A Total Knee Arthroplasty Preoperative Optimization Program Managed by an Advanced Practice Provider (Physician Assistant) Decreases Complications and Cost: A Pilot Study.

BACKGROUND: Studies have shown that optimizing modifiable risk factors leads to improved outcomes, with decreased lengths of stay (LOS), readmissions, complications, and hospital costs. Our goal was to demonstrate that use of an advanced practice provider, physician assistant (PA), within an orthopaedic practice would support these outcomes. METHODS: A preoperative optimization program managed by a PA was instituted at an academic medical center. From November 2019 to December 2022, a pilot group of fifteen (15) consecutive primary total knee arthroplasty (TKA) patients who were successfully optimized with the PA-managed program prior to TKA were matched 2:1 to a cohort of thirty (30) TKA patients who did not undergo optimization. Demographics and the modified readmission risk assessment tool score were used to match patients. Variables evaluated included LOS, emergency department visits, and hospital readmissions within 30 and 90 days after surgery, complications, and hospital costs of care. RESULTS: Optimized patients had less complications (P = .004) and significantly shorter (P < .001) mean LOS (1.27 days vs 2.97 days) compared to nonoptimized patients. The difference of hospital cost between cohorts for the primary admission was significant (P = .049). When readmission costs were included, the average hospital cost for the nonoptimized group was significantly higher than the optimized group (P = .018). CONCLUSIONS: Preoperative optimization led by a PA demonstrated significant reductions in LOS and the costs of care between optimized and non-optimized patients, along with decreased complications.

Telemedicine Hip and Knee Arthroplasty Experience During COVID-19.

BACKGROUND: Although telemedicine visits were essential and adopted by providers and patients alike, few studies have been conducted evaluating orthopedic patient perception of the care delivered during these visits. To our knowledge, no study has evaluated specific factors that affected patient satisfaction with telemedicine and the receptiveness to continue virtual visits post COVID-19 in total joint arthroplasty (TJA) patients. Thus, the purposes of our study are to determine the following: (1) patient satisfaction with using TJA telemedicine services, (2) whether patient characteristics might be associated with satisfaction, and (3) whether virtual clinic visits may be used post-COVID-19. METHODS: A prospective, cross-sectional survey study was completed by 126 TJA patients who participated in telemedicine visits with TJA surgeons from May 1, 2020 to August 31, 2020. The survey consisted of questions regarding demographics, satisfaction, and telemedicine experiences. RESULTS: One hundred one (80.2%) patients were satisfied with their telemedicine visit, with patients <80 years old (P = .008) and those with a longer commute time (P = .01) being more satisfied P = .01. There was a significant preference for in-person visits when meeting arthroplasty surgeons for the first time (P < .001), but patients were equally amenable to follow-up telemedicine visits once there was an established relationship with the surgeon. CONCLUSION: Younger patients, patients with longer commute distances, and patients who had established relationships with their provider expressed higher satisfaction with telemedicine arthroplasty visits. Although >80% of patients were satisfied with their telemedicine visit, an established patient-provider relationship may be integral to the success of an arthroplasty telemedicine practice.

Community-based case management and health care use in older adults: outcomes of a collaborative multiagency approach.

Case management (CM) establishes valuable connections between clients and needed supports. There are, however, mixed results on its prediction of health care use. This quasi-experimental record review (N = 96) of a collaborative CM consortium examined predictors of health care use among older adults (aged older than 60 years) who had received CM for at least 6 months. Descriptive, bivariate, and multivariate models were used to predict differences in outcomes (hospitalization and emergency room [ER] visits) between participants who received CM and those who did not. Hospitalization rates were significantly lower among CM recipients. Living alone, identifying as White/non-Hispanic, and higher numbers of medications were significant copredictors of hospital use. CM was not a significant predictor of ER use. Race/ethnicity, however, remained significant in that White/non-Hispanic participants were 4 times likely to have at least 1 ER visit than persons of color. Implications for future research are discussed to promote better understanding of the effectiveness of CM, particularly within ethnically and racially diverse communities. Further inquiry is needed around the experiences of older adults of color, those who live alone, or who take multiple medications as needed. Further testing of a consortium model is necessary to determine value added through a multiagency approach.

Aging well and gay in rural America: a case study.

Using person-environment-fit theory as a theoretical framework, this qualitative case study examined, through in-depth interviews and thematic analysis, the lived experience of an older gay man who has lived solely in rural communities. An overarching theme of life satisfaction clearly emerged, along with themes regarding supportive social networks and disclosure management of his sexual orientation. The findings suggest that although it is important to understand the challenges faced by the lesbian, gay, bisexual, and transgender community in rural environments, it is equally important to shed light on the ways in which older adults age well within these communities.

A Digital Platform for the Self-Management of Knee Arthritis: MyArthritisRx.com.

