Facility Characteristics and Risk of Developing Pressure Ulcers in US Nursing Homes.

This research studied 12,507 residents in 1174 nursing homes from the 2004 National Nursing Home Survey. A multinomial logistic regression model was used to predict risk-adjusted probabilities of pressure ulcers with 4 stages. A medical director or a director of nursing on board reduced the odds of ulcers. Facilities offering clusters of beds for rehabilitation and special care programs for hospice care or behavior problems reduced the odds of stage IV ulcers.

Predicting State Investment in Medicaid Home- and Community-Based Services, 2000-2011.

Although state use of Medicaid home- and community-based services (HCBS) to provide long-term services and supports to older adults and individuals with physical disabilities continues to increase, progress is uneven across states. We used generalized linear models to examine state factors associated with increased allocation of Medicaid dollars to HCBS for the period 2000 to 2011. We observed enhanced growth in states that began the period with limited investment in HCBS, as reflected in significant year trends among these states. The political environment appeared to be an important influence on states' investment for states with limited initial allocation to HCBS, as was housing affordability, a policy amenable variable. There continues to be wide variation in states' relative investment, calling for additional policy attention and research.

The relation between health insurance and health care disparities among adults with disabilities.

OBJECTIVES: We examined disparities among US adults with disabilities and the degree to which health insurance attenuates disparities by race, ethnicity, and socioeconomic status (SES). METHODS: We pooled data from the 2001-2007 Medical Expenditure Panel Survey on individuals with disabilities aged 18 to 64 years. We modeled measures of access and use as functions of predisposing, enabling, need, and contextual factors. We then included health insurance and examined the extent to which it reduced observed differences by race, ethnicity, and SES. RESULTS: We found evidence of disparities in access and use among adults with disabilities. Adjusting for health insurance reduced these disparities most consistently for emergency department use. Uninsured individuals experienced substantially poorer access across most measures, including reporting a usual source of care and experiencing delays in or being unable to obtain care. CONCLUSIONS: Although health insurance is an important enabling resource among adults with disabilities, its effect on reducing differences by race, ethnicity, and SES on health care access and use was limited. Research exploring the effects of factors such as patient-provider interactions is warranted.

Disparities in access to health care among middle-aged and older adults with disabilities.

Disability is increasing among middle-aged adults and, reversing earlier trends, increasing among older adults as well. Disability is experienced disproportionately by Black and lower socioeconomic status (SES) individuals. We used Medical Expenditure Panel Survey data to examine health care disparities in access to health care for middle-aged (31 to 64 years of age) and older (65+ years of age) adults with disabilities by race and ethnicity, education, and income (n=13,174). Using logistic regression, we examined three measures of potential (e.g., usual source of care), and three measures of realized (e.g., counseling related to smoking) access. Middle-aged and older minority individuals with disabilities had lower relative risks of having usual sources of care and higher relative risks of having suboptimal usual sources of care (e.g., a place rather than a person) than White adults with disabilities. There were SES effects observed for middle-aged adults with disabilities across most measures that were, for certain measures, more pronounced than SES effects among older adults with disabilities. These findings are important, since health resources (e.g., a usual source of care) may mediate relations among disability, morbidity, and mortality. Policy actions that may mitigate the disparities we observed include financial incentives to support access to an optimal usual source of care and mechanisms to foster behavioral interventions related to smoking and exercise. Ensuring that these actions address the specific concerns of individuals with disabilities, such as physical accessibility and provider cultural competency, is essential.

Neurodevelopmental outcome of extremely low birth weight infants with Candida infection.

