How Much Does Medication Nonadherence Cost the Medicare Fee-for-Service Program?

BACKGROUND: Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level. OBJECTIVE: The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions. RESEARCH DESIGN: Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries. SUBJECTS: A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013. MEASURES: Avoidable health care costs and hospital use from medication nonadherence. RESULTS: Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted. CONCLUSION: Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.

Trends in the Relationship Between Obesity and Disability, 1988-2012.

Rising obesity rates, coupled with population aging, have elicited serious concern over the impact of obesity on disability in later life. Prior work showed a significant increase in the association between obesity and disability from 1988 to 2004, calling attention to disability as a cost of longer lifetime exposure to obesity. It is not known whether this trend has continued. We examined functional impairment and impairment in activities of daily living (ADL) (defined as severe or moderate to severe) for adults aged 60 years or older (n = 16,770) over 3 time periods in the National Health and Nutrition Examination Survey. The relative odds of impairment for obese individuals versus normal-weight individuals significantly increased from period 1 (1988-1994) to period 2 (1999-2004) for all outcomes. In period 3 (2005-2012), this association remained stable for functional and severe ADL impairment and decreased for moderate-to-severe ADL impairment. The fraction of population disability attributable to obesity followed a similar trend. The trend of an increasing association between obesity and disability has leveled off in more recent years, and is even improving for some measures. These findings suggest that public health and policy concerns that obesity would continue to become more disabling over time have not been borne out.

Housing strain, mortgage foreclosure, and health.

BACKGROUND: Foreclosure rates have risen rapidly since 2005, reaching historically high levels. The purpose of this study was to examine the health implications of the current housing crisis. METHODS: We conducted a cross-sectional online consumer panel survey including residents of California, Arizona, Nevada, and Florida (n = 798) to determine the feasibility of contacting distressed homeowners via the Internet and to assess mental and physical health among respondents across the spectrum from those having no housing strain to those in loan default or home foreclosure. RESULTS: Homeowners in default or foreclosure exhibited poorer mental health and more physical symptoms than renters, homeowners with moderate strain, and homeowners with no strainöfollowing a gradient that was consistent across multiple health indicators. CONCLUSIONS: Internet panel sampling was an efficient method of contacting distressed homeowners. Record-high foreclosure rates may have broad implications for nursing and public health. Homeowners in default or foreclosure represent an identifiable high-risk group that may benefit from coordinated, affordable health and social services.

Mortgage delinquency and changes in access to health resources and depressive symptoms in a nationally representative cohort of Americans older than 50 years.

OBJECTIVES: We evaluated associations between mortgage delinquency and changes in health and health-relevant resources over 2 years, with data from the Health and Retirement Study, a longitudinal survey representative of US adults older than 50 years. METHODS: In 2008, participants reported whether they had fallen behind on mortgage payments since 2006 (n = 2474). We used logistic regression to compare changes in health (incidence of elevated depressive symptoms, major declines in self-rated health) and access to health-relevant resources (food, prescription medications) between participants who fell behind on their mortgage payments and those who did not. RESULTS: Compared with nondelinquent participants, the mortgage-delinquent group had worse health status and less access to health-relevant resources at baseline. They were also significantly more likely to develop incident depressive symptoms (odds ratio [OR] = 8.60; 95% confidence interval [CI] = 3.38, 21.85), food insecurity (OR = 7.53; 95% CI = 3.01, 18.84), and cost-related medication nonadherence (OR = 8.66; 95% CI = 3.72, 20.16) during follow-up. CONCLUSIONS: Mortgage delinquency was associated with significant elevations in the incidence of mental health impairments and health-relevant material disadvantage. Widespread mortgage default may have important public health implications.

Changes in weight at the end of life: characterizing weight loss by time to death in a cohort study of older men.

The purpose of this analysis was to characterize the natural history of weight change in the years prior to death among older persons and to examine how this pattern varies according to longevity and cause of death. Weight trajectories were analyzed by using data from 800 male decedents from the Baltimore Longitudinal Study of Aging (Maryland, 1958-2005) observed beginning an average of 19 years before death. A model including 3 distinct periods of weight change (weight stability/gain, mild weight loss, and accelerated weight loss before death) provided the best fit for all age-at-death groups. Approximately 9 years before death, the rate of weight loss increased to an average of 0.39 kg/year (P < 0.001) for all-cause mortality. For cancer deaths, weight loss accelerated significantly 3 years before death, regardless of age group. For cardiovascular deaths, the best-fitting inflection point increased with age, from 5 years for participants aged 60-69 years to 9-10 years before death for those aged 80 years or older. Results suggest that weight loss in older persons may begin earlier than previously believed. The duration of weight loss for noncancer deaths suggests that even distal changes in energy balance may be linked to risk of death.