MyArthritisRx.com (MARx) is an online digital platform with resources to effectively manage osteoarthritis and directs patients to the appropriate information and tools to manage their disease. The key to self-management is a self-evaluation and staging program powered by an algorithm based on 150,000 arthritis patients. Outcome data (PROMs), comorbidities, demographics, and personalized characteristics are used to provide a personalized self-evaluation and staging assessment which characterizes disease severity and risk of progression. The initial 6-week program was completed by 100 pilot patients with 92% reporting some improvement. MARx offers evidence of efficacy with promise of cost savings and improved arthritis care.

Linking neighborhood characteristics to food insecurity in older adults: the role of perceived safety, social cohesion, and walkability.

Among the 14.6% of American households experiencing food insecurity, approximately 2 million are occupied by older adults. Food insecurity among older adults has been linked to poor health, lower cognitive function, and poor mental health outcomes. While evidence of the association between individual or household-level factors and food insecurity has been documented, the role of neighborhood-level factors is largely understudied. This study uses data from a representative sample of 1,870 New York City senior center participants in 2008 to investigate the relationship between three neighborhood-level factors (walkability, safety, and social cohesion) and food insecurity among the elderly. Issues relating to food security were measured by three separate outcome measures: whether the participant had a concern about having enough to eat this past month (concern about food security), whether the participant was unable to afford food during the past year (insufficient food intake related to financial resources), and whether the participant experienced hunger in the past year related to not being able to leave home (mobility-related food insufficiency). Unadjusted and adjusted logistic regression was performed for each measure of food insecurity. Results indicate that neighborhood walkability is an important correlate of mobility-related food insufficiency and concern about food insecurity, even after controlling the effects of other relevant factors.

The influence of neighborhood factors on the quality of life of older adults attending New York City senior centers: results from the Health Indicators Project.

PURPOSE: To examine the association between self-assessed quality of life (QOL) and perceived neighborhood safety, social cohesion, and walkability among older adults in New York City (NYC). METHODS: We used data from the 2008 Health Indicators Project, a cross-sectional survey of 1,870 older adults attending 56 NYC senior centers. QOL, a binary measure, was created by dichotomizing a 5-point Likert-scaled global assessment. Neighborhood safety, social cohesion, and walkability were multi-component scale variables that were standardized due to varying response metrics. Multivariate binomial logistic regression analysis was performed on 1,660 participants with complete data. RESULTS: After adjusting for covariates, QOL was significantly associated with neighborhood safety and social cohesion. A one-standard deviation increase in neighborhood safety and social cohesion increased the log odds of having higher QOL by 30% (odds ratio (OR) = 1.30; 95% confidence interval (CI) = 1.14, 1.48; P ≤ 0.001) and 36% (OR = 1.36; 95% CI = 1.16, 1.59; P ≤ 0.001), respectively. Higher QOL was not significantly associated with neighborhood walkability. CONCLUSION: The results of this study underscore the need for initiatives that focus on enhancing age-friendly neighborhood features in large urban centers such as NYC and beyond.

Racial and ethnic diversity in senior centers: comparing participant characteristics in more and less multicultural settings.

The 2008 Health Indicators Project surveyed a probability sample (N = 1,870) of New York City senior center participants. Attendees of racially and ethnically diverse and nondiverse senior centers were compared across 5 domains: demographics; health and quality of life; social support networks; neighborhood perceptions and engagement; health service access/utilization. Although homogeneous and diverse center participants demonstrate similar health and quality-of-life outcomes, those from diverse centers demonstrate greater risk of social isolation, receive less family support, and more likely seek medical care from hospitals or community clinics. Implications and future directions for research, practice and policy are discussed.

The National Family Caregiver Support Program: a multivariate examination of state-level implementation.

Research on caregiver support policy implementation has offered valuable insights but has not incorporated theoretical frameworks or multivariate analysis. This article describes how the communications model for intergovernmental policy implementation was used as a framework to examine predictors of successful statewide implementation of the National Family Caregiver Support Program (NFCSP). Using data from the National Center on Caregiving State of the States survey, U.S. Census, Administration on Aging, and historical records, implementation (extent of service delivery) was examined in 50 states and the District of Columbia. State-level characteristics (demographic, historical, political, and organizational) were tested for their ability to explain more or less successful implementation. Bivariate and multivariate findings suggest that historical characteristics predict the likelihood of delivering more counseling, support group, and training. States that recognize caregivers as both service recipients (through counseling and support groups) and service providers (through training) may demonstrate more effective implementation.

Weight loss before total joint arthroplasty using a remote dietitian and mobile app: study protocol for a multicenter randomized, controlled trial.

BACKGROUND: The months prior to elective surgery may present an opportunity for patients to initiate behavior changes that will simultaneously ready them for surgery and improve their overall health status. An upcoming elective total joint arthroplasty (TJA) may serve as motivation for patients with severe obesity (body mass index [BMI]> 40 kg/m2) to lose weight, as it may optimize clinical outcomes following TJA and help them become eligible for TJA since some surgeons use a BMI of 40 kg/m2 as a cut-off for offering surgery in an effort to optimize outcomes. METHODS: The purpose of this multicenter randomized, controlled trial is to assess the feasibility and efficacy of a 12-week remote dietitian (RD) supervised dietary and physical activity weight loss intervention and mobile app for 60 patients with severe obesity prior to undergoing TJA. Intervention participants will receive access to a smartphone app and connect with an RD who will contact these participants weekly or bi-weekly via video calls for up to nine video calls. Together, participants and RDs will set goals for lifestyle modifications, and RDs will check on progress towards achieving these goals using in-app tools such as food logs and text messages between video calls. All patients will be encouraged to lose at least 20 pounds with a goal BMI < 40 kg/m2 after 12 weeks. Individuals randomized to the control group will receive clinical standard of care, such as nutritionist and/or physical therapy referrals. Outcome and demographic data will be collected from blood serology, chart review, mobile app user data, pre- and postintervention surveys, and phone interviews. The primary outcome measure will be weight change from baseline. Secondary outcome measures will include percentage of patients eligible to undergo TJA, number of sessions completed with dietitians, self-reported global health status (PROMIS Global Health scale), self-reported joint-specific pain and function (Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS)), and serologies such as hemoglobin A1c, total lymphocyte count, albumin, and transferrin. Qualitative responses transcribed from phone interviews about the intervention will also be analyzed. DISCUSSION: This will be the first study to assess pre-operative weight loss in patients with severe obesity anticipating orthopaedic surgery using an RD and mobile app intervention aimed at helping patients become eligible for TJA. TRIAL REGISTRATION: Registered on 1 April 2020 at Clincialtrials.gov. Trial number is NCT04330391 .

Racial and ethnic variations in caregiver service use.

OBJECTIVE: This article examines whether race and ethnicity contribute to the differential use of caregiver support services, when controlling for caregiver and care recipient characteristics, as represented by predisposing, enabling, and need factors included in the Behavioral Model of Health Services Use. METHODS: The study includes 1,508 individuals who provide care to an ill or disabled adult aged 50 or older, identified through a random digit dial telephone survey of California households. Logistic regression analysis is utilized to examine factors that predict use of caregiver support services. RESULTS: Race and ethnicity do not contribute significantly to caregiver service utilization, when controlling for relevant covarying factors such as age, education, emotional support, family contribution, care recipient service use, and care recipient impairment. A significant interaction exists between ethnicity and family closeness, with reduced rates of service use among Asian and Pacific Island caregivers whose families are brought closer by the caregiving experience. DISCUSSION: These findings suggest that racial and ethnic disparities in caregiver service use found at the bivariate level are attributable to covarying predisposing, enabling, and need factors. Further research and theoretical development are suggested to clarify the impact of sociocultural factors on caregiver service use.

Storm Impact and Depression Among Older Adults Living in Hurricane Sandy-Affected Areas.

OBJECTIVE: Research on the impact of natural disasters on the mental health of older adults finds both vulnerabilities and resilience. We report on the rates of clinically significant depression among older adults (aged ≥60 years) living in areas affected by Hurricane Sandy in 2012 and the factors associated with mental health need. METHODS: The Sandy Mobilization, Assessment, Referral and Treatment for Mental Health (SMART-MH) program integrates community outreach and needs assessments to identify older adults with mental health and aging service needs. Older adults with significant anxiety or depressive symptoms were offered short-term psychotherapy. Social service referrals were made directly to community agencies. All SMART-MH activities were offered in Spanish, Russian, Mandarin/Cantonese, and English. RESULTS: Across the full sample, 14% of participants screened positive for depression. Hurricane Sandy stressors predicted increased odds of depression, including storm injury, post-storm crime, and the total count of stressors. Outcomes varied significantly by age group, such that all Sandy-related variables remained significant for younger-old adults (aged 60-74 years), whereas only the loss of access to medical care was significant for older-old adults (aged ≥75 years). CONCLUSIONS: Storm-affected communities show higher rates of depressive symptoms than seen in the general population, with storm stressors affecting mental health needs differentially by age group. (Disaster Med Public Health Preparedness. 2017;11:97-109).

Integrating Assessment and Evaluation Into Partnership Initiatives: Lessons From the Community Partnerships for Older Adults.

Communities nationwide have formed cross-sector partnerships to face the needs of an aging population, particularly for the purpose of improving long-term supportive service systems. Research is limited on how evaluation strategies are incorporated into partnership work, especially in the field of aging. This retrospective qualitative study reviewed administrative and key informant interview data to examine how 15 community partnerships (CPs) within the Community Partnerships for Older Adults (CPFOA) national program incorporated evaluation into their work. The four overarching lessons drawn from our inquiry suggest that effective CPs: (a) incorporate both formative and summative methods into evaluation, (b) use and develop the knowledge and skills of its members, (c) support flexible and creative evaluation methods and strategies, and (d) use internal and external resources to support evaluation efforts, particularly with nontraditional partners. There is a need for continued research to capture the methodological complexity of partnership evaluation.

Parkinson's disease caregiving: implications for care management.

The primary objective of this study was to identify the needs of caregivers of individuals with Parkinson's disease within the context of the common functional, memory, and behavioral problems experienced by Parkinson's patients. A second objective was to evaluate any differences between caregivers of Parkinson's patients and caregivers of adults with other forms of cognitive impairment. Data used for this analysis were collected in 1999, by the 11 Caregiver Resource Centers that form California's statewide Caregiver Resource Center system, as part of the uniform caregiver assessment process. Parkinson's disease caregivers requested assistance with emotional support, respite, and behavior management. Compared with caregivers of non-Parkinson's patients served by the CRC system, caregivers of Parkinson's patients were primarily older, entered the CRC system later, and demonstrated increased depression and other health conditions.

Care management in long-term care insurance: meeting the needs of policyholders?

Despite the increase in long-term care insurance (LTCI) sales, little attention has been given to the quality of services provided to policyholders receiving benefits. This article describes a qualitative analysis of care management (CM) services within LTCI. Key components of analysis included the assessment and care planning process, service coordination, monitoring of policyholder needs, discharge planning, and consumer knowledge and satisfaction. Extensive case record reviews, including longitudinal in-person and telephone interviews with policyholders, caregivers, and other stakeholders, were performed to gain insight into the CM process as experienced by LTCI policyholders under the California Partnership for Long-Term Care. Results suggest that CM may be somewhat restricted under LTCI. While the basic CM services available to policyholders may be appropriate for addressing the simple needs, individuals with chronic and unstable disabling conditions may require a more comprehensive form of CM.

Mind-body techniques, race-ethnicity, and depression among urban senior center participants.

As the older adult population grows and becomes more diverse, more of its members are turning to complementary and alternative medicine (CAM). There are mixed findings regarding racial and ethnic differences in the use of CAM. This article explores racial and ethnic differences in use of a category of CAM known as mind-body techniques (MBT) among senior center participants with symptoms of depression. It also examines the relationship between use of MBT and depression severity. A cross-sectional survey was conducted with a representative sample of senior center participants in New York City, from which a subsample of those with depressive symptoms was drawn. Racial and ethnic differences in MBT use were identified, as was a significant negative relationship between MBT use and depression severity. African American elders were more likely to have used MBT than other racial or ethnic groups. When controlling for race or ethnicity, health status, and barriers to medical care, predictors of depression severity included health status, experiencing barriers to medical care, and Hispanic identity. Findings suggest that being female or younger is associated with a higher likelihood of using CAM. Contrary to some prior research, education level was not associated with use of MBT.

The impact of insurance on satisfaction and family-centered care for CSHCN.

BACKGROUND: Children with special health care needs (CSHCN) have worse health outcomes and satisfaction compared with children with typical needs. Although individual characteristics influence satisfaction and family-centered care, additional effects of health insurance and state child health policies are unknown. OBJECTIVES: To determine if satisfaction and family-centered care varied among CSHCN, after adjusting for individual characteristics, according to insurance type and state child health policies. METHODS: We performed descriptive and multivariate analyses by using demographic, insurance, and satisfaction data from the 2006 National Survey of Children With Special Health Care Needs (N = 40723). Additional state data included Medicaid and State Children's Health Insurance Program (SCHIP) characteristics and the supply of pediatricians. We supplemented the national findings with survey data from Florida's SCHIP comprehensive care program (CMS-Duval ["Ped-I-Care"]) for CSHCN (N = 300). RESULTS: Nationally, 59.8% of parents were satisfied with their child's health services, and two thirds (65.7%) received family-centered care. Adjusting for individual predictors, those uninsured and those with public insurance were less satisfied (odds ratios [ORs]: 0.45 and 0.83, respectively) and received less family-centered care (ORs: 0.43 and 0.80, respectively) than privately insured children. Of note, satisfaction increased with state Medicaid spending. Survey data from Ped-I-Care yielded significantly higher satisfaction (91.7%) compared with national levels of satisfaction in the SCHIP (54.2%) and similar rates of family-centered care (65.6%). These results suggest that satisfaction is based more on experiences with health systems, whereas family-centered care reflects more on provider encounters. CONCLUSIONS: Insurance type affects both satisfaction and family-centered care for CSHCN, and certain state-level health care characteristics affect satisfaction. Future studies should focus on interventions in the health care system to improve satisfaction and patient encounters for family-centered care.