Racial and Ethnic Disparities in Hospital-Based Care Among Dual Eligibles Who Use Health Centers.

Introduction: Health center use may reduce hospital-based care among Medicare-Medicaid dual eligibles, but racial and ethnic disparities in this population have not been widely studied. We examined the extent of racial and ethnic disparities in hospital-based care among duals using health centers and the degree to which disparities occur within or between health centers. Methods: We used 2012-2018 Medicare claims and health center data to model emergency department (ED) visits, observation stays, hospitalizations, and 30-day unplanned returns as a function of race and ethnicity among dual eligibles using health centers. Results: In rural and urban counties, age-eligible Black individuals had more ED visits (7.9 [4.0, 11.7] and 13.7 [10.0, 17.4] per 100 person-years) and were more likely to experience an unplanned return (1.4 [0.4, 2.4] and 1 [0.4, 1.6] percentage points [pp]) than White individuals, but were less likely to be hospitalized (-3.3 [-3.9, -2.8] and -1.2 [-1.6, -0.9] pp). In urban counties, age-eligible Black individuals were 1.2 [0.9, 1.5] pp more likely than White individuals to have observation stays. Other racial and ethnic groups used the same or less hospital-based care than White individuals. Including state and health center fixed effects eliminated Black versus White disparities in all outcomes, except hospitalization. Results were similar among disability-eligible duals. Conclusion: Racial and ethnic disparities in hospital-based care among dual eligibles are less common within than between health centers. If health centers are to play a more central role in eliminating racial and ethnic health disparities, these differences across health centers must be understood and addressed.

Primary care patterns among dual eligibles with Alzheimer's disease and related dementias.

BACKGROUND: Primary care is essential for persons with Alzheimer's disease and related dementias (ADRD). Prior research suggests that the propensity to provide high-quality, continuous primary care varies by provider setting, but the settings used by Medicare-Medicaid dual-eligibles with ADRD have not been described at the population level. METHODS: Using 2012-2018 Medicare data, we identified dual-eligibles with ADRD. For each person-year, we identified primary care visits occurring in six settings. We calculated descriptive statistics for beneficiaries with a majority of visits in each setting, and conducted a k-means cluster analysis to determine utilization patterns, using the standardized count of primary care visits in each setting. RESULTS: Each year from 2012 to 2018, at least 45.6% of dual-eligibles with ADRD received a majority of their primary care in nursing facilities, while at least 25.2% did so in physician offices. Over time, the share relying on nursing facilities for primary care decreased by 5.2 percentage points, offset by growth in Federally Qualified Health Centers (FQHCs) and miscellaneous settings (2.3 percentage points each). Dual-eligibles relying on nursing facilities had more annual primary care visits (16.1) than those relying on other settings (range: 6.8-10.7 visits). Interpersonal care continuity was also higher in nursing facilities (97.0%) and physician offices (87.9%) than in FQHCs (54.2%), rural health clinics (RHCs, 46.6%), or hospital-based clinics (56.8%). Among dual-eligibles without care continuity, 82.7% were assigned to a cluster with few primary care visits. CONCLUSIONS: A trend toward care in different settings likely reflects improved access to patient-centered primary care. Low rates of interpersonal care continuity in FQHCs, RHCs, and physician offices may warrant concern, unless providers in these settings function as a care team. Nonetheless, every healthcare system encounter presents an opportunity to designate a primary care provider for dual-eligibles with ADRD who use little or no primary care.

Characterizing the Uptake of Newly Opened Health Centers by Individuals Dually Enrolled in Medicare and Medicaid.

Federally qualified health centers (FQHCs) increasingly provide high-quality, cost-effective primary care to individuals dually enrolled in Medicare and Medicaid. However, not everyone can access an FQHC. We used 2012 to 2018 Medicare claims and federally collected FQHC data to examine communities where an FQHC first opened and determine which dual eligibles used it. Overall uptake was 10%, ranging from 6.6% among age-eligible urban residents to 14.8% among disability-eligible rural residents. Community-level uptake ranged from 0% to 76.4% (median = 5.5%; interquartile range = 2.8%-11.3%). Certain subpopulations of dual eligibles are significantly more likely to use FQHCs. Our findings should inform the targeting of future FQHC expansions.

