouse gas (GHG) emissions from manufacturing and using NF3 in current PV a-Si and tandem a-Si/nc-Si facilities add 2 and 7 g CO2(eq)/kWh, which can be displaced within the first 1-4 months of the PV system life.

Exercise adoption among older, low-income women at risk for cardiovascular disease.

Using an expanded Social Cognitive Theory (SCT) model, we hypothesized that self-efficacy, outcome expectations, and exercise self-definition would predict exercise adoption. This secondary analysis examined data from a prospective single-group study of low-income women who received a physician screen and referral to a community-based, free exercise program. The sample included 190 older, low-income women with a mean age of 64 years, the majority of whom were African American (66%) and had at least one cardiovascular risk factor (92%). Baseline values of self-efficacy, outcome expectations, and exercise self-definition were measured using instruments developed for the study. Exercise adoption was defined as the number of exercise sessions completed over 8 weeks. Our hypothesis was tested using hierarchical multiple regression. The mean number of exercise sessions completed over the 8-week period was 5.7 out of a recommended 24. Value of Exercise scores, a subscale of the Exercise Self-Definition scale, predicted exercise adoption. Self-efficacy and outcome expectations were not predictive. The significance of Value of Exercise scores reinforces the importance of expanding SCT with additional variables such as exercise self-definition. Future work should emphasize the social and environmental factors that form an important part of SCT.

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults.

BACKGROUND: Mobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use. OBJECTIVE: This study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics. METHODS: Twenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit. RESULTS: Overall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to "Good" to "Excellent" usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians. CONCLUSION: Consumer-facing technology can be a low-cost, scalable intervention to improve older adults' medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change.

Depressive symptom severity as a predictor of attendance in the HOME behavioral weight loss trial.

OBJECTIVE: We examined whether total depressive symptoms and symptom clusters predicted behavioral weight loss attendance among economically disadvantaged adults in a randomized controlled trial. METHODS: 150 adults with obesity were randomized to 12 months of in-person, video conference, or enhanced usual care weight loss groups. We categorized percent session attendance in the intervention arms into three levels: no attendance, poorer attendance, and better attendance. RESULTS: Higher baseline Patient Health Questionnaire-8 (PHQ-8) score was associated with a greater odds of being in the poorer versus better attendance group (OR = 1.94, 95% CI: 1.02-3.69, p = .04). A similar relationship between PHQ-8 score and odds of being in the no attendance versus better attendance group was observed but was not statistically significant (OR = 1.63, 95% CI: 0.94-2.81, p = .08). Both cognitive/affective and somatic clusters contributed to the depressive symptoms-attendance relationships. CONCLUSION: Greater depressive symptoms at the start of a behavioral weight loss program may predict poorer subsequent session attendance. Screening for and addressing depression may improve intervention uptake. ClinicalTrials.gov Identifier: NCT02057952.