Disease-associated astrocytes and microglia markers are upregulated in mice fed high fat diet.

High-fat diet (HFD) is associated with Alzheimer's disease (AD) and type 2 diabetes risk, which share features such as insulin resistance and amylin deposition. We examined gene expression associated with astrocytes and microglia since dysfunction of these cell types is implicated in AD pathogenesis. We hypothesize gene expression changes in disease-associated astrocytes (DAA), disease-associated microglia and human Alzheimer's microglia exist in diabetic and obese individuals before AD development. By analyzing bulk RNA-sequencing (RNA-seq) data generated from brains of mice fed HFD and humans with AD, 11 overlapping AD-associated differentially expressed genes were identified, including Kcnj2, C4b and Ddr1, which are upregulated in response to both HFD and AD. Analysis of single cell RNA-seq (scRNA-seq) data indicated C4b is astrocyte specific. Spatial transcriptomics (ST) revealed C4b colocalizes with Gfad, a known astrocyte marker, and the colocalization of C4b expressing cells with Gad2 expressing cells, i.e., GABAergic neurons, in mouse brain. There also exists a positive correlation between C4b and Gad2 expression in ST indicating a potential interaction between DAA and GABAergic neurons. These findings provide novel links between the pathogenesis of obesity, diabetes and AD and identify C4b as a potential early marker for AD in obese or diabetic individuals.

Rural-Urban Differences in Use of Dental Services and Procedures Among Medicare Beneficiaries in 2018.

OBJECTIVE: Medicare beneficiaries in rural areas may face challenges in access to dental care. This study assessed rural-urban differences in the use of dental services and dental procedures by Medicare beneficiaries. METHODS: We obtained data from the 2018 Medicare Current Beneficiary Survey cost and use files. Outcome variables examined in this study were (1) dental visits (yes/no), whether the Medicare beneficiary had ≥1 dental visit in the past year, and (2) dental procedures-preventive (yes/no), restorative (yes/no), and surgical procedures (yes/no)-whether the beneficiary had the procedure in a dental visit. The independent variable was the beneficiary's residence (rural vs urban). We used multiple logistic regression to analyze data and accounted for the survey design of the Medicare Current Beneficiary Survey. The analytic sample included 7377 respondents aged ≥65 years. RESULTS: Approximately 57.0% (95% CI, 54.9%-59.0%) and 46.4% (95% CI, 41.6%-51.2%) of Medicare beneficiaries in urban and rural communities in the United States had a dental visit in 2018, respectively. Rural beneficiaries were significantly less likely than their urban counterparts to have preventive procedures (adjusted odds ratio = 0.51; 95% CI, 0.36-0.72) but significantly more likely to have restorative procedures (adjusted odds ratio = 1.30; 95% CI, 1.05-1.62). CONCLUSION: We found significant disparities in use of dental services by Medicare beneficiaries in rural communities. When Medicare beneficiaries in rural areas used dental care, they were less likely than beneficiaries in urban areas to have preventive procedures but more likely to have restorative procedures, suggesting a greater burden of oral health needs among them. Policy research is needed to identify models that can incentivize prevention and improve access to dental care for Medicare beneficiaries in rural communities.

Willingness to Get a COVID-19 Vaccine and Reasons for Hesitancy Among Medicare Beneficiaries: Results From a National Survey.