Health center use and hospital-based care among individuals dually enrolled in Medicare and Medicaid, 2012-2018.

OBJECTIVE: To examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid. DATA SOURCES: Data were obtained from 2012 to 2018 Medicare claims. STUDY DESIGN: We modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality. DATA EXTRACTION METHODS: Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease. PRINCIPAL FINDINGS: After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period). CONCLUSIONS: FQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.

Computerized Cognitive Training in Amnestic Mild Cognitive Impairment: A Randomized Clinical Trial.

OBJECTIVE: Computerized cognitive training has been successful in healthy older adults, but its efficacy has been mixed in patients with amnestic Mild Cognitive Impairment (MCI). METHODS: In a randomized, placebo-controlled, double-blind, parallel clinical trial, we examined the short- and long-term efficacy of a brain-plasticity computerized cognitive training in 113 participants with amnestic MCI. RESULTS: Immediately after 40-hours of training, participants in the active control group who played computer games performed better than those in the experimental group on the primary cognitive outcome (p = 0.02), which was an auditory memory/attention composite score. There were no group differences on 2 secondary outcomes (global cognitive composite and rating of daily functioning). After 1 year, there was no difference between the 2 groups on primary or secondary outcomes. No adverse events were noted. CONCLUSIONS: Although the experimental cognitive training program did not improve outcomes in those with MCI, the short-term effects of the control group should not be dismissed, which may alter treatment recommendations for these patients.

The Contribution of Patient, Primary Care Physician, and Primary Care Clinic Factors to Good Bone Health Care.

BACKGROUND/OBJECTIVE: Patient, provider, and system factors can contribute to chronic care management and outcomes. Few studies have examined these multilevel associations with osteoporosis care and outcomes. We examined how key process and structural factors at the patient, primary care physician (PCP), and primary care clinic (PCC) levels were associated with guideline concordant osteoporosis pharmacotherapy, daily calcium intake, vitamin D supplementation, and weekly exercise sessions at 52 weeks following enrollment in a cluster randomized controlled trial. METHODS: We conducted a secondary analysis of observational data from 1 site of the trial. The study sample included 1996 men and women ≥ 50 years of age at the time of recruitment following completion of a dual-energy x-ray absorptiometry (DXA) scan and who had complete data at baseline and 52 weeks. Our primary independent variable was "relationship continuity": the DXA-ordering provider was the patient's PCP. Hierarchical linear and logistic regression accounted for patient, provider, and primary care clinic characteristics. RESULTS: In multivariable regression analyses, relationship continuity (ie, the PCP ordered the study DXA) was associated with higher average daily calcium intake and likelihood of vitamin D supplementation at 52 weeks. No PCP or primary care clinic factors were associated with osteoporosis care. CONCLUSIONS: The relationship continuity, in which the provider ordering a DXA is the patient's PCP and therefore also presents the results of a DXA, may help to promote patient behaviors associated with good bone health.

Does Visual Speed of Processing Training Improve Health-Related Quality of Life in Assisted and Independent Living Communities?: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Visual speed of processing training had clinically and statistically significant beneficial effects on health-related quality of life among 2,802 healthy community-dwelling adults aged 65-94 years at 2 and 5 years post-training in the Advanced Cognitive Training for Independent and Vital Elderly randomized controlled trial. We examined whether that effect would be found among older adults in assisted and independent living communities. RESEARCH DESIGN AND METHODS: We conducted a two-arm, parallel randomized controlled trial stratified by assisted versus independent settings in 31 senior living communities and enrolled 351 adults aged 55-102 years. The targeted intervention dose was 10 hr at baseline with 4-hr boosters at 5 and 11 months. The intervention group received computerized visual speed of processing training, while the attention control group solved computerized crossword puzzles. The health-related quality of life outcomes were the Short-Form 36-item Health Survey's mental and physical component T scores. Linear mixed-effect models were used. RESULTS: Visual speed of processing, assisted living, and their interaction had no clinically or statistically significant effects on the physical component T scores. However, visual speed of processing (p = .022), assisted living (p = .022), and their interaction (p = .007) had clinically and statistically significant effects on the mental component T scores. The estimated marginal means revealed a small effect-sized positive 2.2 point visual speed of processing training effect in the independent living communities, but a clinically important harmful -4.2 point visual speed of processing training effect in the assisted living communities. DISCUSSION AND IMPLICATIONS: Given the medium-sized harmful effect of visual speed of processing training among those in the assisted living communities, caution is advised when using these two visual speed of processing training modalities in assisted living communities until further research verifies or refutes our findings and the underlying etiological pathways.

