Rural-urban prescribing patterns by primary care and behavioral health providers in older adults with serious mental illness.

BACKGROUND: Older adults with serious mental illness (SMI) often have multiple comorbidities and complex medication schedules. Shortages of behavioral health specialists (BHSs), especially in rural areas, frequently make primary care providers (PCPs) the only clinician managing this complex population. The aim of this study was to describe rural/urban psychiatric medication prescribing in older adults with SMI by PCPs and BHSs, and by clinician type. METHODS: This retrospective descriptive analysis used 2018 Medicare data to identify individuals with a bipolar, major depression, schizophrenia, or psychosis diagnosis and examined medication claims for antianxiety, antidepressants, antipsychotics, hypnotics, and anticonvulsants. Descriptive statistics summarized percentage of medications provided by PCPs and BHSs stratified by rural and urban areas and by drug class. Additional analyses compared psychiatric prescribing patterns by physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs). RESULTS: In urban areas, PCPs prescribed at least 50% of each psychiatric medication class, except antipsychotics, which was 45.2%. BHSs prescribed 40.7% of antipsychotics and less than 25% of all other classes. In rural areas, percentages of psychiatric medications from PCPs were over 70% for each medication class, except antipsychotics, which was 60.1%. Primary care physicians provided most psychiatric medications, between 36%-57% in urban areas and 47%-65% in rural areas. Primary care APRNs provided up to 13% of prescriptions in rural areas, which was more than the amount prescribed by BHS physicians, expect for antipsychotics. Psychiatric mental health APRNs provided up to 7.5% of antipsychotics in rural areas, but their prescribing contribution among other classes ranged between 1.1%-3.6%. PAs provided 2.5%-3.4% of medications in urban areas and this increased to 3.9%-5.1% in rural areas. CONCLUSIONS: Results highlight the extensive roles of PCPs, including APRNs, in managing psychiatric medications for older adults with SMI.

Opioid use disorder Cascade of care framework design: A roadmap.

Unintentional overdose deaths, most involving opioids, have eclipsed all other causes of US deaths for individuals less than 50 years of age. An estimated 2.4 to 5 million individuals have opioid use disorder (OUD) yet a minority receive treatment in a given year. Medications for OUD (MOUD) are the gold standard treatment for OUD however early dropout remains a major challenge for improving clinical outcomes. A Cascade of Care (CoC) framework, first popularized as a public health accountability strategy to stem the spread of HIV, has been adapted specifically for OUD. The CoC framework has been promoted by the NIH and several states and jurisdictions for organizing quality improvement efforts through clinical, policy, and administrative levers to improve OUD treatment initiation and retention. This roadmap details CoC design domains based on available data and potential linkages as individual state agencies and health systems typically rely on limited datasets subject to diverse legal and regulatory requirements constraining options for evaluations. Both graphical decision trees and catalogued studies are provided to help guide efforts by state agencies and health systems to improve data collection and monitoring efforts under the OUD CoC framework.

The impact of the introduction of generic aromatase inhibitors on adherence to hormonal therapy over the full course of 5-year treatment for breast cancer.

BACKGROUND: High out-of-pocket costs (OOPCs) often are found to be inversely associated with adherence to medical treatment. The introduction of generic aromatase inhibitors (GAIs) significantly reduced the OOPCs of patients. The objective of the current study was to explore the impact of the introduction of GAIs on adjuvant hormone therapy (AHT) adherence over the full course of breast cancer treatment. METHODS: Women aged ≥65 years who were diagnosed with hormone receptor-positive breast cancer from 2007 through mid-2009 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Multivariate logistic regression was used to estimate the likelihood of AHT initiation and an interrupted time series model was used to predict the association between the introduction of GAIs and AHT adherence. The model was stratified further using Medicare low-income subsidy (LIS) status. RESULTS: A total of 10,905 women were included, approximately 62.8% of whom initiated AHT within the first year of their breast cancer diagnosis. Adjusted adherence among LIS beneficiaries was 11.4% higher than among non-LIS beneficiaries (P < .001). Non-LIS beneficiaries had an overall decreasing trend of adherence (-0.035; P < .001) prior to the introduction of GAIs. They experienced a 3.4% increase in the slope 6 months after the first GAI, anastrozole, entered the market, and an additional 0.8% increase in the slope 6 months after letrozole and exemestane were introduced (P < .001). Adherence change among LIS patients was small and statistically insignificant. CONCLUSIONS: With the introduction of GAIs, the decrease trend of adherence to therapy atteunated over the course of treatment. Although the successful implementation of the Medicare LIS program minimized the OOPCs for financially vulnerable patients, policymakers should be cautious not to introduce disparities for those who may be of low income but ineligible for such a program.