Adipocytokines and the metabolic syndrome among older persons with and without obesity: the InCHIANTI study.

OBJECTIVES: Adipose tissue-derived inflammation may contribute to metabolic alterations and eventually to the metabolic syndrome (MetS). The purpose of this study was to: (1) examine the role of adipocytokines in the association between obesity and the MetS and (2) to determine whether the association is different in obese and non-obese persons. DESIGN: Cross-sectional population-based InCHIANTI study. SUBJECTS: A total of 944 community-dwelling adults aged 65 years and older living in Tuscany, Italy. MEASUREMENTS: Obesity was defined as body mass index > or =30 kg/m2 and MetS as > or =3 of the ATP-III criteria. Circulating levels of C-reactive protein, interleukin (IL)-6, IL-1 receptor antagonist (IL-1ra), IL-18, tumour necrosis factor (TNF)-alpha R1, adiponectin, resistin and leptin were measured. Additionally, insulin resistance was determined using the homeostasis model assessment (HOMA-IR). RESULTS: The prevalence of the MetS was 32%. Both overall and abdominal obesity were significantly associated with the MetS after adjusting for inflammatory cytokines, adipokines and lifestyle factors. After adjusting for multiple confounders and HOMA-IR, IL-1ra, TNF-alpha R1 and adiponectin (P < 0.05) remained significantly associated with the MetS. Having multiple cytokines in the highest tertile increased the likelihood of having the MetS in both obese (P for trend 0.002) and non-obese persons (P for trend 0.001) independent of insulin resistance. CONCLUSIONS: Non-obese and obese individuals who develop an intense pro-inflammatory state may be more prone to develop the MetS than those with lower levels of inflammation.

Foreclosure and health status.

In 2009, more than 2.8 million housing units in the U.S. received a foreclosure notice. That represents about 1 in every 45 properties and a 120% increase in the number of foreclosed properties since 2007. Real estate experts predict even more foreclosures in 2010 as high unemployment continues. The cascading effects of the foreclosure crisis on the U.S. economy are all too clear; the effects on individuals' health status are less obvious. This Issue Brief summarizes two studies that examine the health implications of foreclosure and reveal a vulnerable population that may benefit from coordinated health and financial services.

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age.

OBJECTIVES: We examined associations between material resources and late-life declines in health. METHODS: We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441). RESULTS: Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage. CONCLUSIONS: Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.

Improving Social Needs Intervention Research: Key Questions for Advancing the Field.

Spurred by accumulated evidence documenting how social determinants of health shape health outcomes as well as the push for better value, the healthcare sector is embracing interventions that address patients' health-related social needs. An increasing number of healthcare organizations and payers are experimenting with strategies to identify needs and connect patients to resources that address identified needs with the goal of improving health outcomes, reducing avoidable utilization of costly health services, and improving health equity. Although many studies link social factors to health, relatively little published research exists about how the healthcare sector can effectively intervene to help identify and address social needs. This paper summarizes emerging evidence and identifies key areas where more research is needed to advance implementation and policy development. Although some healthcare-based social needs interventions have been shown to improve health and reduce avoidable utilization, important gaps remain in terms of comparative effectiveness and cost effectiveness of social needs intervention approaches. Additionally, the field would benefit from an increased understanding of mechanisms of action to maximize practitioners' ability to tailor interventions. More research is also needed to guard against unintended consequences and ensure these interventions reduce health inequities. Finally, implementation science research should identify supports and incentives for adoption of effective interventions. Focusing both public and private research efforts on these evidence gaps can help advance identification of interventions that maximize both health equity and healthcare value. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Inflammation and rate of cognitive change in high-functioning older adults.

