Rural and Urban Home Modification Program Users: A Comparative Study.

OBJECTIVE: To understand the sociodemographic, geographical, and clinical characteristics of rural veterans utilizing home modification (HM) healthcare services under the Home Improvement Structural Alterations (HISA) program, to compare these characteristics between rural and urban veteran users, to estimate the costs of HMs performed, and to present distance that users traveled to HISA-prescribing medical facilities within the Veterans Health Administration (VHA). BACKGROUND: Accessible housing is in short supply. HMs allow veterans with disabilities (VWDs) to remain living at home rather than enter institutional-type settings. HISA is associated with decreased inpatient hospitalization rates and increased use of preventative healthcare via outpatient clinic visits. Home accessibility provides psychological benefits improving social interactions and interaction with the physical environment. METHODS: This retrospective database study analyzes data from the National Prosthetics Patient Database and other medical datasets within the VHA. RESULTS: Results provide a profile of and comparison between rural and urban veteran users. HISA users are substantially older compared to younger VWDs. The frequency of bathroom, railing, and wooden ramp HMs differed significantly between rural and urban users (p values < .001). Rural users traveled more miles than urban users to reach a prescribing facility. CONCLUSIONS: Older adults and individuals with disabilities have unmet housing needs since accessible housing is in short supply. This HM healthcare service is helping to meet the housing accessibility needs of older veterans, VWDs, older adults, and people with disabilities, in general.

Predictors of County-Level Home Modification Use Across the US.

Background: Geospatial analyses illustrating where the Home Improvements and Structural Alterations program (HISA) have been prescribed suggest that home modification (HM) services under US Department of Veterans Affairs (VA) is not prescribed and used uniformly across the US. Methods: The objective of this study was to identify county characteristics associated with HISA use rates, such as county-level measures of clinical care and quality of care, variables related to physical environment, and sociodemographic characteristics. Multiple regression analysis was used to predict county-level utilization rate from county-level variables. Results: County-level HISA use was highly skewed and ranged from 0.09 to 59.7%, with a mean of 6.6% and median of 5%. Percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = -8.99, P = .005). The higher the proportion of uninsured adults the lower the HISA utilization rate. The county rate of preventable hospital stays was positively related to county-level HISA utilization rate (b = .0004, P = .009). County-level predictors of housing quality were not significantly associated with county-level HISA utilization rate. Conclusions: Our research fills a gap in the literature about the impact of county-level variables and the geographic distribution and use of HISA. More research is needed to understand and account for geographical variation in HISA use. This work serves as a first step at quantifying and predicting HISA utilization rate at a broad level, with the goal of increasing access to HMs for veterans with disabilities.

Home Modifications for Rural Veterans With Disabilities.

BACKGROUND: Appropriate home modifications (HMs) can make the home environment accessible and relatively safe by reducing the risk of falls. Of special concern are individuals living alone, living in rural communities, and/or living in substandard housing. The Home Improvements and Structural Alterations (HISA) is a Veterans Health Administration (VHA) benefit program providing HMs for veterans with disabilities. METHODS: The objective of this study was to detail the profile of rural veteran (RV) HISA users and report on national HISA utilization patterns. We compare use at US Department of Veterans Affairs (VA) medical centers of varying complexity levels, and in VA regions. An examination of the relationship between travel time/distance and HISA utilization is also provided. This retrospective database study uses GeoSpatial analyses and 3 VA sources: The National Prosthetics Patient Database, the VHA Medical Inpatient Dataset, and the VHA Outpatient Dataset. RESULTS: From 2015 through 2018, 10,810 RVs used HISA with a mean age of 70.9 years. A majority of participants were White (79.5%), married (74.3%), and male (96.5%) veterans. They traveled a mean of 79.8 miles for 94.5 minutes to reach a facility where they received a HISA prescription. Nearly 75% of HISA users were able to receive a HISA prescription from their nearest facility, while about one-quarter traveled to a facility farther away, of which 43% travelled between 100 and 200 miles to obtain the HISA benefit. The top categories of diagnoses were musculoskeletal (19.1%), neurologic (12.5%), and cardiovascular (5.4%). There were about 11,166 HM prescriptions afforded to rural HISA users during the period, including bathroom (82.4%), doorway (4.9%), and railing (3.6%) modifications. CONCLUSIONS: This study documents the national demographics and clinical characteristics of rural HISA users, data that may be useful to policy makers, HM service providers and advocate as well as HISA administrators in predicting future use and users.