Opioid-prescribing Outcomes of Medicare Beneficiaries Managed by Nurse Practitioners and Physicians.

BACKGROUND: Primary care providers are at the center of the opioid epidemic. Whether nurse practitioners (NPs) have different opioid-prescribing outcomes from physicians is not known. OBJECTIVE: To examine opioid-prescribing outcomes of Medicare beneficiaries receiving care from NPs and physicians in primary care. RESEARCH DESIGN: We used Medicare data from 2009 to 2013 and a propensity score-weighted analysis. SUBJECTS: Beneficiaries residing in states in which NPs are able to prescribe controlled substances without physician oversight and who did not have a cancer diagnosis, hospice care, or end-stage renal disease. MEASURES: First, we measured whether beneficiaries received any opioid prescription. Second, for beneficiaries who received opioids, we measured acute (<90 d supply) and chronic (≥90 d supply) use at baseline (2009-2010) and follow-up (2012-2013). Third, we measured potential misuse of opioid prescribing using a daily morphine milligram equivalent dose of >100 mg, overlapping prescriptions of opioids >7 days, and overlapping prescriptions of opioids with benzodiazepines >7 days. RESULTS: Beneficiaries managed by NPs were less likely to receive an opioid [odds ratio (OR), 0.87; P<0.001], were less likely to be acute users at baseline (OR, 0.84; P<0.001), and were more likely to receive a high daily opioid dose of morphine milligram equivalent >100 mg compared with physician-managed beneficiaries (OR, 1.11; P=0.048). CONCLUSIONS: Findings suggest educational programs and clinical guidelines may require approaches tailored to different providers. Future research should examine the contributing factors of these patterns to ensure high-quality pain management and guide policy makers on NP-controlled substance-prescribing regulations.

Projected Spending on Psychotropic Medications 2013-2020.

Spending on psychotropic medications has grown rapidly in recent decades. Using national data on drug expenditures, patent expirations, future drug development and expert interviews, we project that spending will grow more slowly over the period 2012-2020. The average annual increase is projected to be just 3.0 % per year, continuing the steady deceleration in recent years. The main drivers of this expected deceleration include slower development of new drugs, upcoming patent expirations which will lower prices, and payers' growing ability to manage utilization and promote generic use. The slowdown will relieve some cost pressures on payers, particularly Medicare and Medicaid.

Prescriber response to unsolicited prescription drug monitoring program reports in Massachusetts.

PURPOSE: To describe prescriber response to unsolicited patient reports from the Massachusetts prescription drug monitoring program (PDMP). METHODS: Prescribers were surveyed upon receipt of unsolicited reports of their patients' prescription history and three months later. We assessed prescribers' awareness of other prescribers listed in the report, their clinical assessment of medical necessity of all prescribed medications, actions taken by prescribers after receiving the report, and usefulness of the report. RESULTS: Of the 333 respondents to the initial survey, only 28 (8.4%) were aware of most, all, or nearly all other prescribers. A total of 146 (43.8%) reported having sufficient knowledge to determine whether the prescriptions were medically necessary, of whom 102 (69.6%) felt the prescriptions were unwarranted. Of the 163 respondents to the follow-up survey, 31.3% added the report to the patient's file, 22.7% discussed the report with other prescribers on the report, 21.5% took no action, and 6% discussed the report with the patient (representing two-thirds of respondents who saw the patient after receiving the report). Most respondents felt that the report was useful for their practice and easy to understand. CONCLUSIONS: Unsolicited reporting of PDMP data has the potential to improve clinical practice by alerting providers about patients with multiple prescribers and potentially medically unnecessary prescriptions.