BACKGROUND: Inflammatory proteins including interleukin-6 (IL-6) and C-reactive protein (CRP) have been associated with incident cognitive impairment, but little research has addressed their effects on the rate of cognitive change, and findings are mixed. The purpose of this study was to examine the relationship between serum levels of IL-6 and CRP and the rate of cognitive change across a range of cognitive domains in a sample of healthy older persons. METHODS: Growth curve analysis was performed on data from the MacArthur Study of Successful Aging, a longitudinal cohort study of high-functioning older adults aged 70-79 years at baseline in 1988 and reinterviewed in 1991 and 1995 (N = 851). Individual growth curve parameters were derived from baseline and follow-up performance in abstraction, language, spatial ability, verbal recall, spatial recognition, and global cognitive function based on age, IL-6, CRP, and covariates. RESULTS: Cross-sectionally, there is a generally linear negative relationship between inflammation and cognition, such that higher levels of inflammation are associated with lower levels of baseline cognitive function. After controlling for potential confounders, there was no effect of inflammation on baseline cognitive function or the rate of longitudinal cognitive change. However, persons in the top tertile on IL-6 were at an increased risk of incident declines on the Short Portable Mental Status Questionnaire (SPMSQ). CONCLUSIONS: Although high levels of inflammation are associated with incident cognitive impairment, these results do not generalize to the full range of cognitive changes, where the role of inflammation appears to be marginal.

The shape of things to come: obesity, aging, and disability.

Rising obesity represents one of the most disturbing health trends in the U.S. and elsewhere. Obese people are at greater risk for diabetes, cardiovascular disease, disability, and mortality. However, recent studies also suggest that the obese population has grown "healthier" since the 1960s, probably due to improved medical care for cardiovascular disease. It is unclear whether these improvements have resulted in more or less disability in obese people as they age. This issue Brief summarizes two studies that examine the prevalence of obesity over time in the elderly and disabled, and the changing relationship of obesity and disability.

Hispanic paradox in biological risk profiles.

OBJECTIVES: We examined biological risk profiles by race, ethnicity, and nativity to evaluate evidence for a Hispanic paradox in measured health indicators. METHODS: We used data on adults aged 40 years and older (n = 4206) from the National Health and Nutrition Examination Surveys (1999-2002) to compare blood pressure, metabolic, and inflammatory risk profiles for Whites, Blacks, US-born and foreign-born Hispanics, and Hispanics of Mexican origin. We controlled for age, gender, and socioeconomic status. RESULTS: Hispanics have more risk factors above clinical risk levels than do Whites but fewer than Blacks. Differences between Hispanics and Whites disappeared after we controlled for socioeconomic status, but results differed by nativity. After we controlled for socioeconomic status, the differences between foreign-born Hispanics and Whites were eliminated, but US-born Mexican Americans still had higher biological risk scores than did both Whites and foreign-born Mexican Americans. CONCLUSIONS: There is no Hispanic paradox in biological risk profiles. However, our finding that foreign-born Hispanics and Whites had similar biological risk profiles, but US-born Mexican Americans had higher risk, was consistent with hypothesized effects of migrant health selectivity (healthy people in-migrating and unhealthy people out-migrating) as well as some differences in health behaviors between US-born and foreign-born Hispanics.

The changing relationship of obesity and disability, 1988-2004.