OBJECTIVES: To assess (1) the willingness to get a COVID-19 vaccine among Medicare beneficiaries, (2) the associated factors, and (3) the reasons for vaccine hesitancy. METHODS: Data were taken from the Medicare Current Beneficiary Survey (MCBS) 2020 Fall COVID-19 Supplement, conducted October-November 2020. Willingness to get a COVID-19 vaccine was measured by respondents' answer to whether they would get a COVID-19 vaccine when available. We classified responses of "definitely" and "probably" as "willing to get," and responses "probably not," "definitely not," and "not sure" as "vaccine hesitancy." Reasons for vaccine hesitancy were assessed by a series of yes/no questions focusing on 10 potential reasons. The analytical sample included 6715 adults 65 years and older. We conducted a logistic regression model to assess demographic factors and other factors associated with the willingness to get a COVID-19 vaccine. All analyses were conducted in Stata 14 and accounted for the complex survey design of MCBS. RESULTS: Overall, 61.0% (95% confidence interval [CI], 59.1-63.0) of Medicare beneficiaries would be willing to get a vaccine when available. Among those who were hesitant, more than 40% reported that mistrust of the government and side effects as the main reasons. Logistic regression model results showed that non-Hispanic Blacks (adjusted odds ratio [AOR] = 0.33; 95% CI, 0.24-0.44) and Hispanics (AOR = 0.60; 95% CI, 0.47-0.77) were less willing to get a vaccine than non-Hispanic Whites; beneficiaries with an income of less than $25 000 (AOR = 0.71; 95% CI, 0.62-0.81) were less willing to get the vaccine than those with an income of $25 000 or more; those who did not think that the COVID-19 virus was more contagious (AOR = 0.53; 95% CI, 0.41-0.69) or more deadly (AOR = 0.51; 95% CI, 0.41-0.65) were also less willing to get the vaccine than those who thought that the virus was more contagious or more deadly than the influenza virus. CONCLUSIONS: The 2020 MCBS survey data showed that close to 40% of Medicare beneficiaries were hesitant about getting a COVID-19 vaccine, and the hesitancy was greater in racial/ethnic minorities. Medicare beneficiaries were concerned about the safety of the vaccine, and some appeared to be misinformed. Evidence-based educational and policy-level interventions need to be implemented to further promote COVID-19 vaccination.

Long-Term Care Market Trend and Patterns of Caregiving in the U.S.

Informal care is a major source of long-term services and supports (LTSS) for older adults in the U.S. However, the increasing gap between available family caregivers and those needing LTSS in coming years warrants better understanding of the balance between informal and formal home or community-based LTSS to meet the growing demand. The current study aimed to 1) identify patterns of informal and formal LTSS use among community-dwelling individuals, and 2) examine if the supply of formal LTSS predicts the use of informal care. These aims were investigated by linking the market supply of formal LTSS at the state-level to the Health and Retirement Survey data (N = 7,781). Results provide important empirical evidence that patterns of informal and formal LTSS use among older adults are heterogeneous and market supply of formal home and community-based services (HCBS) significantly predicts the use of informal care. Most older adults rely on informal care in combination with some formal supports, suggesting that the two systems work in tandem to meet the growing needs of LTSS. This offers important implications for states allocating resources to meet the LTSS needs of older adults and individuals with disabilities since states play key roles in U.S. long-term care policies.

Rural-urban differences in uptake of diabetes self-management education among Medicare beneficiaries: Results from the 2016 to 2018 Medicare Current Beneficiary Survey.

PURPOSE: To assess rural-urban differences in participation rates of diabetes self-management education and associated factors among Medicare beneficiaries with type 2 diabetes (T2DM). METHODS: Data were from the 2016 to 2018 Medicare Current Beneficiary Survey (MCBS). Participation in diabetes self-management education was self-reported. The study sample included 3,799 beneficiaries aged 65 years and older with self-reported T2DM. Logistic regression was used to assess the association of participation in diabetes self-management education and residential location. Sampling weights embedded in the MCBS were incorporated into all analyses. FINDINGS: Overall, the participation rate of diabetes self-management education was 46.8% (95% CI: 44.4%-49.2%). The rate was 40.3% for beneficiaries in rural areas, 48.0% for suburban areas, and 47.3% for urban areas. About 31% of beneficiaries newly diagnosed with diabetes did not participate within the past year. Controlling for other covariates, beneficiaries in rural areas were less likely to have participated in diabetes self-management education (AOR = 0.73, 95% CI: 0.55-0.95) than those living in urban areas. Asian Americans were less likely to have participated (AOR = 0.49, 95% CI: 0.28-0.84) than Whites. Those who were older, with lower education, and lower income levels were less likely to have participated (P < .05). CONCLUSIONS: Recent MCBS data indicate that more than half of Medicare beneficiaries with T2DM did not participate in diabetes self-management education, and the participation rate in rural areas was 7 percentage points lower than that ​in urban areas. The study findings highlight challenges to maximize the benefits of participating in diabetes self-management education, particularly in rural areas.