Home-Based, Adaptive Cognitive Training for Cognitively Normal Older adults: Initial Efficacy Trial.

OBJECTIVES: We examined whether a home-based, adaptive cognitive training (CT) program would lead to cognitive performance changes on a neuropsychological test battery in cognitively normal older adults. METHOD: Sixty-eight older adults (age = 70.0, SD = 3.74) were randomly assigned to either CT or an active control group (AC, casual computer games). Participants were instructed to train on their assigned programs for 42 min per day, 5 days per week, over 10 weeks (35 hr of total program usage). Participants completed tests of processing speed, working memory, and executive control before and after 10 weeks of training. RESULTS: Training groups did not differ in performance before training. After training, CT participants out-performed AC participants in the overall cognitive composite score, driven by processing speed and working memory domains. DISCUSSION: Our results show that a limited dose of home-based CT can drive cognitive improvements as measured with neuropsychological test battery, suggesting potential cognitive health maintenance implications for cognitively normal older adults.

Speed of processing training and depression in assisted and independent living: A randomized controlled trial.

Late life depression is widely associated with lower quality of life and greater disability, making it an important target for prevention. Earlier randomized controlled trials [RCTs] demonstrated that speed of processing training [SOPT] led to reductions in depressive symptoms and clinical depression in community-dwelling adults. Our purpose was to evaluate depression outcomes related to SOPT among older adults who live in supported senior living settings. This two-arm, parallel RCT included 351 participants aged 55-102 years who resided in assisted and independent settings in 31 senior living communities. Participants were randomized within sites to computerized SOPT vs. computerized crossword puzzles with a targeted dose of 10 hours of playtime at baseline plus 4 hours of booster training at five and eleven months. Depression outcomes included the 9-item Patient Health Questionnaire [PHQ-9] scores, categorical levels, and dichotomous indicators. Random effects linear mixed effect models estimated SOPT effects in intention-to-treat complete case and multiple imputation analyses. Mean age of the sample was 81.0 years, 72.2% were women, and 41.0% resided in assisted living. At baseline 65.7% had no depression [PHQ-9 scores < 5] and 6.6% had clinically meaningful depression [PHQ-9 scores ≥ 10]. At 12 months we found significantly increased PHQ-9 scores [p = 0.006] and categorical levels [p = 0.003], and higher percentages of PHQ-2 scores > 3 [p = 0.016] and major depressive syndrome [p = 0.045] among the assisted living SOPT group. No significant change in depression was observed in the independent living SOPT or attention control groups. In summary, the SOPT known as Road Tour/Double Decision significantly increased, rather than decreased, the burden of depressive symptoms among participants residing in assisted living. Given these risks, this SOPT program should be avoided among older people in assisted living settings, and other SOPT interventions should be combined with systematic depression monitoring.

Characteristics of older adults using patient web portals to view their DXA results.

BACKGROUND: Sharing test results with patients via patient web portals is a new trend in healthcare. No research has been done examining patient web portal use with bone density test results. The objective of our study was to identify patient characteristics associated with the use of patient web portals to view their bone density test results. METHODS: A secondary analysis of data from a pragmatic randomized controlled trial of 7749 participants ≥50 years old that had presented for a dual energy X-ray absorptiometry (DXA) bone density test. Patients were interviewed at enrollment and 12 weeks later. Multivariable logistic regression identified patient characteristics that differentiated those who used the web portal from those who did not. RESULTS: Our sample included 4669 patients at the two (University of Iowa [UI], and Kaiser Permanente of Georgia [KPGA]) clinical sites that had patient web portals. Of these patients, 3399 (72.8%) reported knowing their test results 12 weeks post-DXA, with 649 (13.9%) reporting that they viewed their DXA results using the web portal. Web portal users were more likely to be from UI than KPGA, and were younger, more educated, had higher health literacy, had osteopenia, and had the same sex as their referring physician (all p < 0.05). CONCLUSION: Only 19.1% of the 3399 patients who knew their DXA results used the available patient web portals to find out about them. Web portal users differed from non-users on several characteristics. This suggests that simply making patient web portals available for use may not be sufficient to appreciably enhance patient awareness of their test results. Based on these findings, a better understanding of the reasons why older, less educated, and less activated patients do not access their test results through patient web portals is needed.