Interactions between Alcohol Consumption and Adjuvant Hormone Therapy in Relation to Breast Cancer-Free Survival.

PURPOSE: Alcohol consumption is associated with an increase in breast cancer risk, but findings on the association of alcohol with survival after breast cancer diagnosis have been inconsistent. Further, whether these associations could differ by adjuvant hormone therapy status is unknown. We examined interactions between alcohol consumption and adjuvant hormone therapy in relation to breast cancer-free survival among women with a primary breast cancer diagnosis. METHODS: Participants in this study included 1,399 women diagnosed with primary breast cancer between 2007 and 2012 at the Moffitt Cancer Center. Alcohol consumption during the year preceding diagnosis was assessed in a patient survey. Information on tumor characteristics, breast cancer treatment and outcomes was available from the Moffitt Cancer Registry. Associations were examined using Cox proportional hazards models in stratified analyses by adjuvant hormone therapy status, after adjustment for potential confounders. RESULTS: Overall, alcohol consumption was associated with significantly improved breast cancer-free survival (any vs. none: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.65-0.92). Among women without adjuvant hormone therapy, alcohol consumption was associated with better survival in heavy drinkers (HR, 0.63; 95% CI, 0.43-0.93). Among women with adjuvant hormone therapy, survival was better in women consuming alcohol as compared to nondrinkers (moderate: HR, 0.69, 95% CI, 0.51-0.93; heavy: HR, 0.74, 95% CI, 0.57-0.96; any: HR, 0.71, 95% CI, 0.57-0.87). There was no significant interaction between alcohol and adjuvant hormone therapy (p-interaction=0.54 for alcohol modeled as none or any and p=0.34 for alcohol modeled as none, moderate, and heavy). CONCLUSION: Associations of alcohol consumption with breast cancer-free survival are similar in women with and without adjuvant hormone therapy. Future studies are warranted to elucidate potential mechanisms underlying the observed inverse associations.

A Research Protocol to Test the Effectiveness of Text Messaging and Reminder Calls to Increase Service Use Referrals in a Community Engagement Program.

BACKGROUND: Mobile phoned-based interventions have been increasingly used in clinical populations to improve health and health care delivery. The literature has shown that mobile phone-based text messages (short message service, SMS) are instantaneous, cost effective, and have less chance of being misplaced. Studies using mobile phone based-text messages have reported text messages as effective reminders that have resulted in increased appointment attendance, adherence to treatment, and better self-management. There have been no reports of adverse events when using text messaging in terms of misreading or misinterpreting data, transmitting inaccurate data, losing verbal or nonverbal communication cues, privacy issues, or failure or delay in message delivery. However, the literature has cited a need for personalized messages that are more responsive to individual needs. In addition, there has been a dearth of information on the use of reminders in nonclinical populations. OBJECTIVE: The goal of this study is to assess the effectiveness of adding reminders in the form of text messaging versus reminder calls versus text messages and reminder calls to increase use of service referrals provided through community outreach. METHODS: A total of 300 participants will be recruited for the study. Each participant will be randomized to one of three arms: a group that receives only reminder calls (CALLSONLY); a group that receives only text message reminders (TEXTONLY); and a group that receives both reminder calls and text messages (CALLS+TEXT). All groups will receive their reminder intervention on the 15th and 45th day after baseline when they receive medical and social service referrals from the community health workers (CHWs). A standard script will be used to administer the call and text reminders and a 15-item telephone-based satisfaction survey will be administered to assess the participant satisfaction with the process of receiving periodic reminders. RESULTS: The study is in the recruitment and follow-up phase. The authors anticipate completion of recruitment, interventions, and data entry by July 2016. Preliminary results are expected to be available by September 2016. CONCLUSIONS: This study will provide an opportunity to test the effectiveness of mobile-based interventions on nonclinical, community-recruited populations. In particular, such a protocol would increase the effectiveness of a community-based engagement program by instating a formal reminder system for all program members who receive social and/or medical service referrals during outreach in the community. Findings from this study would guide the development and implementation of reminder protocols for community-based engagement programs nationwide.