OBJECTIVE: Candida remains an important cause of late-onset infection in preterm infants. Mortality and neurodevelopmental outcome of extremely low birth weight (ELBW) infants enrolled in the Candida study were evaluated based on infection status. STUDY DESIGN: ELBW infants born at Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) centers between March 2004 and July 2007 who were screened for suspected sepsis were eligible for inclusion in the Candida study. Primary outcome data for neurodevelopmental impairment (NDI) or death were available for 1317 of the 1515 infants (87%) enrolled in the Candida study. The Bayley Scales of Infant Development-II or -III was administered at 18 months' adjusted age. A secondary comparison was performed with 864 infants enrolled in the NRN Generic Database during the same cohort who were never screened for sepsis and therefore not eligible for the Candida study. RESULTS: Among ELBW infants enrolled in the Candida study, 31% with Candida and 31% with late-onset non-Candida sepsis had NDI at 18 months. Infants with Candida sepsis and/or meningitis had an increased risk of death and were more likely to have the composite outcome of death and/or NDI compared with uninfected infants in adjusted analysis. Compared with infants in the NRN registry never screened for sepsis, overall risk for death were similar but those with Candida infection were more likely to have NDI (OR 1.83, 95% CI 1.01-3.33, P = .047). CONCLUSIONS: In this cohort of ELBW infants, those with infection and/or meningitis were at increased risk for death and/or NDI. This risk was highest among those with Candida sepsis and/or meningitis.

Disparities associated with Medicare Part D Star Ratings measures among patients with Alzheimer's disease and related dementias.

The Medicare Parts C and D Star Ratings system was established to improve care quality in Medicare. Previous studies reported racial/ethnic disparities in the calculation of medication adherence measures of Star Ratings in patients with diabetes, hypertension, and hyperlipidemia. This study aimed to identify possible racial/ethnic disparities in the calculation of adherence measures of Medicare Part D Star Ratings among patients with Alzheimer's disease and related dementias (ADRD) and diabetes, hypertension, or hyperlipidemia. This retrospective study analyzed the 2017 Medicare data and Area Health Resources Files. Non-Hispanic White (White) patients were compared to Black, Hispanic, Asian/Pacific Islander (Asian), and other patients on their likelihood of being included in the calculation of adherence measures for diabetes, hypertension, and/or hyperlipidemia. To adjust for the individual/community characteristics, logistic regression was used when the outcome is the inclusion in the calculation of one adherence measure; multinomial regression was used when examining the inclusion in the calculation of multiple adherence measures. Analyzing the data of 1438,076 Medicare beneficiaries with ADRD, this study found that Black (adjusted odds ratio, or OR = 0.79, 95% confidence interval, or 95% CI = 0.73-0.84) and Hispanic (OR = 0.82, 95% CI = 0.75-0.89) patients were less likely than White patients to be included in the calculation of adherence measure for diabetes medications. Further, Black patients were less likely to be included in the calculation of the adherence measure for hypertension medications than White patients (OR = 0.81, 95% CI = 0.78-0.84). All minorities were less likely to be included in calculating the adherence measure for hyperlipidemia medications than Whites. The ORs for Black, Hispanic, and Asian patients were 0.57 (95% CI = 0.55-0.58), 0.69 (95% CI = 0.64-0.74), and 0.83 (95% CI = 0.76-0.91), respectively. Minority patients were generally likely to be included in the measure calculation of fewer measures than White patients. Racial/ethnic disparities were observed in the calculation of Star Ratings measures among patients with ADRD and diabetes, hypertension, and/or hyperlipidemia. Future studies should explore possible causes of and solutions to these disparities.

Outcomes following candiduria in extremely low birth weight infants.

