Older Americans Were Sicker And Faced More Financial Barriers To Health Care Than Counterparts In Other Countries

Navigating the Crossroads: A 10-Year Population Study on Access to Care Among Patients With Brain Tumor

BACKGROUND AND OBJECTIVES

Health care disparities are introduced at various points along the patient care continuum. This study explores disparities in initial health care access for patients with brain tumor (BT) in New York City (NYC) and New York State (NYS), comparing emergency department (ED) and elective admissions (EA).

METHODS

Using 2010-2020 data from the Statewide Planning and Research Cooperative System of NYS, patients were identified through relevant billing codes. Demographic, socioeconomic, and health care access variables were examined using univariate analysis and logistic mixed effects regression. The data were dichotomized by care location-NYC or NYS- and entry care site, ED vs EA.

RESULTS

The cross-sectional study included 48 135 patients. Over the decade, there was a significant decrease in the percentage of patients with BT admitted through the ED (P < .001) without differences between the 2 cohorts. The NYC cohort (24 283 patients) had a higher proportion of younger, affluent individuals, racial/ethnic minorities, and publicly insured patients (P < .001). Male sex and older age were significantly associated with ED admissions in both cohorts (P < .05). Black, Hispanic/Latinx patients, and those with public health insurance were more likely to be admitted through ED (P < .001). Residing in census tracts within the lowest 3 quartiles was positively associated with ED admission in the NYC but not the NYS cohort (P < .001).

CONCLUSION

Racial minorities with public insurance who reside in urban areas of low median household income are more likely to access BT care through ED rather than EA. Additional studies are needed to evaluate the impact of proximity to a hospital on access to care in rural areas. This study highlights the opportunities for policy and health care delivery changes to address current inequities.

Association of Frailty Index at 66 Years of Age with Health Care Costs and Utilization Over 10 Years in Korea: Retrospective Cohort Study

Background

The long-term economic impact of frailty measured at the beginning of elderhood is unknown.

Objective

The objective of our study was to examine the association between an individual's frailty index at 66 years of age and their health care costs and utilization over 10 years.

Methods

This retrospective cohort study included 215,887 Koreans who participated in the National Screening Program for Transitional Ages at 66 years of age between 2007-2009. Frailty was categorized using a 39-item deficit accumulation frailty index: robust (<0.15), prefrail (0.15-0.24), and frail (≥0.25). The primary outcome was total health care cost, while the secondary outcomes were inpatient and outpatient health care costs, inpatient days, and number of outpatient visits. Generalized estimating equations with a gamma distribution and identity link function were used to investigate the association between the frailty index and health care costs and utilization until December 31, 2019.

Results

The study population included 53.3% (n=115,113) women, 32.9% (n=71,082) with prefrailty, and 9.7% (n=21,010) with frailty. The frailty level at 66 years of age was associated with higher cumulative total costs (robust to frail: $19,815 to $28.281; P<.001), inpatient costs (US $11,189 to US $16,627; P<.001), and outpatient costs (US $8,625 to US $11,654; P<.001) over the next 10 years. In the robust group, a one-year increase in age was associated with increased total health care costs (mean change per beneficiary per year: US $206.2; SE: $1.2; P<.001), inpatient costs (US $126.8; SE: $1.0; P<.001), and outpatient costs (US $74.4; SE: $0.4; P<.001). In the frail group, the increase in total health care costs was greater compared to the robust group (difference in mean cost per beneficiary per year: US $120.9; SE: $5.3; P<.001), inpatient costs (US $102.8; SE: $5.22; P<.001), and outpatient costs (US $15.6; SE: $1.5; P<.001). Similar results were observed for health care utilization (P<.001). Among the robust group, a one-year increase in age was associated with increased inpatient days (mean change per beneficiary per year: 0.9 d; P<.001) and outpatient visits (2.1 visits; P<.001). In the frail group, inpatient days increased annually compared to the robust group (difference in the mean inpatient days per beneficiary per year: 1.5 d; P<.001), while outpatient visits increased to a lesser extent (difference in the mean outpatient visits per beneficiary per year: -0.2 visits; P<.001).