Financial Burdens of Out-of-Pocket Spending Among Medicare Fee-for-Service Beneficiaries: Role of the "Big Four" Chronic Health Conditions.

While Medicare is the universal source of health care coverage for Americans aged 65 years or older, the program requires significant cost sharing in terms of out-of-pocket (OOP) spending. We conducted a retrospective study using data from 2016 to 2018 Medicare Current Beneficiary Surveys of elderly community-dwelling beneficiaries (n = 10,431) linked with administrative data to estimate OOP spending associated with the "big four" chronic diseases (cardiovascular disease, cancer, diabetes, and chronic lung disease). We estimated a generalized linear model adjusting for predisposing, enabling, and need factors to estimate annual OOP spending. We found that beneficiaries with any of the "big four" chronic conditions spent 15% (p < .001) higher OOP costs and were 56% more likely to spend ≥20% of annual income on OOP expenditure (adjusted odds ratio = 1.56; p < .001) compared with those without any of those conditions. OOP spending appears to be heterogeneous across disease types and changing by conditions over time.

Association between home health agency ownership status and discharge to community among Medicare beneficiaries.

To investigate the association of ownership status, discharge rate and length of stay (LOS) of home health care (HH) services under the prospective payment system (PPS). We used 2016-2018 Outcome Assessment and Information Set (OASIS) data sets for Medicare beneficiaries. Two outcome variables were investigated: rate of discharge from an HH agency and LOS. Our main independent variable was ownership status: for-profit (FP) versus not-for-profit (NFP). FP agencies were 4.2% (p <.01) less likely to discharge patients to the community but more likely (7.3%; p <.001) to have longer LOS (>99 days) compared to NFPs. Findings that FP agencies were less likely to discharge patients to the community and more likely to have a longer length of stay than NFP agencies have implications for quality of care initiatives by the Medicare Post-Acute Transformation Act 2014.

Rural-Urban Differences in Dental Service Utilization and Dental Service Procedures Received Among US Adults: Results From the 2016 Medical Expenditure Panel Survey.

PURPOSE: To assess rural-urban differences in dental service use and procedures and to explore the interaction effects of individual- and county-level factors on having dental service use and procedures. METHODS: Data were from the 2016 Medical Expenditure Panel Survey (MEPS). We assessed rural-urban differences in 3 outcome variables: number of dental visits (1, 2, or 3+ visits), preventive care procedures (Yes/No), and treatment procedures (Yes/No). The study sample included 8,199 adults ≥ 18 years of age who reported at least 1 dental visit in the past year. Sampling weights embedded in MEPS were incorporated into all the analyses. FINDINGS: A significant interaction between residential location and race/ethnicity (P = .030) suggested limited access to dental visits for minority groups, especially for blacks in the more rural areas. Adults from a more rural area were less likely to have received a preventive procedure (AOR = 0.55, 95% CI: 0.35-0.87) than those from an urban area. Adults of racial/ethnic minority groups, with lower SES, and without dental insurance were less likely to have received a preventive procedure (all P < .01) but were more likely to have received a treatment procedure (all P < .05). CONCLUSIONS: The study showed rural adults were less likely to have received preventive dental procedures than their urban counterparts. Racial/ethnic minority groups living in a more rural area had even more limited access to dental services. Innovative service delivery models that integrate telehealth and community-based case management may contribute to addressing these gaps in rural communities.

Multiple chronic condition profiles and survival among oldest-old male patients with hip fracture.