Expanding access to medication treatment for opioid use disorders: Findings from the Washington State hub and spoke effort.

BACKGROUND: Opioid use disorder (OUD) is a leading cause of preventable death and injury nationwide. Efforts to increase the use of medication for opioid use disorder (MOUD) are needed. In 2017, Washington State implemented a Hub and Spoke (HS) model of care with the primary goal of expanding access to MOUD. We examined changes in MOUD utilization among Washington State Medicaid beneficiaries before and after HS implementation. METHODS: We used Medicaid claims data to examine longitudinal changes in MOUD use for beneficiaries with OUD. We conducted a comparative interrupted time series analysis to examine the association between HS policy implementation and rates of MOUD utilization, overall and by type of medication. RESULTS: Between 2016 and 2019, a period of increasing OUD prevalence, rates of MOUD utilization among Washington Medicaid beneficiaries increased overall from 39.7 to 50.5. Following HS implementation, rates of MOUD use grew at a significantly greater rate in the HS cohort than in the non-HS cohort (ß=0.54, SE=0.02, p< 0.0001, 95% CI 0.49, 0.59). Analyses by medication type show that this rate increase was primarily due to buprenorphine use (ß= 0.61, SE= 0.02, p< 0.0001, 95% CI 0.57, 0.65). CONCLUSION: Improved systems of care are needed to make MOUD accessible to all patients in need. The Washington HS model is one strategy that may facilitate and expand MOUD use, particularly buprenorphine. Over the study period, Washington State saw increased use of buprenorphine, which was an emphasis of their HS model.

Characterization of pyruvate dehydrogenase subunit B and enolase as plasminogen-binding proteins in Mycoplasma pneumoniae.

The obligate pathogenic mycoplasma species Mycoplasma pneumoniae uses a limited but effective repertoire of virulence factors to infect and colonize the human respiratory tract. Besides the development of a unique adhesion complex and the expression of tissue-damaging factors, surface-located glycolytic enzymes and their capacity to bind to components of the human extracellular matrix (ECM) support pathogen-host interactions. Here, we demonstrated that the glycolytic enzymes enolase (Mpn606) and pyruvate dehydrogenase subunit B (Mpn392; PDHB) of M. pneumoniae show concentration-dependent binding to human plasminogen. Monospecific polyclonal antisera against both recombinant proteins reduced the binding to plasminogen significantly. The surface location of PDHB but not of enolase was demonstrated using Triton X fractionation of M. pneumoniae total protein content, membrane fractionation, colony blotting, mild proteolysis of mycoplasma cells, and immunofluorescence tests. To characterize the binding site of plasminogen in surface-displaced PDHB, the mycoplasmal protein was separated into four recombinant proteins followed by investigation of the binding behaviour of peptides that overlap the protein part interacting with plasminogen. Spot analysis resulted in a novel region of 12 amino acids (FPAMFQIFTHAA, position 91 to 102 of PDHB), which is responsible exclusively for binding of human plasminogen and also interacts in a dose-dependent manner with this host protein. The data indicate that the plasminogen-binding enzymes enolase and especially the surface-associated PDHB may contribute to the pathogenesis of M. pneumoniae infections.

Quality of Opioid Use Disorder Treatment for Persons With and Without Disabling Conditions.

Importance: Adverse outcomes associated with opioid use disorder (OUD) are disproportionately high among people with disabilities (PWD) compared with those without disability. A gap remains in understanding the quality of OUD treatment for people with physical, sensory, cognitive, and developmental disabilities, specifically regarding medications for OUD (MOUD), a foundation of treatment. Objective: To examine the use and quality of OUD treatment in adults with diagnosed disabling conditions, compared with adults without these diagnoses. Design, Setting, and Participants: This case-control study used Washington State Medicaid data from 2016 to 2019 (for use) and 2017 to 2018 (for continuity). Data were obtained for outpatient, residential, and inpatient settings with Medicaid claims. Participants included Washington State full-benefit Medicaid enrollees aged 18 to 64 years, continuously eligible for 12 months, with OUD during the study years and not enrolled in Medicare. Data analysis was performed from January to September 2022. Exposures: Disability status, including physical (spinal cord injury or mobility impairment), sensory (visual or hearing impairments), developmental (intellectual or developmental disability or autism), and cognitive (traumatic brain injury) disabilities. Main Outcomes and Measures: The main outcomes were National Quality Forum-endorsed quality measures: (1) use of MOUD (buprenorphine, methadone, or naltrexone) during each study year and (2) 6-month continuity of treatment (for those taking MOUD). Results: A total of 84 728 Washington Medicaid enrollees had claims evidence of OUD, representing 159 591 person-years (84 762 person-years [53.1%] for female participants, 116 145 person-years [72.8%] for non-Hispanic White participants, and 100 970 person-years [63.3%] for participants aged 18-39 years); 15.5% of the population (24 743 person-years) had evidence of a physical, sensory, developmental, or cognitive disability. PWD were 40% less likely than those without a disability to receive any MOUD (adjusted odds ratio [AOR], 0.60; 95% CI, 0.58-0.61; P < .001). This was true for each disability type, with variations. Individuals with a developmental disability were least likely to use MOUD (AOR, 0.50; 95% CI, 0.46-0.55; P < .001). Of those using MOUD, PWD were 13% less likely than people without disability to continue MOUD for 6 months (adjusted OR, 0.87; 95% CI, 0.82-0.93; P < .001). Conclusions and Relevance: In this case-control study of a Medicaid population, treatment differences were found between PWD and people without these disabilities; these differences cannot be explained clinically and highlight inequities in treatment. Policies and interventions to increase MOUD access are critical to reducing morbidity and mortality among PWD. Potential solutions include improved enforcement of the Americans with Disabilities Act, workforce best practice training, and addressing stigma, accessibility, and the need for accommodations to improve OUD treatment for PWD.

State alignment with federal regulations in 2022 to relax buprenorphine 30-patient waiver requirements.

Background: In 2021, the Department of Health and Human Services released guidelines allowing waiver-eligible providers seeking to treat up to 30 patients to be exempt from waiver training (WT) and the counseling and other ancillary services (CAS) attestation. This study evaluates if states and the District of Columbia had more restrictive policies preventing adoption of the 2021 federal guidelines. Methods: First, the Westlaw database was searched for buprenorphine regulations. Second, state medical, osteopathic, physician assistant, nursing boards, and single state agencies (SSA) were surveyed to assess for the WT and CAS requirements and if they were discussing the 2021 guidelines. Results were recorded and compared by state and waiver-eligible provider types. Results: The Westlaw search revealed seven states with regulations requiring the WT and ten states requiring CAS. Survey results showed ten state boards/SSAs required WT for at least one waiver-eligible practitioner type and eleven state boards/SSAs required CAS. In some states, the WT and CAS requirements only applied in special circumstances. Eleven states had discrepancies between the Westlaw and survey results among three waiver-eligible provider types. Conclusions: Despite the 2021 federal change intended to increase access to buprenorphine, several states had regulations and/or provider boards and SSAs that were not supportive. Now, the Mainstreaming Addiction Treatment (MAT) Act of 2022 eliminated the federal x-waiver requirement to prescribe buprenorphine. However, these states may continue to have barriers to treatment access despite the MAT Act. Strategies to engage states with these restrictive policies are needed to improve buprenorphine treatment capacity.

Commentary: Moving Toward Clear, Evidence-based, and Effective State Policies for Addiction Medicine.

State policies play a critical role in determining health care delivery, health equity, and health outcomes, but vary widely in scope, target, restrictiveness, and goals. Understanding how such policies impact health care is critical to development of evidence-based policies, but difficult in the absence of organized and standardized approaches to analysis. Development of themes and frameworks for analysis, and identification of policies supported by evidence, are important steps in moving toward more rational and aligned policies. Buprenorphine treatment for opioid use disorder provides a good example and methodological foundation. At the same time, state policies are promulgated within a larger policy, treatment, and socio-economic environment, and these influences must be considered as well.