Conclusions

Our study demonstrates the potential utility of assessing frailty at 66 years of age in identifying older adults who are more likely to incur high health care costs and utilize health care services over the subsequent 10 years. The long-term high health care costs and utilization associated with frailty and prefrailty warrants public health strategies to prevent and manage frailty in aging populations.

The medical institution and transgender health: The role of healthcare barriers and negative healthcare experiences

Transgender health has risen as a topic of key interest. Yet little is known about factors that might stratify health among transgender people. In this paper, we suggest that the medical institution, which both prevents and provides access to transition-related care and thus sociolegal recognition for many transgender people, is a key institution for the health of transgender people. Drawing on 2015 US Transgender Survey data (USTS; N = 27,715), we examine whether transgender people who report barriers to healthcare and negative healthcare experiences have worse health than transgender people who do not. We contextualize the USTS sample against, and replicate our analyses when possible with, a probability-based sample of transgender people from the 2014-2017 Behavioral Risk Factor Surveillance System (BRFSS; N = 2,386). We find that transgender people who have unmet medical needs and negative healthcare experiences have worse self-rated health than their transgender counterparts who do not. Findings also suggest that such barriers and experiences are more negatively associated with the health of non-binary/genderqueer people compared with transgender men and transgender women. Our study moves past prior work documenting a transgender health disadvantage by identifying specific characteristics associated with poor health of transgender people and by illuminating heterogeneity in such associations.

Procrastination and preventive health-care in the older U.S. population

OBJECTIVE

Maintaining health preventive behaviours in later life reduces the risk of non-communicable diseases. However, these behaviours often require effort and discipline to adopt and may be prone to procrastination. This study examined whether procrastination affected engagement in health preventive behaviours among older adults.

METHODS

We applied generalised additive models to data from the 2020 wave of the United States Health and Retirement Study. Our analytic sample consisted of adults aged 50+ (n = 1338; mean = 68.24; range = 50-95). Our analysis focused on six health preventive behaviours: prostate exams, mammograms, cholesterol screenings, pap smears, flu shots, and dental visits.

RESULTS

Procrastination was associated with less frequent engagement in mammograms and cholesterol screenings among women, though it had no significant association with pap smears or flu shots. Additionally, procrastination interacted with depression reducing the likelihood of prostate exams in men and dental visits in both men and women, such that individuals with high procrastination and low depression were associated with less frequent engagement in both preventive health behaviours.

CONCLUSIONS

Procrastination may be a behavioral risk factor for maintaining optimal health in older adults. Given that procrastination is a potentially modifiable behaviour, interventions aimed at reducing procrastination, such as simplifying tasks or providing default appointment, could improve engagement in critical health preventive behaviours.

Assessing how frailty and healthcare delays mediate the association between sexual and gender minority status and healthcare utilization in the All of Us Research Program

OBJECTIVES

To understand how frailty and healthcare delays differentially mediate the association between sexual and gender minority older adults (OSGM) status and healthcare utilization.

MATERIALS AND METHODS

Data from the All of Us Research Program participants ≥50 years old were analyzed using marginal structural modelling to assess if frailty or healthcare delays mediated OSGM status and healthcare utilization. OSGM status, healthcare delays, and frailty were assessed using survey data. Electronic health record (EHR) data was used to measure the number of medical visits or mental health (MH) visit days, following 12 months from the calculated All of Us Frailty Index. Analyses adjusted for age, race and ethnicity, income, HIV, marital status ± general MH (only MH analyses).

RESULTS

Compared to non-OSGM, OSGM adults have higher rates of medical visits (adjusted rate ratio [aRR]: 1.14; 95% CI: 1.03, 1.24) and MH visits (aRR: 1.85; 95% CI: 1.07, 2.91). Frailty mediated the association between OSGM status medical visits (Controlled direct effect [Rcde] aRR: 1.03, 95% CI [0.87, 1.22]), but not MH visits (Rcde aRR: 0.37 [95% CI: 0.06, 1.47]). Delays mediated the association between OSGM status and MH visit days (Rcde aRR: 2.27, 95% CI [1.15, 3.76]), but not medical visits (Rcde aRR: 1.06 [95% CI: 0.97, 1.17]).