BACKGROUND: Candidiasis carries a significant risk of death or neurodevelopmental impairment (NDI) in extremely low birth weight infants (ELBW; <1000 g). We sought to determine the impact of candiduria in ELBW preterm infants. METHODS: Our study was a secondary analysis of the Neonatal Research Network study Early Diagnosis of Nosocomial Candidiasis. Follow-up assessments included Bayley Scales of Infant Development examinations at 18-22 months of corrected age. Risk factors were compared between groups using exact tests and general linear modeling. Death, NDI, and death or NDI were compared using generalized linear mixed modeling. RESULTS: Of 1515 infants enrolled, 34 (2.2%) had candiduria only. Candida was isolated from blood only (69 of 1515 [4.6%]), cerebrospinal fluid (CSF) only (2 of 1515 [0.1%]), other sterile site only (not urine, blood, or CSF; 4 of 1515 [0.3%]), or multiple sources (28 of 1515 [2%]). Eleven infants had the same Candida species isolated in blood and urine within 3 days; 3 (27%) had a positive urine culture result first. Most urine isolates were Candida albicans (21 of 34 [62%]) or Candida parapsilosis (7 of 34 [29%]). Rate of death or NDI was greater among those with candiduria (50%) than among those with suspected but not proven infection (32%; odds ratio, 2.5 [95% confidence interval, 1.2-5.3]) after adjustment. No difference in death and death or NDI was noted between infants with candiduria and those with candidemia. CONCLUSIONS: These findings provide compelling evidence that ELBW infants with candiduria are at substantial risk of death or NDI. Candiduria in ELBW preterm infants should prompt a systemic evaluation (blood, CSF, and abdominal ultrasound) for disseminated Candida infection and warrants treatment.

Empiric antifungal therapy and outcomes in extremely low birth weight infants with invasive candidiasis.

OBJECTIVE: To assess the impact of empiric antifungal therapy for invasive candidiasis on subsequent outcomes in premature infants. STUDY DESIGN: This was a cohort study of infants with a birth weight ≤ 1000 g receiving care at Neonatal Research Network sites. All infants had at least one positive culture for Candida. Empiric antifungal therapy was defined as receipt of a systemic antifungal on the day of or the day before the first positive culture for Candida was drawn. We created Cox proportional hazards and logistic regression models stratified on propensity score quartiles to determine the effect of empiric antifungal therapy on survival, time to clearance of infection, retinopathy of prematurity, bronchopulmonary dysplasia, end-organ damage, and neurodevelopmental impairment (NDI). RESULTS: A total of 136 infants developed invasive candidiasis. The incidence of death or NDI was lower in infants who received empiric antifungal therapy (19 of 38; 50%) compared with those who had not (55 of 86; 64%; OR, 0.27; 95% CI, 0.08-0.86). There was no significant difference between the groups for any single outcome or other combined outcomes. CONCLUSION: Empiric antifungal therapy was associated with increased survival without NDI. A prospective randomized trial of this strategy is warranted.

A profile of middle-aged and older adults admitted to nursing homes: 2000-2008.

Middle-aged adults are becoming an increasing share of the nursing home population. Minimum Data Set assessment data for 2000 and 2008 are used to explore similarities and differences in sociodemographic, residential, medical, and psychiatric characteristics of newly admitted middle-aged adults (31-64) compared to their older counterparts (65+). Relative to their share of the state population, Black middle-aged adults are overrepresented in nursing homes across 45 states and the District of Columbia. Chronic conditions, including diabetes, renal failure, chronic obstructive pulmonary disease, asthma, and circulatory/heart disorders, appeared to contribute to the increasing presence of middle-aged adults. There were substantial increases in diagnoses of psychiatric disorders at admission; psychiatric diagnoses were significantly higher among middle-aged adults. Middle-aged adults were also more likely to have residential histories of prior stays in psychiatric facilities relative to older adults. States' rebalancing efforts need to attend to the increasing presence of disability associated with chronic medical and psychiatric conditions among middle-aged adults.

Effects of the Medicaid expansion under the Affordable Care Act on health insurance coverage, health care access, and use for people with disabilities.