To improve understanding of survival among very elderly male patients with surgically repaired hip fractures, this study applied classification techniques to multiple chronic conditions (MCC) then modeled survival by latent class. Veterans Health Administration (VHA)'s electronic medical records on male inpatients age 85-100 years (n=896) with hip fracture diagnosis and repair were used. MCC defined by Charlson and Elixhauser disorders, medications, demographic covariates, and 5 years follow-up survival were included. Latent Class Analysis (LCA) identified three classes based on patterns of MCC, medications, and demographic covariates: Low-comorbidity (16%), High-longevity (55%), and High-comorbidity (29%). Overall, survival censored at 5 years post-op averaged 717days. The Low-comorbidity group was more likely to be Hispanic, less disabled per VHA determination of eligibility for care, with less risk of postoperative emergency department (ED) visit, and taking no prescription medications. The High-longevity group had longer survival. The High-comorbidity group had more MCC, more prescription medications and shorter survival than the other two groups. Accelerated failure time (AFT) modeled associations between MCC and 5-year survival by class. In AFT models, fewer days until first postoperative ED visit was significantly associated with survival across the three classes. About one in male hip fractured veteran patients over the age of 85 had high levels of MCC and ED use and experienced shorter survival. Hip fracture patients with MCC may merit enhanced post-discharge management. Close investigation targeted to MCC and hip fractures is needed to optimize clinical practices for oldest-old patients in community healthcare systems as well as VHA.

A Model Program of Community-Based Supports for Older Adults at Risk of Nursing Facility Placement.

Transitioning an older adult into a nursing facility is a major life event for older adults (care recipients, CRs) and their family caregivers (CGs). This article describes the implementation of a community living program and presents findings on important health and well-being indicators. One hundred ninety-one participants aged 60 and older not eligible for or currently enrolled in Medicaid and meeting four risk domains (functional, health, cognitive/emotional, informal support system) were enrolled for the 10-month program. Two evidence-based interventions were blended into a comprehensive community-based approach to long-term care that included $750 per month for home care services. Measures were conducted at baseline and 6 and 12 months. Nine (6%) participants did not complete the program because of nursing facility admission. CRs had fewer physician visits (4.1 vs 7.3, P < .001), emergency department visits (0.3 vs 1.4, P < .001), hospital stays (0.4 vs 0.9, P < .001), and total nights in the hospital (0.8 vs 5.1, P < .001) at 12 months than at baseline. Center for Epidemiologic Studies Depression Scale (CES-D) scores also improved significantly (6.8 vs 9.4, P < .001). CGs had improvements in CES-D scores (5.9 vs 3.9, P < .001) and CG burden (14.7 s 12.6, P = .01) from baseline to 12 months. This multicomponent program improved the physical and mental health of CGs and CRs at risk of nursing facility placement. Future studies are needed to compare the overall placement rate to determine the success of diverting nursing facility placement in this population of older adults.

Cost-effectiveness of the chronic disease self-management program: implications for community-based organizations.

Chronic conditions are the leading cause of growing healthcare spending, disability, and death in the U.S. In the wake of national health reform, policy makers and healthcare professionals are becoming increasingly concerned in containing healthcare costs while improving quality of patient care. A basic policy question is whether the Chronic Disease Self-Management Program (CDSMP), a widely distributed evidenced-based self-managed program, can be cost-effective in managing chronic conditions while improving quality of life. Utilizing data from the National Study of CDSMP, the primary objective of the current study is to estimate cost-effectiveness of the CDSMP program among individuals with at least one chronic condition. The second objective is to determine how cost-effectiveness ratios vary by depression status. EuroQol-5D (EQ-5D) was used to measure health-related quality of life (HRQOL) of CDSMP participants, which was then converted to quality-adjusted life years (QALYs) for cost-effectiveness analysis. Participants who completed the CDSMP program experienced higher EQ-5D scores from baseline to 12-month follow-up (increased from 0.736 to 0.755; p < 0.001). The incremental cost-effectiveness ratio (ICER) ranges from $83,285 to $31,285 per QALYs, which can be comparable to the common benchmark of $50,000/QALYs. ICER by baseline depression status indicates that it will cost more per QALYs gained for those diagnosed with depression based on their Patient Health Questionnaire-8 score. However, cautions should be taken while considering this point estimate too literally because the average cost for CDSMP participants was a rough estimate and based on several simplifying assumptions. Identifying cost-effective strategies that can lower the burden of chronic disease among community-dwelling adults is critical for decision makers in allocating limited resources. Policy makers and community organizations can use this information to guide funding decisions and delivery of CDSMP programs for individuals with multiple chronic health conditions.

The Impact of the REACH II Intervention on Caregivers' Perceived Health.