The prevalence of overtreatment of osteoporosis: results from the PAADRN trial.

Overtreatment of osteoporosis increases costs and puts patients at unnecessary risk of experiencing adverse drug events. In the Patient Activation After DXA Receipt Notification (PAADRN) trial, we found that 8% of individuals with no indication for therapy were recommended a new osteoporosis medication or continuation of an existing medication. PURPOSE: There is a robust body of literature addressing undertreatment in osteoporosis, but limited data addressing overtreatment. Understanding overtreatment is important to minimize harm and decrease costs. METHODS: One of the pre-specified post hoc analyses of the PAADRN trial, a randomized, controlled, pragmatic clinical trial, was to quantify and identify risk factors associated with osteoporosis overtreatment. PAADRN included patients ≥ 50 years of age presenting for bone density testing between February, 2012, and August, 2014, at three US healthcare systems. We assessed 20,397 patients for eligibility and randomized 7749. Intervention patients received a tailored letter containing their dual-energy X-ray absorptiometry (DXA) results and an educational osteoporosis brochure. Control patients received usual care. Using the National Osteoporosis Foundation treatment guidelines, we defined overtreatment as the receipt of osteoporosis pharmacotherapy 12 weeks after DXA when treatment was not indicated. We evaluated the relationship between the following baseline variables-sex, race/ethnicity, educational attainment, and differences across health systems-and overtreatment using a series of multivariable logistic regression models. RESULTS: Among 3602 patients with no apparent indication for osteoporosis treatment, 292 (8.1%; 95% CI, 7.22 to 9.00%) received a new prescription for osteoporosis pharmacotherapy or were instructed to continue an existing medication (presumed overtreatment). Presumed overtreatment was more common among participants with prior DXA history, those who reported a history of osteoporosis or low bone mass, and those referred for testing by family medicine providers. CONCLUSION: In our sample of older adults, overuse of osteoporosis pharmacotherapy was only 8.1%. Nevertheless, overtreatment exposes patients to possible risk with negligible chance of benefit and should be minimized. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01507662.

Speed-of-Processing Training in Assisted and Independent Living: A Randomized Controlled Trial.

OBJECTIVES: To examine speed-of-processing training (SOPT) in older adults in senior living communities, especially those in assisted living. DESIGN: Two-arm, parallel, randomized controlled trial. SETTING: Assisted and independent residence settings in 31 senior living communities. PARTICIPANTS: Individuals aged 55 to 102 (mean 81.0, 73.8% female, 76.4% living alone, 47.0% residing in assisted living; N=351). INTERVENTION: The intervention was 10 hours of computerized SOPT at baseline with 4-hour boosters at 5 and 11 months; the attention control was 10 hours of solving computerized crossword puzzles at baseline with 4-hour boosters at 5 and 11 months. MEASURES: Outcomes were useful field of view (UFOV) scores and improvements of 0.5 standard deviations (SDs) or more (> 158.4 ms). Data collection occurred at baseline, after training, and 6 and 12 months. Random-effects linear mixed-effect models were used to estimate SOPT effects in intention-to-treat complete-case and multiple imputation analyses. RESULTS: We found statistically significantly small standardized effect sizes (Cohen's ds 0.25-0.40) for SOPT, reflecting processing speed improvements on UFOV scores (of 39-63 ms) and greater percentages (9.8 to 14.9 percentage point advantages) for achieving more than 0.5 SD improvements (> 158.4 ms) over the 3 time periods. CONCLUSION: These findings support public health messaging about the potential benefits of SOPT for older adults in senior living communities and support the feasibility and acceptability of SOPT in assisted and independent living for older adults.

Diet and exercise changes following bone densitometry in the Patient Activation After DXA Result Notification (PAADRN) study.