BACKGROUND: People with disabilities have higher health care needs, service utilization, and expenditures. They are also more likely to lack insurance and experience unmet need for medical care. There has been limited research on the effects of the Affordable Care Act Medicaid expansion on people with disabilities. OBJECTIVE: To examine the effects of the Medicaid expansion on health insurance coverage, access, and service use for working-age adults with disabilities. METHODS: A retrospective study using 11 years (2007-2017) of data from the Medical Expenditure Panel Survey - Household Components, linked to Area Health Resource Files and Local Area Unemployment Statistics (N = 40,995). Difference-in-differences multinomial logistic and linear probability models with state and year fixed-effects were used to estimate the effects. RESULTS: We found strong evidence of increased Medicaid coverage in expansion states (3.2 to 5.0 percentage points), reasonably strong evidence of reduced private insurance coverage (-2.2 to -2.5 percentage points), and some evidence of reduced uninsured rate (from no effect to -3.7 percentage points). Results suggest that the increase in Medicaid coverage was due at least in part to the "crowd-out" of private insurance in expansion states. No statistically significant effects were detected for access and use outcomes. CONCLUSIONS: Findings suggest that state Medicaid expansions led to an increase in Medicaid coverage and a decrease in private insurance coverage as well as the uninsured. However, no evidence was found for health care access and use outcomes. Further research into access and use is needed when more data become available for the post-expansion period.

The heterogeneous mechanical properties of adolescent growth plate cartilage: A study in rabbit.

The growth plate is a cartilaginous tissue that functions to lengthen bones in children. When fractured, however, the growth plate can lose this critical function. Our understanding of growth plate fracture and mechanobiology is currently hindered by sparse information on the growth plate's microscale spatial gradients in mechanical properties. In this study, we performed microindentation across the proximal tibia growth plate of 9-week-old New Zealand White rabbits (n = 15) to characterize spatial variations in mechanical properties using linear elastic and nonlinear poroelastic material models. Mean indentation results for Hertz reduced modulus ranged from 380 to 690 kPa, with a peak in the upper hypertrophic zone and significant differences (p < 0.05) between neighboring zones. Using a subset of these animals (n = 7), we characterized zonal structure and extracellular matrix content of the growth plate through confocal fluorescent microscopy and Raman spectroscopy mapping. Comparison between mechanical properties and matrix content across the growth plate showed that proteoglycan content correlated with compressive modulus. This study is the first to measure poroelastic mechanical properties from microindentation across growth plate cartilage and to discern differing mechanical properties between the upper and lower hypertrophic zones. This latter finding may explain the location of typical growth plate fractures. The spatial variation in our reported mechanical properties emphasize the heterogeneous structure of the growth plate which is important to inform future regenerative implant design and mechanobiological models.

Relations among home- and community-based services investment and nursing home rates of use for working-age and older adults: a state-level analysis.

OBJECTIVES: I examined state-level rates of nursing home use for the period from 2000 to 2007. METHODS: I used multivariate fixed-effects models to examine associations between state sociodemographic, economic, supply, and programmatic characteristics and rates of use. RESULTS: Nursing home use declined among older adults (aged ≥65 years) in more than two thirds of states and the District of Columbia but increased among older working-age adults (aged 31-64 years) in all but 2 states. State characteristics associated with these trends differed by age group. Although relatively greater state investment in Medicaid home- and community-based services coupled with reduced nursing home capacity was associated with reduced rates of nursing home care for adults aged 65 years and older, neither characteristic was associated with use among older working-age adults. Their use was associated with state sociodemographic characteristics, as well as chronic disease prevalence. CONCLUSIONS: Policy efforts to expand home- and community-based services and to reduce nursing facility capacity appear warranted. To more fully extend the Supreme Court's Olmstead decision's promise to older working-age adults, additional efforts to understand factors driving their increasing use are required.

Medicaid 1915(c) waiver use and expenditures for persons living with HIV/AIDS.

States' use of Medicaid 1915(c) waiver services for persons living with HIV/AIDS (PLWHA) has been limited. The authors examine state-level factors related to the decision to offer waiver services, as well as waiver use and expenditures in states offering waivers for PLWHA. They use fixed effects cross-sectional time series models to explore these state factors. States with Democratic governors were more likely to offer waiver services and were found to have higher rates of use and greater expenditures and to devote a larger share of long-term care dollars to waiver services for PLWHA. State supply of both institutional and residential care beds was negatively related to use and expenditures. Medicaid community-based care has been found to be related to improved outcomes and reduced costs of care. Ways to foster 1915(c) waiver expansion are important so as to increase access to care for PLWHA.