CONTEXT: Recent studies suggest that the obese population may have been growing healthier since the 1960s, as indicated by a decrease in mortality and cardiovascular risk factors. However, whether these improvements have conferred decreased risk for disability is unknown. The obese population may be living longer with better-controlled risk factors but paradoxically experiencing more disability. OBJECTIVE: To determine whether the association between obesity and disability has changed over time. DESIGN, SETTING, AND PARTICIPANTS: Adults aged 60 years and older (N = 9928) with measured body mass index from 2 waves of the nationally representative National Health and Nutrition Examination Surveys (NHANES III [1988-1994] and NHANES 1999-2004). MAIN OUTCOME MEASURES: Reports of much difficulty or inability to perform tasks in 2 disability domains: functional limitations (walking one-fourth mile, walking up 10 steps, stooping, lifting 10 lb, walking between rooms, and standing from an armless chair) and activities of daily living (ADL) limitations (transferring, eating, and dressing). RESULTS: Among obese individuals, the prevalence of functional impairment increased 5.4% (from 36.8%-42.2%; P = .03) between the 2 surveys, and ADL impairment did not change. At time 1 (1988-1994), the odds of functional impairment for obese individuals were 1.78 times greater than for normal-weight individuals (95% confidence interval [CI], 1.47-2.16). At time 2 (1999-2004), this odds ratio increased to 2.75 (95% CI, 2.39-3.17), because the odds of functional impairment increased by 43% (OR 1.43; 95% CI, 1.18-1.75) among obese individuals during this period, but did not change among nonobese individuals. With respect to ADL impairment, odds for obese individuals were not significantly greater than for individuals with normal weight (OR, 1.31; 95% CI, 0.92-1.88) at time 1, but increased to 2.05 (95% CI, 1.45-2.88) at time 2. This was because the odds of ADL impairment did not change for obese individuals but decreased by 34% among nonobese individuals (OR, 0.66; 95% CI, 0.50-0.88). CONCLUSIONS: Recent cardiovascular improvements have not been accompanied by reduced disability within the obese older population. Rather, obese participants surveyed during 1999-2004 were more likely to report functional impairments than obese participants surveyed during 1988-1994, and reductions in ADL impairment observed for nonobese older individuals did not occur in those who were obese. Over time, declines in obesity-related mortality, along with a younger age at onset of obesity, could lead to an increased burden of disability within the obese older population.

Population Health Measurement at Centers for Medicare & Medicaid Services: Bridging the Gap Between Public Health and Clinical Quality.

As Medicare and Medicaid increasingly shift to alternative payment models focused on population-based payments, there is an urgent need to develop measures of population health that can drive health improvement. In response, an assessment and design project established a framework for developing population health measures from a payer perspective, conducted environmental scans of existing measures and available data infrastructure, and conducted a gap analysis informing measure development and infrastructure needs. The work, summarized here, makes recommendations for creating a set of core measures, demonstrates some of the key challenges in applying a traditional quality measure development framework to population health, and complements recent efforts by the National Academy of Medicine and others with a focus on a payer perspective.

Gerontology's future: An integrative model for disciplinary advancement.

Scholars have debated the legitimacy of gerontology as a discipline since Metchnikoff coined the term more than 100 years ago. Recent developments such as the emergence of interdisciplinary aging theories and consensus on longitudinal research methods suggest that gerontology is materializing as a unique discipline, rather than a subset of another more established disciplinary tradition. In this article we review substantive evidence from gerontological theory and scholarship to suggest orienting principles for the emerging discipline of gerontology. We offer a conceptual framework of gerontology as a discipline that integrates contributions of biopsychosocial perspectives with well-established concepts of age, aging, and aged and multiple contextual elements. We conclude with a discussion of how our model relates to gerontology's progress, including examples of successful interdisciplinary research, and offer questions for gerontologists to consider for further advancement of the field.

Comparison of Handgrip and Leg Extension Strength in Predicting Slow Gait Speed in Older Adults.

OBJECTIVES: To compare the relative predictive power of handgrip and leg extension strength in predicting slow walking. DESIGN: Report of correlative analysis from two epidemiological cohort studies. SETTING: Foundation of the National Institutes of Health Sarcopenia Project. PARTICIPANTS: Men and women aged 67 to 93 (N=6,766). MEASUREMENTS: Leg strength, handgrip strength, and gait speed were measured. Strength cutpoints associated with slow gait speed were developed using classification and regression tree analyses and compared using ordinary least squares regression models. RESULTS: The cutpoints of lower extremity strength associated with slow gait speed were 154.6 N-m in men and 89.9 N-m in women for isometric leg extension strength and 94.5 N-m in men and 62.3 N-m in women for isokinetic leg extension strength. Weakness defined according to handgrip strength (odds ratios (OR)=1.99 to 4.33, c-statistics=0.53 to 0.67) or leg strength (ORs=2.52 to 5.77; c-statistics=0.61 to 0.66) was strongly related to odds of slow gait speed. Lower extremity strength contributed 1% to 16% of the variance and handgrip strength contributed 3% to 17% of the variance in the prediction of gait speed depending on sex and mode of strength assessment. CONCLUSION: Muscle weakness of the leg extensors and forearm flexors is related to slow gait speed. Leg extension strength is only a slightly better predictor of slow gait speed. Thus, handgrip and leg extension strength appear to be suitable for screening for muscle weakness in older adults.