Calcium and vitamin D intake and exercise are suboptimal among older adults. Following bone densitometry, a letter communicating individualized fracture risk accompanied by an educational brochure improved participants' lifestyle-but no more than existing communication strategies-over 52 weeks. Simple communication strategies are insufficient for achieving optimal levels of bone health behaviors. PURPOSE: The Patient Activation After DXA Result Notification (PAADRN) study was designed to evaluate whether a letter with individualized fracture risk and an educational brochure mailed to patients soon after their DXA might improve bone health behaviors (daily calcium intake, vitamin D supplementation, and weekly exercise sessions) compared to slower, less individualized communication characterizing usual care. METHODS: Participants ≥ 50 years were recruited, at three sites, following their DXA and randomized with 1:1 allocation to intervention and control (usual care only) groups. Data were collected at enrollment interview and by phone survey at 12 and 52 weeks thereafter. Intention-to-treat analyses were conducted on 7749 of the 20,397 eligible participants who enrolled. Changes in bone health behaviors were compared within and between study groups. Average treatment effects and heterogeneity of treatment effects were estimated with multivariable linear and logistic regression models. RESULTS: In unadjusted analyses, calcium intake, vitamin D supplementation, and weekly exercise sessions increased significantly over 52 weeks within both the intervention and control groups (all p < 0.001). In unadjusted analyses and multivariable models, increases in each behavior did not significantly differ between the intervention and control groups. Intervention group participants with a > 20% 10-year fracture risk at enrollment did, however, have a significantly greater increase in calcium intake compared to other study participants (p = 0.031). CONCLUSIONS: Bone health behaviors improved, on average, over 52 weeks among all participants following a DXA. Receipt of the PAADRN letter and educational brochure did not directly improve bone health behaviors compared to usual care. TRIAL REGISTRATION: The Patient Activation after DXA Result Notification (PAADRN) Study is registered at ClinicalTrials.Gov: NCT01507662, https://clinicaltrials.gov/ct2/show/NCT01507662.

Computerized Cognitive Training to Improve Mood in Senior Living Settings: Design of a Randomized Controlled Trial.

PURPOSE: This two-arm, randomized controlled trial was designed to evaluate a computerized cognitive speed of processing (SOP) training known as Road Tour in the generally older group of adults residing in assisted living (AL) and related senior housing. Study aims focused on depression-related outcomes that were observed in earlier SOP studies using Road Tour with younger, home-dwelling seniors. Study design and baseline outcomes are discussed. PARTICIPANTS AND METHODS: A community-based design engaged AL and related senior living settings as partners in research. Selected staff served as on-site research assistants who were trained to recruit, consent, and train a target of 300 participants from AL and independent living (IL) programs to use the intervention and attention-control computerized training. Ten hours of initial computerized training was followed by two booster sessions at 5 and 11 months. Outcome measures included Useful Field of View (UFOV), 9-item Patient Health Questionnaire (PHQ-9), 12-item Centers for Epidemiological Studies Depression scale (CESD-12), 7-item Generalized Anxiety Disorders GAD-7), Brief Pain Inventory (BPI) and SF-36 Health Survey. Assessments occurred before randomization (pre-training), post-training, 26 and 52 weeks. RESULTS: A total of 351 participants were randomized to the intervention (n=173) and attention-control (n=178) groups. There were no significant differences between groups in demographic characteristics with the exception of education and reported osteoporosis. There were no significant differences in study outcomes between groups at baseline. Participants in AL had significantly lower SOP and self-rated health, and significantly higher depression, anxiety and pain when compared to those in IL programs on the same campus. CONCLUSIONS: Compared to earlier SOP training studies using Road Tour, this sample of senior living participants were older, reported more health conditions and poorer overall health, had lower UFOV scores and greater depressive symptoms at baseline. Moreover, participants in AL had greater health challenges than those in IL.

Genetic Risks for Chronic Conditions: Implications for Long-term Wellbeing.