Factors that influence the receipt of eye care.

OBJECTIVES: To better understand what factors influence the receipt of eye care so that screening and education programs can be designed to promote early detection and treatment. METHODS: Twenty focus groups were conducted. Analyses entailed debriefing sessions, coding, and interpreting transcribed data. RESULTS: Attitudes about eyesight and eye exams influence the receipt of preventive eye care. Limited knowledge about certain eye diseases and conditions was reported. Participants stated that their primary care providers did not communicate information with them about eyesight nor did they conduct basic eye screenings. CONCLUSIONS: Improving provider-patient interactions and developing public health messages about eye diseases and preventive eye care can facilitate increased use of appropriate eye care services.

The Effect of the Affordable Care Act's Dependent Coverage Provisionon Health Insurance Gaps for Young Adults With SpecialHealthcare Needs.

PURPOSE: This study examined the impact of the 2010 Affordable Care Act's dependent coverage provision on gaps in insurance coverage for young adults with special healthcare needs (YASHCN). METHODS: We used the 2008 Survey on Income and Program Participation, a longitudinal survey covering 2008-2013. Our sample was comprised of 3,316 YASHCN ages 19-29. We used a difference-in-differenceregression approach to assess the effect of the dependent coverage provision on the probability that a YASHCN experienced a gap in insurance coverage. We compared outcomes for a treatment group, YASHCN ages 19-25, and a control group, YASHCN ages 27-29, before and after the 2010 policy change. The longitudinal data allow us to estimate regressions that control for individual and time fixed effects. RESULTS: After controlling for fixed effects and other confounding variables, we found that extending coverage until age 26 for YASHCN was associated with reduced insurance gaps. Specifically, our estimates suggest that the Affordable Care Act dependent coverage provision was associated with reduced insurance gaps among YASHCN by 2.4 percentage points. CONCLUSIONS: The Affordable Care Act dependent coverage provision helped mitigate the number ofinsurance gaps experienced by YASHCN. This is of particular importance to YASHCN, as they are a vulnerablepopulation and their continuity of insurance coverage is a critical part of their transition into adulthood.

Race and mental health disorders' impact on older patients' nursing home admissions upon hospital discharge.

INTRODUCTION: Despite policy efforts to reduce unwanted nursing home (NH) admissions, NH residents increasingly are being admitted from hospitals, with a significant share diagnosed with mental health disorders. OBJECTIVES: We examined interactive effect of Black race and mental health disorder's impact on older patients' (age 65 and older) NH admission upon hospital discharge. MATERIAL AND METHODS: We analyzed 186,646 older patients using pooled data from the 2007 through 2010 National Hospital Discharge Survey. Logistic regression analyses were used to examine the risk factors for NH admission. RESULTS: Diagnosis of mental health disorders increased the odds of NH admission among the older sample patients (OR = 1.15, 95%CI[1.04,1.28]). Black race was not associated with higher odds, whereas black patients experienced higher odds if they were diagnosed with mental health disorders (OR = 1.60, 95%CI[1.43,1.79]). Medicare as primary payer was associated with greater odds of NH admission. Admission from nursing facilities substantially increased the odds of NH admission upon hospital discharge. Patients discharged with diagnoses of stroke, lower-limb fractures, and a chronic ulcer, as well as those with a longer length-of-stay (> 5 days) experienced increased odds of NH admission. Being discharged from a larger hospital (with >200 beds) decreased the odds for NH admission; as did being discharged from a government-owned hospital. CONCLUSIONS: Older Black patients with mental health disorder experienced significantly greater odds of NH admission after adjusting for other factors. Public policy initiatives are needed to address the specific needs in the vulnerable population to avoid unwanted NH admission.

Utilizing new prescription drugs: disparities among non-Hispanic whites, non-Hispanic blacks, and Hispanic whites.

