Annual wellness visits are associated with increased use of preventive services in patients with diabetes living in the Diabetes Belt

Assessing older adult physical activity levels in clinical settings: The modified PAVS for older adults

BACKGROUND

Participating in recommended levels of physical activity (PA) is critical for preventing functional decline, falls, and frailty, making it essential to identify older adults not meeting national PA guidelines. However, guidance on assessing older adult PA levels, particularly in clinical settings, is lacking. This article presents an overview of clinically feasible PA assessment tools for older adults, identifies gaps in current tools, and provides recommendations on addressing these gaps.

METHODS

We conducted a literature review on clinically feasible PA assessment tools, suggested modifications to an existing PA assessment for older adult patients, and highlighted opportunities for integrating the modified PA assessment tool in clinical settings.

RESULTS

We identified 16 PA assessment tools used in clinical settings. The most widely used tool is the Physical Activity Vital Sign (PAVS), which has been successfully integrated into several electronic health records (EHR) and clinical practices. Most tools, including the PAVS, primarily focus on aerobic activities, with limited consideration for strength and balance. We recommend the use of a Modified PAVS for Older Adults that includes items on muscle-strengthening and balance activities to better align with national PA guidelines. We then identified several existing opportunities for broad implementation of the Modified PAVS for Older Adults within clinical settings.

CONCLUSIONS

Widespread integration of the Modified PAVS for Older Adults will better support healthcare providers in identifying individuals not meeting national PA recommendations, assisting them in prescribing tailored PA prescriptions and better connecting their patients to appropriate resources and professionals for further support.

Association of Maternal Cervical Cancer Screening Adherence with Adolescent HPV Vaccination Among Adolescent-Mother Pairs

Less than two-thirds of US adolescents are up-to-date with HPV vaccination. While mothers engaged in preventive care are more likely to seek preventive care for their children, current studies on associations between maternal cervical cancer screening (CCS) and adolescent HPV vaccination are needed. We assessed associations between maternal preventive service utilization and adolescent HPV vaccination using electronic health record data from a healthcare system in Washington State. We included adolescents (11-17 years) and their mothers with ≥ 1 primary care visit between 2018 and 2020. Outcomes were HPV vaccine initiation and completion. The primary exposure was maternal adherence to guideline-recommended CCS. Secondary exposures were maternal breast cancer screening adherence (for mothers ≥ 52 years) and ≥ 1 wellness visit ≤ 2 years. We used Generalized Estimating Equations to estimate prevalence ratios, and explore effect modification by adolescent sex, adolescent provider characteristics, and maternal language interpreter use. Of 4121 adolescents, 66% had a CCS-adherent mother, 82% initiated HPV vaccination, and 49% completed the series. CCS adherence was associated with higher initiation (adjusted prevalence ratio (APR):1.10, 95%CI:1.06-1.13) and completion (APR:1.16, 95%CI:1.08-1.23). Associations were stronger for male vs. female adolescents, adolescents who had a primary care provider in family practice vs. pediatrics, and adolescents who had the same primary care provider as their mother vs. not. Recent maternal wellness visit was also associated with higher initiation (APR:1.04, 95%CI:1.01-1.07) and completion (APR:1.12, 95%CI:1.05-1.20). Results suggest that delivering healthcare through a family-centered approach and engaging mothers in broad preventive care could increase adolescent HPV vaccination coverage.

Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program: A Qualitative Study

Importance

The Medicare Shared Savings Program (MSSP) includes more than 400 accountable care organizations (ACOs) and is among the largest and longest running value-based payment efforts in the US. However, given recent program reforms and other changes in the health care system, the experiences and perspectives of ACO leaders remain incompletely characterized.

Objective

To understand the priorities, strategies, and challenges of ACO leaders in MSSP.

Design, Setting, and Participants

In this qualitative study, interviews were conducted with leaders of 49 ACOs of differing sizes, leadership structures, and geographies from MSSP between September 29 and December 29, 2022. Participants were asked about their clinical and care management efforts; how they engaged frontline clinicians; the process by which they distributed shared savings and added or removed practices; and other factors that they believed influenced their success or failure in the program.

Main Outcomes and Measures

Leader perspectives on major themes related to ACO initiatives, performance improvement, and the recruitment, engagement, and retention of clinicians.

Results

Of the 49 ACOs interviewed, 34 were hospital-associated ACOs (69%), 35 were medium or large (>10 000 attributed beneficiaries) (71%), and 17 were rural (35%). The ACOs had a mean (SD) tenure of 8.1 (2.1) years in MSSP. Five major themes emerged: (1) ACO leaders reported a focus on annual wellness visits, coding practices, and care transitions; (2) leaders used both relationship-based and metrics-based strategies to promote clinician engagement; (3) ACOs generally distributed half or more of shared savings to participating practices; (4) ACO recruitment and retention efforts were increasingly influenced by market competition; and (5) some hospital-associated ACOs faced misaligned incentives.

Conclusions and Relevance

In this study, the ACO leaders reported varied approaches to promoting clinician alignment with ACO goals, an emphasis on increasing annual wellness visits, and new pressures related to growth of other care models. Policymakers hoping to modify or expand the program may wish to incorporate these perspectives into future reforms.

Regional and racial disparities in major amputation rates among medicare beneficiaries with diabetes: a retrospective study in the southeastern USA

Objective

While rates for non-traumatic lower extremity amputations (LEA) have been declining, concerns exist over disparities. Our objectives are to track major LEA (MLEA) rates over time among Medicare beneficiaries residing in a high diabetes prevalence region in the southeastern USA (the diabetes belt) and surrounding areas.

Methods

We used Medicare claims files for ~900 000 fee-for-service beneficiaries aged ≥65 years in 2006-2015 to track MLEA rates per 1000 patients with diabetes. We additionally conducted a cross-sectional analysis of data for 2015 to compare regional and racial disparities in major amputation risks after adjusting for demographic, socioeconomic, access-to-care and foot complications and other health factors. The Centers for Disease Control and Prevention defined the diabetes belt as 644 counties across Appalachian and southeastern US counties with high prevalence.

Results

MLEA rates were 3.9 per 1000 in the Belt compared with 2.8 in the surrounding counties in 2006 and decreased to 2.3 and 1.6 in 2015. Non-Hispanic black patients had 8.5 and 6.9 MLEAs per 1000 in 2006 and 4.8 and 3.5 in 2015 in the Belt and surrounding counties, respectively, while the rates were similar for non-Hispanic white patients in the two areas. Although amputation rates declined rapidly in both areas, non-Hispanic black patients in the Belt consistently had >3 times higher rates than non-Hispanic whites in the Belt. After adjusting for patient demographics, foot complications and healthcare access, non-Hispanic blacks in the Belt had about twice higher odds of MLEAs compared with non-Hispanic whites in the surrounding areas.

Discussion

Our data show persistent disparities in major amputation rates between the diabetes belt and surrounding counties. Racial disparities were much larger in the Belt. Targeted policies to prevent MLEAs among non-Hispanic black patients are needed to reduce persistent disparities in the Belt.