Background: Relationships between genetic risks for chronic diseases and long-run wellbeing are largely unexplored. We examined the associations between genetic predispositions to several chronic conditions and long-term functional health and socioeconomic status (SES). Methods: We used data on a nationally representative sample of 9,317 adults aged 65 years or older from the 1992 to 2012 Health and Retirement Survey (HRS) in the US. Survey data were linked to genetic data on nearly 2 million single-nucleotide polymorphisms (SNPs). We measured individual-level genetic predispositions for coronary-artery disease, type 2 diabetes (T2D), obesity, rheumatoid arthritis (RA), Alzheimer's disease, and major depressive disorder (MDD) by polygenic risk scores (PRS) derived from genome-wide association studies (GWAS). The outcomes were self-rated health, depressive symptoms, cognitive ability, activities of everyday life, educational attainment, and wealth. We employed regression analyses for the outcomes including all polygenic scores and adjusting for gender, birth period, and genetic ancestry. Results: The polygenic scores had important associations with functional health and SES. An increase in genetic risk for all conditions except T2D was significantly (p < .01) associated with reduced functional health and socioeconomic outcomes. The magnitudes of functional health declines were meaningful and in many cases equivalent in magnitude to several years of aging. These associations were robust to several sensitivity checks for ancestry and adjustment for parental educational attainment and age at death or the last interview if alive. Conclusion: Stronger genetic predispositions for leading chronic conditions are related to worse long-run health and SES outcomes, likely reflecting the adverse effects of the onset of these conditions on one's wellbeing.

Genetic Predisposition to Obesity and Medicare Expenditures.

BACKGROUND: The relationship between obesity and health expenditures is not well understood. We examined the relationship between genetic predisposition to obesity measured by a polygenic risk score for body mass index (BMI) and Medicare expenditures. METHODS: Biennial interview data from the Health and Retirement Survey for a nationally representative sample of older adults enrolled in fee-for-service Medicare were obtained from 1991 through 2010 and linked to Medicare claims for the same period and to Genome-Wide Association Study (GWAS) data. The study included 6,628 Medicare beneficiaries who provided 68,627 complete person-year observations during the study period. Outcomes were total and service-specific Medicare expenditures and indicators for expenditures exceeding the 75th and 90th percentiles. The BMI polygenic risk score was derived from GWAS data. Regression models were used to examine how the BMI polygenic risk score was related to health expenditures adjusting for demographic factors and GWAS-derived ancestry. RESULTS: Greater genetic predisposition to obesity was associated with higher Medicare expenditures. Specifically, a 1 SD increase in the BMI polygenic risk score was associated with a $805 (p < .001) increase in annual Medicare expenditures per person in 2010 dollars (~15% increase), a $370 (p < .001) increase in inpatient expenses, and a $246 (p < .001) increase in outpatient services. A 1 SD increase in the polygenic risk score was also related to increased likelihood of expenditures exceeding the 75th percentile by 18% (95% CI: 10%-28%) and the 90th percentile by 27% (95% CI: 15%-40%). CONCLUSION: Greater genetic predisposition to obesity is associated with higher Medicare expenditures.

The Onset of ADL Difficulties and Changes in Health-Related Quality of Life.

BACKGROUND: The effect of the onset of difficulties with activities of daily living (ADLs) on the health-related quality of life (HRQoL) of older adults is not well understood. We identified strong longitudinal associations between ADL onset and HRQoL changes for older adults in Medicare Advantage Organizations (MAOs). METHODS: We analyzed 473,282 age-eligible MAO beneficiaries in the 2008-2013 Medicare Health Outcomes Surveys (M-HOS) who reported no ADL difficulties at baseline and completed their two-year follow-ups in 2010-2015. The four HRQoL measures were the physical and mental health component scores (PCS and MCS) from the SF-12V, and the CDC's counts of physically unhealthy and mentally unhealthy days (PUD and MUD) in the past month. Ordinary least squares (OLS) and zero-inflated negative binomial regressions were used. RESULTS: The onset of difficulty/inability in bathing, dressing, eating, getting in/out of chairs, walking, and using the toilet significantly reduced PCS scores by 10.84, 11.29, 9.18, 8.98, 9.49 and 10.67 points, and MCS scores by 7.93, 8.72, 10.13, 5.34, 4.37 and 9.00 points, respectively. The onset of difficulty/inability in bathing, dressing, eating, getting in/out of chairs, walking, and using the toilet increased PUD days by 6.24, 6.83, 6.34, 4.93, 4.96 and 6.72 days, and MUD days by 3.00, 3.19, 3.54, 2.26, 2.07 and 3.27 days, respectively. CONCLUSIONS: There is robust evidence that the onset of ADL difficulties/inabilities significantly and substantially reduced age-eligible MAO beneficiaries' HRQoL. Prevention strategies focused on ADLs would benefit the performance of MAOs.

