Financial Incentives to Improve Patient Follow-up and Weight Loss After Bariatric Surgery.

OBJECTIVE: To examine effects of a financial incentives program on follow-up and weight loss after bariatric surgery. SUMMARY BACKGROUND DATA: Consistent follow-up may improve weight loss and other health outcomes after bariatric surgery. Yet, rates of follow-up after surgery are often low. METHODS: Patients from 3 practices within a statewide collaborative were invited to participate in a 6-month financial incentives program. Participants received incentives for attending postoperative appointments at 1, 3, and 6 months which doubled when participants weighed less than their prior visit. Participants were matched with contemporary patients from control practices by demographics, starting body mass index and weight, surgery date, and procedure. Preintervention estimates used matched historic patients from the same program and control practices with the criteria listed above. Patients between the 2 historic groups were additionally matched on surgery date to ensure balance on matched variables. We conducted differ-ence-in-differences analyses to examine incentives program effects. Follow-up attendance and percent excess weight loss were measured postoperative months 1, 3, 6, and 12. RESULTS: One hundred ten program participants from January 1, 2018 to July 31, 2019 were matched to 203 historic program practice patients (November 20 to December 27, 2017). The control group had 273 preinter-vention patients and 327 postintervention patients. In difference-in-differ-ences analyses, the intervention increased follow-up rates at 1 month (+14.8%, P <0.0001), 3months (+29.4%, P <0.0001), and 6 months (+16.4%, P <0.0001), but not at 12 months. There were no statistically significant differences in excess weight loss. CONCLUSIONS: A financial incentives program significantly increased follow-up after bariatric surgery for up to 6 months, but did not increase weight loss. Our study supports use of incentivized approaches as one way to improve postoperative follow-up, but may not translate into greater weight loss without additional supports.

Racial and ethnic variances in preparedness for aging in place among US adults ages 50-80.

OBJECTIVES: To investigate the preparations made by adults to age in place and identify disparities. METHODS: A cross-sectional survey was conducted among U.S. adults ages 50-80 years old (n = 2277). Individual, environmental, social, and community factors influencing readiness for aging in place were examined using chi-square tests and logistic regression. RESULTS: Income, disability status, and household composition, emerged as influential factors, often negatively affecting minority aging. Participants' consideration of aging in place was related to their disability status (OR 1.80 [1.32, 2.45]) and age (OR age 60-69 2.06 [1.54, 2.74], age 70-80 (OR 1.98 [1.46,2.67]), compared with age 50-59). Indigenous and Black older adults reported significantly higher levels of consideration for aging in place than White older adults (Indigenous OR 7.89 [2.35, 26.42], Black OR 1.71 [1.11, 2.64]). CONCLUSION: Aging in place is best facilitated by inclusive communities that prioritize adaptive homes and accessible community services.

Perceptions of Overall Mental Health and Barriers to Mental Health Treatment Among US Older Adults.

OBJECTIVES: We surveyed older adults about their perceived mental health and their comfort discussing and engaging in mental health treatment. METHODS: A nationally representative survey of community-dwelling older adults aged 50-80 (N = 2,021), with respondents asked to rate their current mental health as compared to 20 years ago, comfort discussing their mental health, and potential hesitations to seeking treatment in the future. RESULTS: About 79.6% reported their mental health as the same or better than 20 years ago; 18.6% reported their mental health to be worse. Most respondents reported that they were comfortable (87.3%) discussing their mental health, preferring to discuss such concerns with their primary care provider (30.6%). About 28.5% of respondents did endorse some hesitation seeking mental health care in the future. CONCLUSIONS: Most older adults reported that their mental health was as good if not better than it was 20 years ago and felt comfortable discussing mental health concerns.

Female Patient Perceptions on Financial Incentives to Promote Follow-Up After Bariatric Surgery.

INTRODUCTION: Financial incentives to promote recommended behaviors have been applied in many healthcare settings, but to our knowledge, have never been tested as a strategy to improve patient follow-up after bariatric surgery. Given that females make up majority of bariatric surgery patients, our goal was to explore female patient perceptions on the effects of a financial incentive program designed to increase follow-up after bariatric surgery. METHODS: This was an exploratory qualitative study of patient participants in a pilot program investigating financial incentives. We performed qualitative interviews with female patients to include personal experiences with bariatric surgery, progress toward goals, and concerns related to post-surgical behaviors. The data was analyzed iteratively through inductive thematic analysis. RESULTS: Twenty-one female patients who had undergone bariatric surgery and enrolled in the financial incentive program participated in this study. Participants had generally positive impressions of the financial incentive program. Participants described the utility of the program in helping to pay for expenses associated with bariatric surgery; feeling that participation was their way of demonstrating that they were compliant with post-surgical recommendations; and that it provided additional motivation. All patients stated that even without the financial incentive they would have continued to follow-up. CONCLUSIONS: While financial incentives can provide additional motivation for patients following bariatric surgery, they are not the primary reason that patients choose to follow-up. Understanding the motivation of patients who choose to follow-up (or not) may better inform investigations intended to improve follow-up rates after bariatric surgery.

Firearm ownership, attitudes, and safe storage practices among a nationally representative sample of older U.S. adults age 50 to 80.

Firearms are a leading cause of injury mortality across the lifespan, with elevated risks for older adult populations. To inform prevention efforts, we conducted a probability-based web survey (12/1/2019-12/23/2019) of 2048 older adults (age 50-80) to characterize national estimates of firearm ownership, safety practices, and attitudes about health screening, counseling, and policy initiatives. Among older U.S. adults, 26.7% [95%CI = 24.8%-28.8%] report owning one or more firearms. The primary motivation for ownership was protection (69.5%), with 90.4% highlighting a fear of criminal assault. 39.4% of firearm owners reported regularly storing firearm(s) unloaded and locked, with 24.2% regularly storing at least one loaded and unlocked. While most firearm owners found healthcare screening (69.2% [95%CI: 64.9-73.1]) and safety counseling (63.2% [95%CI = 58.8-67.3]) acceptable, only 3.7% of older adults reported being asked about firearm safety by a healthcare provider in the past year. Among firearm owners, there was support for state-level policy interventions, including allowing family/police to petition courts to restrict access when someone is a danger to self/others (78.9% [95%CI = 75.1-82.3]), comprehensive background checks (85.0% [95%CI = 81.5-87.9]), restricting access/ownership under domestic violence restraining orders (88.1%; 95%CI = 84.9-90.7], and removing firearms from older adults with dementia/confusion (80.6%; 95%CI = 76.8-84.0]. Healthcare and policy-level interventions maintained higher support among non-owners than owners (p's < 0.001). Overall, data highlights opportunities exist for more robust firearm safety prevention efforts among older adults, particularly healthcare-based counseling and state/federal policies that focus on addressing lethal means access among at-risk individuals.

Cost-sharing With Medicaid Expansion in Michigan: Obligations and Propensity to Pay.

BACKGROUND: Six states expanding Medicaid under the Affordable Care Act have obtained waivers to incorporate cost-sharing. OBJECTIVE: We describe the magnitude and distribution of cost-sharing imposed by the Healthy Michigan Plan and enrollees' propensity to pay. RESEARCH DESIGN: Enrollees are followed for at least 18 months (6-mo baseline period for utilization and spending before receipt of first cost-sharing statement; ≥12 mo follow-up thereafter to ascertain obligations and payments). Analyses stratified by income, comparing enrollees with income less than Federal Poverty Level (FPL) who faced only utilization-based copayments and those greater than or equal to FPL who also faced premium contributions. SUBJECTS: A total of 158,322 enrollees aged 22-62 who initially enrolled during the first year of the program and remained continuously enrolled ≥18 months. RESULTS: Among those enrolled ≥18 months, 51.0% faced cost-sharing. Average quarterly invoices were $4.85 ($11.11 for those with positive invoices) for income less than FPL and $26.71 ($30.93 for those with positive invoices) for incomes greater than or equal to FPL. About half of enrollees with obligations made at least partial payments, with payments being more likely among those >100% FPL. Payment of the full obligation was highest in the initial 6 months. CONCLUSIONS: Many payment obligations go uncollected, suggesting that in a system without the threat of disenrollment, the impacts of cost-sharing may be muted. Similarly, the ability of cost-sharing to defray the program's budgetary impact may also be less than anticipated.

Completing the MISSION: a Blueprint for Helping Veterans Make the Most of New Choices.

The June 6, 2019, implementation of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act commenced a new era in health care for Veterans in which the more than 9 million Veterans who use VA care can now choose community (i.e., non-VA) clinicians or facilities when certain new criteria are met. This expansion of Veterans' health care options could give many Veterans more freedom to decide which settings best meet their individual needs and expectations, and could also lead to unintended consequences for Veterans who do not have all of the information they need to make personalized decisions about VA and community care. In this Perspective article, we recommend initial steps that VA leaders and VA clinicians need to take, and community clinicians should be aware of, in order to ensure that Veterans' expanded health care options translate into improvements in their access and outcomes.

Primary Care, Health Promotion, and Disease Prevention with Michigan Medicaid Expansion.

BACKGROUND: Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services. OBJECTIVE: Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services. DESIGN: Telephone survey conducted during January-November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment. PARTICIPANTS: 4090 HMP enrollees aged 19-64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services' copayments. Utilization of preventive services was assessed using Medicaid claims. KEY RESULTS: In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor's office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor's office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services. CONCLUSIONS: After enrolling in Michigan's Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services.

Attitudes About Consumer Strategies Among Americans in High-deductible Health Plans.

BACKGROUND: More than 70 million Americans are enrolled in a high-deductible health plan (HDHP), with high upfront cost-sharing to encourage strategies such as price shopping to mitigate out-of-pocket spending. Recent research suggests HDHP enrollees are reluctant to engage in these consumer strategies, but there is little information on why. OBJECTIVES: To describe associations between HDHP enrollees' attitudes about and intent to engage in consumer strategies. RESEARCH DESIGN: We conducted a nationally representative web survey of 1637 HDHP enrollees that included 2 hypothetical scenarios amenable to consumer strategies. For each scenario, we asked participants whether they would compare price or quality information, discuss cost with a provider, or try to negotiate a service price. We measured participants' ratings of the difficulty of each strategy, its effectiveness at reducing cost or increasing the likelihood of getting care, and how likely participants would be to actually engage in each strategy. RESULTS: Fewer than half of HDHP enrollees intended to engage in any of the surveyed strategies. Enrollees who viewed a consumer strategy as helpful were more likely to engage in that strategy; no associations were found with perceived difficulty of a strategy and intent to engage in it. CONCLUSIONS: HDHP enrollees may not pursue consumer strategies because they believe they are not helpful for getting care or lowering costs. Providers and payers should ensure these strategies are actually helpful to HDHP enrollees and that enrollees understand how they could use these strategies to reduce their out-of-pocket costs.

Diagnosis and Care of Chronic Health Conditions Among Medicaid Expansion Enrollees: a Mixed-Methods Observational Study.

BACKGROUND: It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions. OBJECTIVE: Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being. DESIGN: Mixed-methods study including a telephone survey and semi-structured interviews. SETTING: Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP). PARTICIPANTS: 4090 survey respondents (response rate 54%) with ≥ 12 months HMP enrollment and 67 interviewees with ≥ 6 months enrollment. MAIN MEASURES: Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status. KEY RESULTS: Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health. CONCLUSIONS: Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.

Changes in Health and Ability to Work Among Medicaid Expansion Enrollees: a Mixed Methods Study.

BACKGROUND: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy. OBJECTIVE: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities. CONCLUSIONS: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.

Building Toward a Population-Based Approach to Diabetes Screening and Prevention for US Adults.

PURPOSE OF REVIEW: Evidence-based treatments for prediabetes can prevent and delay the development of type 2 diabetes in adults. In this review, we propose a framework for population-based diabetes prevention that links screening and prevention activities across key stakeholders. We also discuss gaps in current practice, while highlighting opportunities to improve diabetes screening and prevention efforts population-wide. RECENT FINDINGS: Awareness of diabetes risk is low, and many adults with prediabetes are not identified through existing screening efforts. Accumulating evidence and policies support expansion of the Diabetes Prevention Program (DPP) into clinical and community settings. However, the infrastructure to facilitate referrals and promote data exchange among patients, clinical settings, and community-based DPP programs is lacking. Development of evidence-driven, scalable processes for assessing diabetes risk, screening eligible adults, and delivering preventive treatments are needed to effectively improve the glycemic health of the US adult population.

Association Between Purpose in Life and Glucose Control Among Older Adults.

Background: Greater purpose in life is associated with lower rates of certain chronic diseases. Whether purpose in life can protect against development of prediabetes or type 2 diabetes is unknown. Purpose: To examine the association between purpose in life and blood glucose control among adults ≥50 years. Methods: We conducted a longitudinal cohort study of 3,907 participants of the Health and Retirement Study who at baseline did not have type 2 diabetes or prediabetes. Baseline purpose in life was measured using the Ryff and Keyes' Scales of Psychological Well-Being and grouped into tertiles (high, medium, and low). We used multivariable linear regression to examine the association between baseline purpose in life and HbA1c over 4 years. Multivariable logistic regression was used to examine the association between baseline purpose and incident prediabetes or type 2 diabetes over the same period. Results: After adjusting for sociodemographic factors, body mass index, physical activity, and physical and mental health factors, HbA1c was 0.07 percentage points lower among participants with high purpose than those with low purpose (95% confidence interval [CI] -0.12 to -0.02; p = .011). Participants with high purpose had lower odds of developing prediabetes or type 2 diabetes than those with low purpose (adjusted odds ratio 0.78; 95% CI 0.62 to 0.98; p = .037). Conclusions: Among older adults, greater purpose in life is associated with a lower incidence of prediabetes or type 2 diabetes. Strategies to promote greater purpose in life should be tested as a part of type 2 diabetes prevention efforts.

Polypharmacy and Deprescribing.

This JAMA Patient Page describes the problem of polypharmacy and its consequences, and how deprescribing can reduce polypharmacy.

Perceived Barriers to Implementing Individual Choosing Wisely® Recommendations in Two National Surveys of Primary Care Providers.

BACKGROUND: While some research has examined general attitudes about efforts to reduce overutilization of services, such as the Choosing Wisely® (CW) initiative, little data exists regarding primary care providers' attitudes regarding individual recommendations. OBJECTIVE: We sought to identify whether particular CW recommendations were perceived by primary care providers as difficult to follow, difficult for patients to accept, or both. DESIGN: Two national surveys, one by mail to a random sample of 2000 U.S. primary care physicians in November 2013, and the second electronically to a random sample of 2500 VA primary care providers (PCPs) in October-December 2014. PARTICIPANTS: A total of 603 U.S. primary care physicians and 1173 VA primary care providers. Response rates were 34 and 48 %, respectively. MAIN MEASURES: PCP ratings of whether 12 CW recommendations for screening, testing and treatments applicable to adult primary care were difficult to follow and difficult for patients to accept; and ratings of potential barriers to reducing overutilization. KEY RESULTS: For four recommendations regarding not screening or testing in asymptomatic patients, less than 20 % of PCPs found the CW recommendations difficult to accept (range 7.2-16.6 %) or difficult for patients to follow (12.2-19.3 %). For five recommendations regarding testing or treatment for symptomatic conditions, however, there was both variation in reported difficulty to follow (9.8-32 %) and a high level of reported difficulty for patients to accept (35.7-87.1 %). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists. CONCLUSIONS: While PCPs found many CW recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. Overcoming PCPs' perceptions of patient acceptability will require approaches beyond routine physician education, feedback and financial incentives.

A Scoping Review of Behavioral Economic Interventions for Prevention and Treatment of Type 2 Diabetes Mellitus.

PURPOSE OF REVIEW: The purpose of this paper was to review studies of behavioral economic interventions (financial incentives, choice architecture modifications, or commitment devices) to prevent type 2 diabetes mellitus (T2DM) among at-risk patients or improve self-management among patients with T2DM. RECENT FINDINGS: We found 15 studies that used varied study designs and outcomes to test behavioral economic interventions in clinical, workplace, or health plan settings. Of four studies that focused on prevention of T2DM, two found that financial incentives increased weight loss and completion of a fasting blood glucose test, and two choice architecture modifications had mixed effects in encouraging completion of tests to screen for T2DM. Of 11 studies that focused on improving self-management of T2DM, four of six tests of financial incentives demonstrated increased engagement in recommended care processes or improved biometric measures, and three of five tests of choice architecture modifications found improvements in self-management behaviors. Though few studies have tested behavioral economic interventions for prevention or treatment of T2DM, those that have suggested such approaches have the potential to improve patient behaviors and such approaches should be tested more broadly.

Workplace Interventions to Prevent Type 2 Diabetes Mellitus: a Narrative Review.

PURPOSE OF REVIEW: This study aims to summarize the recent peer-reviewed literature on workplace interventions for prevention of type 2 diabetes mellitus (T2DM), including studies that translate the Diabetes Prevention Program (DPP) curriculum to workplace settings (n = 10) and those that use different intervention approaches to achieve the specific objective of T2DM prevention among employees (n = 3). RECENT FINDINGS: Weight reduction was achieved through workplace interventions to prevent T2DM, though such interventions varied substantially in their effectiveness. The greatest weight loss was reported among intensive lifestyle interventions (i.e., at least 4 months in duration) that implemented the structured DPP curriculum (n = 3). Weight reduction was minimal among less intensive interventions, including those that substantially modified the DPP curriculum (n = 2) and those that used non-DPP intervention approaches to prevent T2DM (n = 3). Most studies (n = 12) reported increased levels of physical activity following the intervention. Implementation of the DPP in workplaces may be an effective strategy to prevent T2DM among employees.

Understanding type 2 diabetes mellitus screening practices among primary care physicians: a qualitative chart-stimulated recall study.

BACKGROUND: Early diagnosis and treatment of prediabetes and type 2 diabetes mellitus (T2DM) can prevent future health problems, yet many individuals with these conditions are undiagnosed. This could be due, in part, to primary care physicians' (PCP) screening practices, about which little is known. The objectives of this study were to identify factors that influence PCPs' decisions to screen patients for T2DM and to characterize their interpretation and communication of screening test results to patients. METHODS: We conducted semi-structured chart-stimulated recall interviews with 20 University of Michigan Health System (UMHS) primary care physicians. PCPs were asked about their recent decisions to screen or not screen 134 purposively sampled non-diabetic patients who met American Diabetes Association criteria for screening for T2DM. Interviews were audio-recorded, transcribed, and analyzed using qualitative directed content analysis. Data on patient demographic characteristics and comorbidities were abstracted from the electronic health record. RESULTS: The most common reasons PCPs gave for not screening 63 patients for T2DM were knowledge of a previously normal screening test (49%) and a visit for reasons other than a health maintenance examination (48%). The most common reasons PCPs gave for screening 71 patients for T2DM were knowledge of a previously abnormal screening test (49%), and patients' weight (42%) and age (38%). PCPs correctly interpreted 89% of screening test results and communicated 95% of test results to patients. Among 24 patients found to have prediabetes, PCPs usually (58%) recommended weight loss and increased physical activity but never recommended participation in a Diabetes Prevention Program or use of metformin. CONCLUSIONS: Previous screening test results, visit types, and patients' weight and age influenced PCPs' decisions to screen for T2DM. When patients were screened, test results were generally correctly interpreted and consistently communicated. Recommendations to patients with prediabetes could better reflect evidence-based strategies to prevent T2DM.