Disability stage and receipt of recommended care among elderly medicare beneficiaries

Addition of community paramedics to a physician home-visit program: A prospective cohort study

BACKGROUND

Home-based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in-home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model.

METHODS

This prospective cohort study enrolled older adults in home-based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30-day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR).

RESULTS

We screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76-86 years, with 3-5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06-1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48-1.18) or 30-day readmissions (IRR 1.32, 95% CI 0.49-3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001).

CONCLUSION

Older adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations.

Potential Factors Associated with Healthcare Utilization for Balance Problems in Community-Dwelling Adults within the United States: A Narrative Review

Falls are the leading cause of mortality and chronic disability in elderly adults. There are effective fall prevention interventions available. But only a fraction of the individuals with balance/dizziness problems are seeking timely help from the healthcare system. Current literature confirms the underutilization of healthcare services for the management of balance problems in adults, especially older adults. This review article explores factors associated with healthcare utilization as guided by the Andersen Healthcare Utilization Model, a framework frequently used to explore the factors leading to the use of health services. Age, sex, race/ethnicity, BMI, and comorbidities have been identified as some of the potential predisposing factors; socioeconomic status, health insurance, and access to primary care are the enabling and disabling factors; and severity of balance problem, perceived illness, and its impact on daily activities are the factors affecting need for care associated with healthcare utilization for balance or dizziness problems. Knowledge about these barriers can help direct efforts towards improved screening of vulnerable individuals, better access to care, and education regarding effective fall prevention interventions for those who are at risk for underutilization. This can aid in timely identification and management of balance problems, thereby reducing the incidence of falls.

Bounce-Back: Predicting Acute Readmission From Inpatient Rehabilitation for Patients With Stroke

OBJECTIVE

The aim of the study was to identify demographic, medical, and functional risk factors for discharge to an acute hospital before completion of an inpatient rehabilitation program and 7- and 30-day readmissions after completion of an inpatient rehabilitation program.

DESIGN

This cohort study included 138,063 fee-for-service Medicare beneficiaries with a primary diagnosis of new onset stroke discharged from an inpatient rehabilitation facility from June 2009 to December 2011. Multivariate models examined readmission outcomes and included data from 6 mos before onset of the stroke to 30 days after discharge from the inpatient rehabilitation facility.

RESULTS

In the acute discharge model (n = 9870), comorbidities and complications added risk, and the longer the stroke onset to admission to inpatient rehabilitation facility, the more likely discharge to the acute hospital. In the 7-day (n = 4755) and 30-day (n = 9861) readmission models, patients who were more complex with comorbidities, were black, or had managed care Medicare were more likely to have a readmission. Functional status played a role in all three models.

CONCLUSIONS

Results suggest that certain demographic, medical, and functional characteristics are associated differentially with rehospitalization after completion inpatient rehabilitation. The strongest model was the discharge to the acute hospital model with concordance statistic (c-statistic) of 0.87.

Misuse of Prescription Medications among Individuals with Mobility Disability

BACKGROUND

The ability of walking a quarter mile is predictive of subsequent disability, mortality, and health care costs. Individuals with mobility disability are at increased risk of chronic conditions and unmet care needs. Thus they may misuse prescription medications to self-medicate.

OBJECTIVES

We aimed to explore the difference of misuse of four types of prescription medications (sedatives, tranquilizers, painkillers, depression medications) and overall misuse by mobility status and identify the correlates of overall misuse.

METHODS

A national probability sample from the survey Midlife in the United States (MIDUS) was used to assess the difference in misuse by mobility status during 2011-2014. To assess the correlates of misuse, mobility status, usual source of care, unmet care needs, insurance coverage, sociodemographic variables, and clinical conditions were added to a survey weighted logistic regression model with backward selection.

RESULTS

Compared to those without mobility disability, individuals with mobility disability had higher risk of misuse in most types of medications and in overall misuse. Mobility disability, lower education, unmarried status, the emergency room or public health clinic as the most often used care, pain, and depressed affect were identified as correlates of overall misuse of studied medications.

CONCLUSIONS

Individuals with mobility disability are a vulnerable group susceptible to medication misuse, which warrants the urgent need for interventions to ameliorate misuse and reduce risks in this population.

Psychological and behavioral responses during the COVID-19 pandemic among individuals with mobility and/or self-care disabilities

Background

The lockdowns during the COVID-19 pandemic created major obstacles for individuals with disabilities to obtain support in their daily living.

Objectives

This study was to examine the psychological and behavioral responses of US individuals with mobility and/or self-care disabilities during the pandemic.

Methods

From a nationally representative longitudinal survey (n = 6403) administered during the pandemic, individuals were classified at baseline as having no mobility/self-care disability (ADL = 0, n = 4975), mobility or self-care disability (ADL = 1, n = 1061), and both mobility and self-care disabilities (ADL = 2, n = 367). Weighted mean of baseline mental distress scores (PHQ4), psychological risk factors (loneliness, stress, perceived COVID risk), resilience, and coping were compared among these groups. Random effects models were employed to assess the effects of disability and disability-moderated effects of risk factors on mental distress.

Results

At baseline, mental distress increased with greater ADL disabilities (Mean[95%CI] = 1.88[1.77, 1.98], 2.54[2.29, 2.79], and 3.55[3.01, 4.08] for ADL = 0, 1, and 2, respectively, p < .0001). Loneliness, stress, and perceived risk increased with ADL disabilities, but resilience and social coping decreased with it (p's < 0.0001). In the random-effects models, greater ADL disabilities, higher psychological risks, and use of cannabis and other recreational drugs were associated with greater mental distress. Greater ADL disabilities augmented the detrimental effects of risk factors on mental health, but resilience protected mental health both independently and through a buffering effect on its risk factors across all groups.

Conclusion

Individuals with mobility and/or self-care disability tend to have poorer mental health and are differentially more affected by its risk factors. Mental health professionals should address these modifiable factors in interventions.

Disparities in mental health, social support and coping among individuals with mobility impairment

BACKGROUND

CDC estimated that 19.4 million (7.8%) US adults are living with mobility impairment, who are unable to walk a quarter mile. Individuals with physical disability reported greater depression and, in some cases, insufficient social support.

OBJECTIVES

This study explores the extent of disparities in psychological health, social support, and coping mechanisms among those with mobility impairment as compared to those without such impairment, and the longitudinal effect of onset of mobility impairment on subsequent psychosocial health and coping.

METHODS

Individuals with mobility impairment were matched to controls from a nationally representative sample, using the propensity score method. The final sample included 345 matched pairs. Regression models with robust standard errors were used to assess disparities in outcomes by mobility status. Autoregressive models were used to assess the longitudinal effect of the onset of mobility limitation on these outcomes.

RESULTS

Those with impaired mobility fared significantly higher on negative affect (p < .05) and pessimism (p < .05), and significantly lower on life satisfaction (p < .05) and positive affect (p = .001). In terms of coping, they showed disparities in health locus of control (self) (p < .05), planning (p < .05), active coping (p < .05), and problem-focused coping (p < .05), as compared to those without mobility limitation. The onset of mobility impairment had significant effects in similar psychological and coping domains.

CONCLUSION

Our work revealed a piece of reality of individuals living with mobility impairment and will inform designing effective interventions to mitigate psychosocial health disparities in this population.

Inpatient rehabilitation facilities' hospital readmission rates for medicare beneficiaries treated following a stroke

BACKGROUND

Stroke is the leading cause for admission to the nearly 1,200 Inpatient Rehabilitation Facilities (IRFs) nationally in the US. For many patients, post-acute care is an important component of their rehabilitation. Several quality measures have been publicly reported for post-acute care providers, including hospital readmissions. However, to date none have focused on specific medical conditions, limiting the usability for patients and quality improvement.

OBJECTIVE

To assess hospital readmission rates for Medicare patients receiving inpatient rehabilitation following stroke and to identify risk factors in order to evaluate the feasibility of a stroke-specific hospital readmission measure.

METHODS

Observational study analyzing national Medicare inpatient claims and administrative data to assess hospital readmissions. Using logistic regression, we calculated unadjusted and risk-standardized readmission rates, which adjusted for patient characteristics, including type of stroke and admission function, to capture stroke severity.

RESULTS

Our national study included 116,073 fee-for-service Medicare beneficiary discharged from IRFs in 2013-2014 following stroke from 1,162 IRFs nationally. The observed hospital readmission rate among IRF patients following stroke was 11.6% and varied by patients' admission motor function. Patients with greater functional dependence had higher readmission rates on average. Lower admission function, hemorrhagic and other stroke types (relative to ischemic) were significantly associated with higher odds of hospital readmission.

CONCLUSION

Results suggest it is feasible to assess hospital readmission rates among a stroke-cohort treated in IRFs. Stroke-focused quality measures would be useful to patients in selecting a provider and for providers in evaluating their stroke rehabilitation program outcomes. Secondary results suggest that admission function (FIM) capture stroke severity, a limitation with other claims-based stroke measures.

Trends, Coverage and Influencing Determinants of Influenza Vaccination in the Elderly: A Population-Based National Survey in Spain (2006-2017)

Influenza is a significant public health problem and the elderly are at a greater risk of contracting the disease. The vaccination coverage of the elderly is below the Spanish target of 65% for each influenza season. The aims of this study were to report the coverage of influenza vaccination in Spain among the population aged ≥65 years and high-risk groups for suffering chronic diseases, to analyze the time trends from 2006 to 2017 and to identify the factors which affect vaccination coverage. A nationwide cross-sectional study was conducted including 20,753 non-institutionalized individuals aged ≥65 years who had participated in the Spanish National Health Surveys in 2006, 2011/2012, and 2017. Sociodemographic, health-related variables, and influenza vaccination data were used. A logistic regression analysis was performed to determine the variables associated with influenza vaccination. Influenza vaccination coverage was 60%. By chronic condition, older people with high cholesterol levels and cancer had the lowest vaccination coverage (62.41% and 60.73%, respectively). This coverage declined from 2006 to 2017 in both groups. Higher influenza vaccination was associated with males, Spanish nationality, normal social support perceived, polypharmacy, worse perceived health, participation in other preventive measures, and increasing age and the number of chronic diseases.

Premorbid Activity Limitation Stages Are Associated With Posthospitalization Discharge Disposition

OBJECTIVE

Activity of daily living stages and instrumental activity of daily living stage have demonstrated associations with mortality and health service use among older adults. This cohort study aims to assess the associations of premorbid activity limitation stages with acute hospital discharge disposition among community-dwelling older adults.

DESIGN

Study participants were Medicare beneficiaries aged 65 yrs or older who enrolled in the Medicare Current Beneficiary Survey between 2001 and 2009. Associations of premorbid stages with discharge dispositions were estimated with multinomial logistic regression models adjusted for covariates.

RESULTS

The proportions of elderly Medicare patients discharged to home with self-care, home with services, postacute care facilities, and other dispositions were 59%, 15%, 19%, and 7%, respectively. The following adjusted relative risk ratios and 95% confidence intervals of postacute care facilities versus home with self-care discharge increased with higher premorbid activity limitation stages (except nonfitting stage III): 1.7 (1.5-2.0), 2.4 (2.0-2.9), 2.4 (1.9-3.0), and 2.5 (1.6-4.1) for activity of daily living stages I-IV; a similar pattern was found for instrumental activity of daily living stages. The adjusted relative risk ratios of discharge to home with services also increased with higher premorbid activity limitation stages compared with no limitation.

CONCLUSIONS

Routinely assessed activity limitation stages predict posthospitalization discharge disposition among older adults and may be used to anticipate postacute care and services use by elderly Medicare beneficiaries.

Functional Impairments Associated With Patient Activation Among Community-Dwelling Older Adults

OBJECTIVES

Activity of daily living stages and instrumental activity of daily living stages demonstrated ordered associations with mortality, risk of hospitalization, and receipt of recommended care. This article explores the associations of stages with the following three dimensions of patient activation: self-care efficacy, patient-doctor communication, and health-information seeking. We hypothesized that higher activity of daily living and instrumental activity of daily living stages (greater limitation) are associated with a lower level of patient activation.

METHODS

Patient activation factors were derived from the 2004 and 2009 Medicare Current Beneficiary Survey. In this cross-sectional study (N = 8981), the associations of activity limitation stages with patient activation factors were assessed in latent factor models.

RESULTS

Greater activity limitation was in general inversely associated with self-efficacy, patient-doctor communication, and health information seeking, even after adjusting for sociodemographic and clinical characteristics. For instance, the mean of self-care efficacy across activity of daily living stages I-IV (mild, moderate, severe, and complete limitation) compared with stage 0 (no limitation) decreased significantly by 0.17, 0.29, 0.34, and 0.60, respectively. Covariates associated with suboptimal patient activation were also identified.

DISCUSSION

Our study identified multiple opportunities to improve patient activation, including providing support for older adults with physical impairments, at socioeconomic disadvantages, or with psychological or cognitive impairment.

Health care access and quality for persons with disability: Patient and provider recommendations

BACKGROUND

Significant disparities in health care access and quality persist between persons with disabilities (PWD) and persons without disabilities (PWOD). Little research has examined recommendations of patients and providers to improve health care for PWD.

OBJECTIVE

We sought to explore patient and health care provider recommendations to improve health care access and quality for PWD through focus groups in the physical world in a community center and in the virtual world in an online community.

METHODS

In all, 17 PWD, 4 PWOD, and 6 health care providers participated in 1 of 5 focus groups. Focus groups were conducted in the virtual world in Second Life^® with Virtual Ability, an online community, and in the physical world at Agape Community Center in Milwaukee, WI. Focus group data were analyzed using a grounded theory methodology.

RESULTS

Themes that emerged in focus groups among PWD and PWOD as well as health care providers to improve health care access and quality for PWD were: promoting advocacy, increasing awareness and knowledge, improving communication, addressing assumptions, as well as modifying and creating policy. Many participants discussed political empowerment and engagement as central to health care reform.

CONCLUSIONS

Both PWD and PWOD as well as health care providers identified common themes potentially important for improving health care for PWD. Patient and health care provider recommendations highlight a need for modification of current paradigms, practices, and approaches to improve the quality of health care provision for PWD. Participants emphasized the need for greater advocacy and political engagement.

Psychosocial Well-Being Associated With Activity of Daily Living Stages Among Community-Dwelling Older Adults

Objectives: Activity of daily living (ADL) stages demonstrated ordered associations with risk of chronic conditions, hospitalization, nursing home use, and mortality among community-living elderly. This article explores the association of stages with psychosocial well-being. We hypothesized that higher ADL stages (greater ADL limitation) are associated with more restricted social networks, less perceived social support, greater social isolation, and poorer mental health. Methods: Cross-sectional data from the National Social Life, Health, and Aging Project (N = 3,002) were analyzed in regression models and latent factor models. Results: Although ADL stages had a nearly monotonic relationship with most mental health measures (e.g., Center for Epidemiologic Studies Depression Scale [CES-D]), only the complete limitation stage (Stage IV) showed significant disadvantage in the majority of social network measures. Discussion: The study may aid clinicians and policy makers to better understand the social and mental health needs of older adults at different ADL stages and provide well-planned social and mental health care.