Patient-centered professional practice models for managing low back pain in older adults: a pilot randomized controlled trial.

BACKGROUND: Low back pain is a debilitating condition for older adults, who may seek healthcare from multiple providers. Few studies have evaluated impacts of different healthcare delivery models on back pain outcomes in this population. The purpose of this study was to compare clinical outcomes of older adults receiving back pain treatment under 3 professional practice models that included primary medical care with or without chiropractic care. METHODS: We conducted a pilot randomized controlled trial with 131 community-dwelling, ambulatory older adults with subacute or chronic low back pain. Participants were randomly allocated to 12 weeks of individualized primary medical care (Medical Care), concurrent medical and chiropractic care (Dual Care), or medical and chiropractic care with enhanced interprofessional collaboration (Shared Care). Primary outcomes were low back pain intensity rated on the numerical rating scale and back-related disability measured with the Roland-Morris Disability Questionnaire. Secondary outcomes included clinical measures, adverse events, and patient satisfaction. Statistical analyses included mixed-effects regression models and general estimating equations. RESULTS: At 12 weeks, participants in all three treatment groups reported improvements in mean average low back pain intensity [Shared Care: 1.8; 95% confidence interval (CI) 1.0 to 2.6; Dual Care: 3.0; 95% CI 2.3 to 3.8; Medical Care: 2.3; 95% CI 1.5 to 3.2)] and back-related disability (Shared Care: 2.8; 95% CI 1.6 to 4.0; Dual Care: 2.5; 95% CI 1.3 to 3.7; Medical Care: 1.5; 95% CI 0.2 to 2.8). No statistically significant differences were noted between the three groups on the primary measures. Participants in both models that included chiropractic reported significantly better perceived low back pain improvement, overall health and quality of life, and greater satisfaction with healthcare services than patients who received medical care alone. CONCLUSIONS: Professional practice models that included primary care and chiropractic care led to modest improvements in low back pain intensity and disability for older adults, with chiropractic-inclusive models resulting in better perceived improvement and patient satisfaction over the primary care model alone. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01312233 , 4 March 2011.

Evaluation of a "Just-in-Time" Nurse Consultation on Bone Health: A Pilot Randomized Controlled Trial.

CONTEXT: Evidence is inconclusive whether a nurse consultation can improve osteoporosis-related patient outcomes. OBJECTIVE: To evaluate whether a nurse consultation immediately after dual-energy x-ray absorptiometry (DXA) produced better osteoporosis-related outcomes than a simple intervention to activate adults in good bone health practices or usual care. DESIGN: Pilot randomized controlled trial, conducted within the larger Patient Activation After DXA Result Notification (PAADRN) trial (NCT01507662). After DXA, consenting adults age 50 years or older were randomly assigned to 3 groups: nurse consultation, PAADRN intervention (mailed letter with individualized fracture risk and an educational brochure), or usual care (control). Nurse consultation included reviewing DXA results, counseling on bone health, and ordering needed follow-up tests or physician referrals. MAIN OUTCOME MEASURES: Change from baseline to 52 weeks in participant-reported osteoporosis-related pharmacotherapy, lifestyle, activation and self-efficacy, and osteoporosis care satisfaction. RESULTS: Nurse consultation participants (n = 104) reported 52-week improvements in strengthening and weight-bearing exercise (p = 0.09), calcium intake (p < 0.01), osteoporosis knowledge (p = 0.04), activation (p < 0.01), dietary self-efficacy (p = 0.06), and osteoporosis care satisfaction (p < 0.01). Compared with PAADRN intervention participants (n = 39), nurse consultation participants had improved dietary self-efficacy (p = 0.07) and osteoporosis care satisfaction (p = 0.05). No significant improvements in osteoporosis-related outcomes were achieved vs PAADRN controls (n = 70). CONCLUSION: "Just-in-time" nurse consultation yielded a few improvements over 52 weeks in osteoporosis-related outcomes; however, most changes were not different from those obtained through the lower-cost PAADRN intervention or usual care.

Patient-reported reasons for nonadherence to recommended osteoporosis pharmacotherapy.

OBJECTIVES: As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence. METHODS: Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence. RESULTS: Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%). CONCLUSION: One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence.