A telemedicine bridge clinic improves access and reduces cost for opioid use disorder care.

Objective: We evaluated the impact of a telemedicine bridge clinic on treatment outcomes and cost for patients with opioid use disorder. Telemedicine bridge clinics deliver low-barrier rapid assessment of patients with opioid use disorder via audio-only and audiovisual telemedicine to facilitate induction on medication therapy and connection to ongoing care. Methods: A pre-post analysis of UPMC Health Plan member claims was performed to evaluate the impact of this intervention on the trajectory of care for patients with continuous coverage before and after bridge clinic visit(s). Results: Analysis included 150 UPMC Health Plan members evaluated at the bridge clinic between April 2020 and October 2021. At least one buprenorphine prescription was filled within 30 days by 91% of patients; median proportion of days covered by buprenorphine was 73.3%, 54.4%, and 50.6% at 30, 90, and 180 days after an initial visit compared to median of no buprenorphine claims 30 days prior among the same patients. Patients had an 18% decline in unplanned care utilization 30 days after initial Bridge Clinic visit, with a 62% reduction in unplanned care cost per member per month (PMPM), 38% reduction in medical cost PMPM, and 10% reduction in total PMPM (medical + pharmacy cost) at 180 days. Primary care, outpatient behavioral health, and laboratory costs increased while emergency department, urgent care, and inpatient costs declined. Conclusion: Utilization of a telemedicine bridge clinic was associated with buprenorphine initiation, linkage to ongoing care with retention including medication treatment, reduced unplanned care cost, and overall savings.

A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes.

In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.

Lower Leg Power and Grip Strength Are Associated With Increased Fall Injury Risk in Older Men: The Osteoporotic Fractures in Men Study.

BACKGROUND: Past research has not investigated both lower-extremity power and upper-extremity strength in the same fall injury study, particularly nonfracture fall injuries. METHODS: In the Osteoporotic Fractures in Men Study (baseline: N = 5 994; age 73.7 ± 5.9 years; 10.2% non-White), fall injuries (yes/no) were assessed prospectively with questionnaires approximately every 3 years over 9 years. Maximum leg power (Watts) from Nottingham single leg press and maximum grip strength (kg) from handheld dynamometry were assessed at baseline and standardized to kg body weight. Physical performance included gait speed (6-m usual; narrow walk) and chair stands speed. RESULTS: Of men with ≥1/4 follow-ups (N = 5 178; age 73.4 ± 5.7 years), 40.4% (N = 2 090) had ≥1 fall injury. In fully adjusted repeated-measures logistic regressions, lower power/kg and grip strength/kg had higher fall injury risk (trend across quartiles: both p < .0001), with lower quartiles at significantly increased risk versus highest Q4 except for grip strength Q3 versus Q4. Fall injury risk was 19% higher per 1 standard deviation (SD) lower power/kg (95% confidence interval [CI]: 1.12-1.26) and 16% higher per SD lower grip strength/kg (95% CI: 1.10-1.23). In models including both leg power/kg and grip strength/kg, odds ratios (ORs) were similar and independent of each other and physical performance (leg power/kg OR per SD = 1.13, 95% CI: 1.06-1.20; grip strength/kg OR per SD = 1.11, 95% CI: 1.05-1.17). CONCLUSIONS: Lower leg power/kg and grip strength/kg predicted future fall injury risk in older men independent of physical performance. Leg power potentially identifies fall injury risk better than grip strength at higher muscle function, though grip strength may be more suitable in clinical/practice settings.

Professional agency vs consumer directed care workers: Outcomes in managed care.

Direct care workers are a major part of the long-term services and supports (LTSS) needed to address the health of individuals and accounted for $112 billion in United States spending in 2015. Direct care workers are hired within professional agency models (PAMs) or consumer-directed models (CDMs) where workers (including family) are contracted by the individual to obtain services. We sought to identify differences in cost and utilisation outcomes between PAM and CDM participants. Data were obtained from the University of Pittsburgh Medical Center (UPMC) Insurance Services Division from the participants enrolled in UPMC Community HealthChoices in Pennsylvania during 2018. A retrospective, observational cohort study design was performed using claims data. Utilisation outcomes were assessed using multivariate logistic regression and cost outcomes by linear regression. The 3,232 participants met the inclusion criteria. Of these, 69% (N = 2,217) were in a PAM, 23% (N = 752) were in a CDM, and 8% (N = 263) used a combination of services. PAM groups were older (mean 62.4 years vs 54.1 years), more likely to be women (69.0% vs 62.8%), and had more healthcare needs. Hospital utilisation was the same among groups. However, total cost was lower in CDM groups due to differences in LTSS costs between CDM and PAM services. Among dually eligible Medicare and Medicaid beneficiaries receiving LTSS, there are significant differences in age, gender, race and health needs. While hospital utilisation was not different between groups, CDM groups had lower total costs of care compared to PAM. These findings have implications for families, policymakers and insurers in helping to govern community LTSS while supporting member autonomy.

Jump power, leg press power, leg strength and grip strength differentially associated with physical performance: The Developmental Epidemiologic Cohort Study (DECOS).

BACKGROUND: Weight-bearing jump tests that measure lower-extremity muscle power may be more strongly related to physical performance measures vs. non-weight-bearing leg press power, leg press strength and grip strength. We investigated if multiple muscle function measures differentially related to standard physical performance measures. MATERIALS/METHODS: In the Developmental Epidemiologic Cohort Study (DECOS; N = 68; age 78.5 ± 5.5 years; 57% women; 7% minorities), muscle function measures included power in Watts/kg (functional, weight-bearing: jump; mechanical: Nottingham power rig; Keiser pneumatic leg press) and strength in kg/kg body weight (Keiser pneumatic leg press; hand-held dynamometry). Physical performance outcomes included 6 m usual gait speed (m/s), usual-paced 400 m walk time (seconds), and 5-repeated chair stands speed (stands/s). RESULTS: Women (N = 31; 79.8 ± 5.0 years) had lower muscle function and slower gait speed compared to men (N = 25; 78.7 ± 6.6 years), though similar 400 m walk time and chair stands speed. In partial Pearson correlations adjusted for age, sex, race and height, muscle function measures were moderately to strongly correlated with each other (all p < 0.05), though the individual correlations varied. In multiple regression analyses, each muscle function measure was statistically associated with all physical performance outcomes in models adjusted for age, sex, race, height, self-reported diabetes, self-reported peripheral vascular disease and self-reported pain in legs/feet (all p < 0.05). Jump power (ß = 0.75) and grip strength (ß = 0.71) had higher magnitudes of association with faster gait speed than lower-extremity power and strength measures (ß range: 0.32 to 0.58). Jump power (ß = 0.56) had a slightly lower magnitude of association with faster 400 m walk time vs. Keiser power70% 1-RM (ß = 0.61), and a higher magnitude of association vs. Nottingham power, Keiser strength and grip strength (ß range: 0.41 to 0.47). Jump power (ß = 0.38) had a lower magnitude of association with chair stands speed than any other power or strength measures (ß range: 0.50 to 0.65). CONCLUSIONS: Jump power/kg and grip strength/kg may be more strongly related to faster gait speed, a standard measure of physical function and vital sign related to disability and mortality in older adults, compared to leg press power/strength. However, jump power/kg had a similar magnitude of association with 400 m walk time as Keiser power70% 1-RM/kg and a lower magnitude of association with faster chair stands speed than the other muscle function measures. Importantly, choice of muscle function measures should carefully reflect the study focus and methodologic considerations, including population.

Associations between novel jump test measures, grip strength, and physical performance: the Osteoporotic Fractures in Men (MrOS) Study.

BACKGROUND/AIMS: Weight-bearing jump tests measure lower extremity muscle power, velocity, and force, and may be more strongly related to physical performance than grip strength. However, these relationships are not well described in older adults. METHODS: Participants were 1242 older men (mean age 84 ± 4 years) in the Osteoporotic Fractures in Men (MrOS) Study. Jump peak power (Watts/kg body weight), force (Newton/kg body weight) at peak power, and velocity (m/s) at peak power were measured by jump tests on a force plate. Grip strength (kg/kg body weight) was assessed by hand-held dynamometry. Physical performance included 400 m walk time (s), 6 m usual gait speed (m/s), and 5-repeated chair stands speed (#/s). RESULTS: In adjusted Pearson correlations, power/kg and velocity moderately correlated with all performance measures (range r = 0.41-0.51; all p < 0.001), while correlations for force/kg and grip strength/kg were weaker (range r = 0.20-0.33; all p < 0.001). Grip strength/kg moderately correlated with power/kg (r = 0.44; p < 0.001) but not velocity or force/kg. In adjusted linear regression with standardized ßs, 1 SD lower power/kg was associated with worse: 400 m walk time (ß = 0.47), gait speed (ß = 0.42), and chair stands speed (ß = 0.43) (all p < 0.05). Associations with velocity were similar (400 m walk time: ß = 0.42; gait speed: ß = 0.38; chair stands speed: ß = 0.37; all p < 0.05). Force/kg and grip strength/kg were more weakly associated with performance (range ß = 0.18-0.28; all p < 0.05). CONCLUSIONS/DISCUSSION: Jump power and velocity had stronger associations with physical performance than jump force or grip strength. This suggests lower extremity power and velocity may be more strongly related to physical performance than lower extremity force or upper extremity strength in older men.

Knee Osteoarthritis and the Risk of Medically Treated Injurious Falls Among Older Adults: A Community-Based US Cohort Study.

OBJECTIVE: The risk of falls among adults with knee osteoarthritis (OA) has been documented, yet, to our knowledge no studies have examined knee OA and the risk of medically treated injurious falls (overall and by sex), which is an outcome of substantial clinical and public health relevance. METHODS: Using data from the Health Aging and Body Composition Knee Osteoarthritis Substudy, a community-based study of white and African American older adults, we tested associations between knee OA status and the risk of injurious falls among 734 participants with a mean ± SD age of 74.7 ± 2.9 years. Knee radiographic OA (ROA) was defined as having a Kellgren-Lawrence grade of ≥2 in at least 1 knee. Knee symptomatic ROA (sROA) was defined as having both ROA and pain symptoms in the same knee. Injurious falls were defined using a validated diagnosis code algorithm from linked Medicare fee-for-service claims. Cox regression modeling was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs). RESULTS: The mean ± SD follow-up time was 6.59 ± 3.12 years. Of the 734 participants, 255 (34.7%) had an incident injurious fall over the entire study period. In the multivariate model, compared with those without ROA or pain, individuals with sROA (HR 1.09 [95% CI 0.73-1.65]) did not have a significantly increased risk of injurious falls. Compared with men without ROA or pain, men with sROA (HR 2.57 [95% CI 1.12-5.91]) had a significantly higher risk of injurious falls. No associations were found for women or by injurious fall type. CONCLUSION: Knee sROA was independently associated with an increased risk of injurious falls in older men, but not in older women.