Emergency department interventions for opioid use disorder: A synthesis of emerging models.

INTRODUCTION: Opioid overdose deaths are increasing, and improving access to evidence-based treatment is necessary. Emergency department (ED) initiation of treatment for opioid use disorder (OUD) via medications and referral to treatment is one approach that leverages a critical health care entry point for individuals with OUD. Efforts to engage patients in treatment through the ED are growing, but systematic analysis of program features as implemented and challenges across different models remains limited. Lessons from early adopter programs may benefit clinicians and others looking to offer ED-initiated treatment for OUD. METHODS: We conducted case studies of five ED-based efforts to address OUD across the United States, selected for diversity in structure, approach, and geography. We conducted telephone interviews with 37 individuals (ED physicians, ED nurses, navigators, hospital administrators, community providers, and state policymakers) affiliated with the five programs. Interviews were transcribed, coded, and analyzed using a framework analysis approach, identifying relevant lessons for replication. RESULTS: These five programs (an academic medical center, two large urban hospitals, a rural community hospital, and a community-based program) successfully implemented ED-initiated MOUD. Often a champion with knowledge of OUD treatment and a reliable connection with outpatient treatment began the program. The approach to patient identification varied from universal screening to relying on patient self-identification. Substance use treatment navigators provide crucial services but can be difficult to pay for within current reimbursement frameworks. Barriers to implementation include lack of knowledge about treatment options and effectiveness, stigma, community treatment capacity limits, and health insurance and reimbursement policies. Facilitators of success include taking a patient-centered, low-barrier approach, having a passionate champion, a strong structure with health system support, and a relationship with community partners. Metrics for success vary across programs. Some programs are expanding to include treating the use of other substances such as alcohol and stimulants. CONCLUSION: ED-initiated MOUD is feasible across different settings. Research and real world efforts need to promote programs that include OUD treatment as standard in ED treatment.

Improving Interorganizational Coordination Between Primary Care and Oncology: Adapting a Chronic Care Management Model for Patients With Cancer.

The objective of this study was to explore the implementation of a payment and delivery system innovation to improve coordination and communication between primary care and oncology. We employed a qualitative case study approach, conducting interviews (n = 18), and reviewing archival materials. Chronic care coordinators and the cancer center social worker acted as boundary spanners. The chronic care coordinator role built on medical home infrastructure, applying the chronic care model to cancer care. Coordination from primary care to oncology became more routinized, with information sharing prompted by specific events. These new boundary spanner roles enabled greater coordination around uncertain and interdependent tasks. Recommendations for scaling up include the following: establish systematic approaches to learning from implementation, leverage existing capacity for scalability, and attend to the content and purpose of information sharing.

Emergency department-based efforts to offer medication treatment for opioid use disorder: What can we learn from current approaches?

BACKGROUND: The opioid epidemic remains a public health crisis and most people with opioid use disorder (OUD) do not receive effective treatment. The emergency department (ED) can be a critical entry point for treatment. EDs are developing and implementing ED-based efforts to address OUD to improve access to OUD treatment. This study's objective is to identify features of ED-based OUD treatment programs that relate to program implementation, effectiveness, and sustainability. METHODS: We obtained data through literature review and semistructured interviews with ED physicians and leaders. The study analyzed these data to develop a framework of key components of ED-based efforts and highlight barriers and facilitators to implementation and program effectiveness. RESULTS: We identify five key features of ED-based opioid treatment programs that vary across programs and may influence effectiveness and impact: patient identification methods; treatment approaches; program structure; relationship with community partners; and financing and sustainability. Successful implementation of ED-based OUD treatment includes having a champion, a reliable referral network, and systematic tracking and reporting of data for monitoring and feedback. CONCLUSION: Going forward, attention to these features may help to improve effectiveness. As researchers conduct studies of ED-based care models, they should assess the impact of variation in key features to improve program effectiveness.

Association between medication adherence and non-drug healthcare utilisation and costs: a retrospective longitudinal cohort study among US women age 65 and older.

OBJECTIVES: To explore the association between hormone therapy (HT) adherence and non-drug healthcare utilisation and healthcare costs among patients with breast cancer. DESIGN: Retrospective longitudinal cohort study. SETTING: The US Medicare beneficiaries in the SEER-Medicare-linked database PARTICIPANTS: Women aged ≥ 65 with hormone-receptor positive breast cancer from 2007 through mid-2009 in the USA. INTERVENTIONS: We examined the relationship between HT and adherence and outcomes of our interests. PRIMARY AND SECONDARY OUTCOME MEASURES: Our study cohort's HT adherence, non-drug healthcare utilisation and healthcare costs for the first year of HT and each year, thereafter, for a total of 5 years. RESULTS: 6045 eligible Medicare beneficiaries that met our selection criteria were included. We found that patients who were adherent to HT were associated with lower healthcare utilisation of all kinds (inpatient (0.35 vs 0.43, p<0.001), length of study during hospitalisation (4.19 vs 4.89, p<0.01), physician office visits (25.16 vs 26.17, p<0.001)), and significant reductions in many types of medical costs and neutral total healthcare costs despite the increased pharmacy costs. Half of the total medical cost reduction came from savings in hospitalisation costs. CONCLUSIONS: Our study suggests that the added cost of HT adherence was all but offset by the reduced cost for other medical care. Our study provides evidence on the potential success of implementing value-based insurance design (VBID) plans among patients with breast cancer to improve their long-term oral medication adherence. Policymakers should consider adherence improvement strategies such as VBID plans, given that the costs likely will not surpass the total savings.

Cost sharing for breast cancer hormone therapy: How do dual eligible patients' copayment impact adherence.

OBJECTIVE: To examine the different levels of copayment assistance and treatment adherence among Medicare and Medicaid dual eligible beneficiaries with breast cancer in the U.S. RESEARCH DESIGN: Propensity Score methodology was adopted to minimize potential selection bias from the nonrandom allocation of the treatment group (i.e., full Medicaid beneficiaries) and control group (i.e., Medicare Savings Programs [MSPs] beneficiaries). Longitudinal hierarchical model and Cox proportional-hazard model were adopted to examine patients' adherence over their full five-year course of adjuvant hormone therapy. RESULTS: Our study cohort consisted of 1,133 dual eligible beneficiaries diagnosed with hormone receptor-positive early stage breast cancer in years 2007 -mid 2009. About 80.5% of them received MSPs benefits, while the rest received full Medicaid benefits. On average for a standardized 30-day hormone therapy medication, full Medicaid beneficiaries spent $0.5-$2.0 and MSP beneficiaries spent $1.4-$4.8 in copayment. After adjusting for other factors, this copayment reduction wasn't associated with a significantly better adherence. However, when the catastrophic coverage threshold was reached (copayments reduced to zero), significant improvement in adherence was found in both groups. CONCLUSIONS: Our study found that small amount of cost-sharing reduction did not affect Medicare and Medicaid dual eligible patients' medication treatment adherence, however, the elimination of cost-sharing (even a minimal amount) was associated with improved adherence. Future legislative and advocacy efforts should be paid on eliminating cost sharing for dual eligibles, and possibly even a broader group of financially vulnerable patients.

Characterization of THSD7A-antibodies not binding to glomerular THSD7A in a patient with diabetes mellitus but no membranous nephropathy.

Membranous nephropathy (MN) is an autoimmune disease caused by autoantibodies against the podocyte antigens phospholipase A2 receptor 1 (PLA2R1) and thrombospondin type 1 domain containing protein 7A (THSD7A) in 80% and 2-3% of patients, respectively. THSD7A antibodies are considered to be pathogenic and highly specific for MN patients. Using an indirect immunofluorescence test (IIFT) we detected THSD7A-antibodies (titre 1:10) in the serum of a patient with high proteinuria who, however, in the kidney biopsy was diagnosed with diabetic nephropathy and MN was excluded as a possible cause of proteinuria. Different immunofluorescence assays and Western blot techniques using recombinant THSD7A (rTHSD7A) or THSD7A from different human tissues revealed that the circulating THSD7A-autoantibodies were only of the IgG3 subclass. The patient serum reacted exclusively with rTHSD7A and only when the antigen was present in reducing Western blot conditions, or on formaldehyde-fixed cells for the IIFT. Our findings show for the first time the existence of circulating THSD7A-antibodies recognizing denatured/reduced rTHSD7A, which do not react with glomerular THSD7A in vivo and are thus presumptively non-pathogenic. As a consequence, kidney biopsy or Western blot analyses of THSD7A under non-reducing conditions should be performed to confirm the diagnosis of THSD7A-associated MN, especially in cases with low THSD7A-antibody levels in the IIFT.

The Impact of Tai Chi Exercise on Health Care Utilization and Imputed Cost in Residents of Low-Income Senior Housing.

BACKGROUND/OBJECTIVES: This study was designed to test the impact of Tai Chi (TC) on healthcare utilization and cost in older adults living in low-income senior housing. We hypothesized that TC would improve overall health enough to reduce the use of emergency department (ED) and inpatient services. DESIGN: Cluster randomized controlled trial with randomization at the housing site level. SETTING: Greater Boston, Massachusetts. PARTICIPANTS: The study includes 6 sites with 75 individuals in the TC treatment condition and 6 sites with 67 individuals in the health education control condition. INTERVENTION: Members of the treatment group received up to a year-long intervention with twice weekly, in-person TC exercise sessions along with video-directed exercises that could be done independently at home. The comparison group received monthly, in-person healthy aging education classes (HE). Study recruitment took place between August, 2015 and October, 2017. Key outcomes included acute care utilization (inpatient stays, observation stays and emergency department visits). In addition, the cost of utilization was estimated using the age, sex and race adjusted allowed amount from Medicare claims for a geographically similar population aged ≥ 65. RESULTS: The results suggested a possible reduction in the rate of ED visits in the TC group vs. controls (rate ratio = 0.476, p-value = 0.06), but no findings achieved statistical significance. Adjusted estimates of imputed costs of ED and hospital care were similar between TC and HE, averaging approximately $3,000 in each group. CONCLUSION: ED utilization tended to be lower over 6 to 12 months of TC exercises compared to HE in older adults living in low-income housing, although estimated costs of care were similar.

Comparative Genotoxicity and Mutagenicity of Cigarette, Cigarillo, and Shisha Tobacco Products in Epithelial and Cardiac Cells.

Epidemiology studies link cigarillos and shisha tobacco (delivered through a hookah waterpipe) to increased risk for cardiopulmonary diseases. Here we performed a comparative chemical constituent analysis between 3 cigarettes, 3 cigarillos, and 8 shisha tobacco products. The potency for genotoxicity and oxidative stress of each product's generated total particulate matter (TPM) was also assessed using immortalized oral, lung, and cardiac cell lines to represent target tissues. Levels of the carcinogenic carbonyl formaldehyde were 32- to 95-fold greater, while acrolein was similar across the shisha aerosols generated by charcoal heating compared to cigarettes and cigarillos. Electric-mediated aerosol generation dramatically increased acrolein to levels exceeding those in cigarettes and cigarillos by up to 43-fold. Equivalent cytotoxic-mediated cell death and dose response for genotoxicity through induction of mutagenicity and DNA strand breaks was seen between cigarettes and cigarillos, while minimal to no effect was observed with shisha tobacco products. In contrast, increased potency of TPM from cigarillos compared to cigarettes for inducing oxidative stress via reactive oxygen radicals and lipid peroxidation across cell lines was evident, while positivity was seen for shisha tobacco products albeit at much lower levels. Together, these studies provide new insight into the potential harmful effects of cigarillos for causing tobacco-associated diseases. The high level of carbonyls in shisha products, that in turn is impacted by the heating mechanism, reside largely in the gas phase which will distribute throughout the respiratory tract and systemic circulation to likely increase genotoxic stress.