The primary goal of the current study was to examine the impact of a caregiving support program on caregivers' perceived health at 6 months following baseline assessment in the Resources for Enhancing Alzheimer's Caregiver Health II (REACH II) intervention. A composite measure of perceived health was established and incorporated self-rated health, change in self-rated health, and improvement in physical health. A total of 494 participants receiving the REACH II intervention or an education-only intervention were included in this study. Mixed effect linear regression analysis was performed to examine the effect of the intervention and the factors that mediate this relationship. Findings suggest that the enhanced supportive intervention led to significant improvement in caregivers' overall perceived health at 6 months. This effect remains significant after controlling for positive satisfaction with caregiving. Improving caregivers' stress and burden while fostering positive rewards and appraisals may provide indirect health benefits and maintain overall health in dementia caregivers.

The association between office-based provider visits and emergency department utilization among Medicaid beneficiaries.

The purpose of our study was to describe the relationship between office-based provider visits and emergency department (ED) utilization by adult Medicaid beneficiaries. Data were extracted from the publicly-available Medical Expenditure Panel Survey, a nationally representative sample of the civilian non-institutionalized population in the United States. The sample included 1,497 respondents who had full year Medicaid coverage in 2009. Study variables included insurance coverage type, usual source of care, chronic illnesses, and beneficiary demographics. Multivariate analyses were conducted to describe associations between individual characteristics and (a) likelihood of any ED utilization, and (b) number of ED visits by those who utilized the ED at least once in the study year. The analysis was adjusted for demographic characteristics and chronic health conditions. A greater number of office-based provider visits was associated with a higher likelihood of ED utilization. Among those with at least one ED visit, a greater number of office-based visits was associated with a higher number of ED visits. A respondent's age, history of hypertension or myocardial infarction, and Hispanic/Latino ethnicity were associated with having one or more ED visits; age and Hispanic/Latino ethnicity were associated with total number of ED visits among those with at least one. In this representative sample of adult Medicaid beneficiaries, there was no evidence that office-based provider visits reduced ED utilization. Office visits were associated with higher ED utilization, as were certain chronic conditions, older age, and Hispanic/Latino ethnicity. Findings do not support efforts to reduce ED utilization by increasing office-based visits alone.

Retrospective cohort study of medication adherence and risk for 30-day hospital readmission in a Medicare Cost Plan.

PURPOSE: Reducing hospital readmissions requires deploying appropriate interventions to groups at highest risk for readmission. Long-term medication adherence may indicate one's ability to manage recovery and chronic illness after discharge. If so, medication adherence also may be a predictor of hospital readmission. DESIGN: The objective of this study was to test the association of long-term medication adherence with hospital readmission in a cohort of beneficiaries enrolled in a Medicare Cost Plan. METHODOLOGY: The study employed a retrospective cohort design using administrative pharmacy and health care claims for a sample hospitalized in 2009. Medication adherence was measured with the medication possession ratio (MPR) for the 12 months prior to the first hospitalization in 2009. The likelihood of readmission within 30 days from the first hospitalization in 2009 was estimated using the logistic regression model. RESULTS: Long-term medication adherence was not associated with likelihood of 30-day hospital readmission (odds ratio [OR] = 0.82, P = .71). However, older age (OR = 1.07, P = .003) and longer length of hospital stay (OR = 1.2, P < .001) were associated with higher likelihood of 30-day readmission, while having an office visit within 30 days of discharge (OR = 0.38, P = .03) was associated with lower odds of readmission. CONCLUSION: Except for older age, variables associated with likelihood of readmission are difficult for clinical teams to access during a hospital stay to identify those at risk for readmission. Additional work is needed to identify indicators of readmission risk that can be utilized during hospitalization to identify patients needing post-discharge support to help prevent readmission.

The impact of chronic disease self-management programs: healthcare savings through a community-based intervention.

BACKGROUND: Among the most studied evidence-based programs, the Chronic Disease Self-Management Program (CDSMP) has been shown to help participants improve their health behaviors, health outcomes, and reduce healthcare utilization. However, there is a lack of information on how CDSMP, when nationally disseminated, impacts healthcare utilization and averts healthcare costs. The purposes of this study were to: 1) document reductions in healthcare utilization among national CDSMP participants; 2) calculate potential cost savings associated with emergency room (ER) visits and hospitalizations; and 3) extrapolate the cost savings estimation to the American adults. METHODS: The national study of CDSMP surveyed 1,170 community-dwelling CDSMP participants at baseline, 6 months, and 12 months from 22 organizations in 17 states. The procedure used to estimate potential cost savings included: 1) examining the pattern of healthcare utilization among CDSMP participants from self-reported healthcare utilization assessed at baseline, 6 months, and 12 months; 2) calculating age-adjusted average costs for persons using the 2010 Medical Expenditure Panel Survey; 3) calculating costs saved from reductions in healthcare utilization; 4) estimating per participant program costs; 5) computing potential cost savings by deducting program costs from estimated healthcare savings; and 6) extrapolating savings to national populations using Census data combined with national health statistics. RESULTS: Findings from analyses showed significant reductions in ER visits (5%) at both the 6-month and 12-month assessments as well as hospitalizations (3%) at 6 months among national CDSMP participants. This equates to potential net savings of $364 per participant and a national savings of $3.3 billion if 5% of adults with one or more chronic conditions were reached. CONCLUSIONS: Findings emphasize the value of public health tertiary prevention interventions and the need for policies to support widespread adoption of CDSMP.

Willingness-to-pay to prevent Alzheimer's disease: a contingent valuation approach.

As the prevalence of Alzheimer's disease (AD) increases, the need to develop effective and well-tolerated pharmacotherapies for the prevention of AD is becoming increasingly important. Understanding determinants and magnitudes of individuals' preferences for AD prevention programs is important while estimating the benefits of any new pharmacological intervention that targets the prevention of the disease. This paper applied contingent valuation, a method frequently used for economic valuation of goods or services not transacted in the markets, to estimate the willingness-to-pay (WTP) to prevent AD based on the nationally representative Health and Retirement Survey data. The WTP was associated in predictable ways with respondent characteristics. The mean estimated WTP for preventing AD is $155 per month (95 % CI $153-$157) based on interval regression. On average, a higher WTP for the prescription drug for AD prevention was reported by respondents with higher perceived risks, and greater household wealth. The findings provide useful information about determinants and the magnitude of individuals' preferences for AD prevention drugs for healthcare payers and individual families while making decisions to prevent AD.

Effects of education and income on cognitive functioning among Indians aged 50 years and older: evidence from the Study on Global Ageing and Adult Health (SAGE) Wave 1 (2007-2010).

OBJECTIVES: Relatively little is known about socioeconomic predictors of cognitive health among middle-aged and elderly Indians. The primary objective of this study was to examine the extent to which education and income influence cognitive functioning after adjusting for demographic characteristics, health risk factors and transgenerational factors such as parental education. The study also examined gender disparities in cognitive functioning across geographic regions in India. METHODS: Using cross-sectional data from the World Health Organization Study on Global Ageing and Adult Health (SAGE) Wave 1 (2007-2010) in a national sample of adults aged 50 years or older, a generalized linear model was used to examine the impacts of education and per-capita income on overall cognitive functioning. The generalized estimating equation approach was utilized to quantify these impacts on respondents' overall cognitive performance score. This technique accounted for any correlation of responses of individuals within the same household. RESULTS: Respondents with primary or secondary education and those with education above secondary level scored 3.8 and 6 points (P < 0.001) respectively more than respondents who had no formal education. In a similar vein, individuals in higher per-capita income quartiles scored 0.4,1.0 and 1.8 (P < 0.001) more than respondents in the lowest income quartile. Although respondents in northern states scored 1.8 points higher than those from other geographic locations (P < 0.001), females in northern states had the worst cognitive performance (1.9 points lower) compared with females in other Indian states. In addition, early and adult life characteristics such as parental education, physical activity and a history of depression were found to be significant predictors of overall cognitive functioning. CONCLUSION: Education and income play important roles in influencing overall cognitive performance among middle-aged and elderly Indians. In addition, cognitive performance scores varied across geographic regions, and female disadvantage was observed in northern Indian states. Policies directed towards greater educational opportunities, particularly for women in northern Indian states, or promotion of physical activity programmes, have potential to improve cognitive performance and enhance cognitive health among middle-aged and older adults in India.