OBJECTIVE: To examine racial and ethnic disparities in new prescription drug use. DATA SOURCES/STUDY SETTING: Secondary data analyses of the Medical Expenditure Panel Survey (1996-2001), a national survey representative of U.S. noninstitutionalized civilian population. Drug approval dates were from the GenRx database of Mosby. STUDY DESIGN: A negative binomial model was used to compare annual number of times when new drugs were obtained across racial and ethnic groups. Covariates in the model were demographic, economic characteristics, and health status. Drugs were considered new if approved within the past 5 years. We compared non-Hispanic whites with non-Hispanic blacks, and non-Hispanic whites with Hispanic whites, respectively, to examine racial and ethnic disparities separately. PRINCIPAL FINDINGS: Descriptive analyses found smaller racial disparities than ethnic disparities: the average annual number of times when new drugs were obtained was higher among non-Hispanic whites than non-Hispanic blacks (1.71 versus 1.36; p<.01) and Hispanic whites (1.71 versus 1.11; p<.01). Multivariate analyses found smaller ethnic than racial disparities: the number was 22-33 percent lower among non-Hispanic blacks than non-Hispanic whites (significant), and 5-16 percent lower among Hispanic whites than non-Hispanic whites (not always significant), respectively. While the absolute racial disparities decreased over the early years of the life cycles of the products, the reduction in disparities over time was not significant. CONCLUSIONS: There are racial disparities in the use of new medications, which persist during the first 5 years of marketing. Socioeconomic and health characteristics account for a larger share of ethnic disparities than racial disparities.

Relations among race/ethnicity, gender, and mental health status in primary care use.

OBJECTIVE: Many working-age individuals with a serious mental health disability go without primary care. Gender and racial/ethnic disparities have been found in primary care utilization. This article examines whether the interaction of gender and race/ethnicity with serious mental health disability is associated with primary care use among working-age individuals. METHOD: We pooled data from the Medical Expenditure Panel Survey-Household Component (MEPS-HC) panels for the years 2001 to 2007 creating a sample of 34,199 individuals, 1,605 of whom had serious mental health disability. MEPS-HC is a nationally representative survey of the civilian noninstitutionalized population of the United States. We defined serious mental health disability as having scored less than 30 on the Mental Health Composite Score of the Short Form 12. Primary care visits were defined as nonspecialty, nonemergency visits to a physician's office or clinic. Zero-inflated Poisson regression models and bootstrapped predictive margins of visits were estimated using weights to account for survey design. RESULTS: Relative to women, men with serious mental health disability had significantly more primary care visits and lower log odds of "zero" visits-the opposite pattern was found for people without serious mental health disability. We did not find a significant interaction between race/ethnicity and serious mental health disability. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Serious mental health disability appears to have differing impacts on men and women's use of primary care. There is a continued need to understand what differentiates users from nonusers among adults with serious mental health disability and the relative contribution of patient, provider, and system factors. (PsycINFO Database Record

Disparities in access to essential new prescription drugs between non-Hispanic whites, non-Hispanic blacks, and Hispanic whites.

Prior studies do not address racial and ethnic disparities in essential new drug use and whether disparities decrease through time. Using the Medical Expenditure Panel Survey (1996-2001), racial and ethnic disparities were examined separately by comparing non-Hispanic whites to non-Hispanic blacks and Hispanic whites, respectively. New drugs were defined as approved within the past 5 years, and an expert panel identified essential drugs. Negative binomial models adjusted for socioeconomic and health characteristics. The mean annual number of times essential new drugs were obtained among non-Hispanic whites, non-Hispanic blacks, and Hispanic whites were 1.02, 0.94, and 0.70, respectively. After adjusting for confounders, ethnic disparities generally were not significant, but racial disparities became significant. This study did not identify declining disparities during early years of drugs' life cycles. Disparities exist in new, essential drug acquisition between non-Hispanic whites and non-Hispanic blacks. Socioeconomic and health characteristics explain many of the observed disparities.