DISCUSSION

Frailty represents a need for medical care among OSGM adults, highlighting the importance of addressing it to improve health and healthcare utilization disparities. In contrast, healthcare delays are a barrier to MH care, underscoring the necessity of targeted strategies to ensure timely MH care for OSGM adults.

Long-term Monitoring of Blood Pressure in Older Adults: A Focus on Self-Measured Blood Pressure Monitoring

Hypertension is among the most common chronic conditions in older adults. Effective treatment exists, yet many older adults do not achieve recommended control of their blood pressure (BP). Self-measured blood pressure (SMBP) monitoring, in which patients check their BP at home, is one underutilized tool for improving hypertension control. Older adults may face unique challenges in using SMBP monitoring and therefore require unique solutions. An individualized approach to guiding older adults to use SMBP monitoring is preferred.

Living Alone With Mild-to-Moderate Dementia Over a Two-Year Period: Longitudinal Findings From the IDEAL Cohort

OBJECTIVES

To compare the experiences of people with dementia living alone or with others and how these may change over two years.

DESIGN

We analysed longitudinal data from three assessment waves, one year apart, in the British IDEAL cohort.

SETTING

Participants with mild-to-moderate dementia were recruited through National Health Service providers, where possible with a family caregiver, and interviewed at home.

PARTICIPANTS

The current analyses include 281 people with dementia living alone and 1,244 living with others at baseline; follow-up data were available for 200 and 965 respectively at time 2 and 144 and 696 respectively at time 3. For those living alone, 140 nonresident caregivers contributed at baseline, 102 at time 2 and 81 at time 3. For those living with others, 1,127 family caregivers contributed at baseline, 876 at time 2 and 670 at time 3.

MEASUREMENTS

Assessments covered: cognitive and functional ability; self-reported perceptions of health, mood, social engagement, quality of life, satisfaction with life and well-being; use of in-home and community care; and transitions into residential care.

RESULTS

People living alone tended to have better cognitive and functional ability and were more frequent users of in-home care. However, they experienced poorer physical, social, and psychological health and reduced quality of life, satisfaction with life, and well-being. These differences persisted over time and rates of transition into residential care were higher.

CONCLUSIONS

To facilitate continuing in place for people with dementia living alone, a dual focus on supporting functional ability and add ressing psychosocial needs is essential in the context of an enabling policy framework.

International survey of people living with chronic conditions (PaRIS survey): effects of general practitioner non-participation on the representativeness of the Norwegian patient data

BACKGROUND

The International Survey of People living with Chronic Conditions (OECD-PaRIS survey), aims to systematically gather patient-reported experiences (PREMs) and - outcomes (PROMs) and potential predictors for these outcomes for persons with chronic conditions as well as information from professionals about health care provided. In such patient surveys, the advantages of a multilevel (nested) approach in which patients are sampled 'within providers' need to be balanced against the potential for bias if patient populations from participating GPs significantly differ from those of non-participating GPs. The objective was to assess the effects of general practitioner (GP) non-participation on the representativeness of the Norwegian patient data of the International Survey of People living with Chronic Conditions (OECD-PaRIS survey).

METHODS

To test all aspects of the first main PaRIS survey, it was preceded by a field trial which this paper reports on the Norwegian part of. For the Norwegian part of the field trial in 2022, we randomly sampled and surveyed 75 GPs and 125 patients 45 years and older for each GP, regardless of whether their GP were also participating in the study. GPs were sampled from a national register that included all GPs. The surveys were primarily digital, but we sent postal questionnaires to non-digital patients and non-responding digital patients. We compared GP and patient characteristics as well as patient-reported experiences and outcomes according to GP participation status in bivariate analysis, supplemented with multiple linear regressions with PREMs/PROMs as dependent variables and participation status as independent adjusting for significant patient factors.

RESULTS

17 of 75 sampled GPs participated (22.7%), of which 993 of 2,015 patients responded (49.3%). 3,347 of 7,080 patients of non-responding GPs answered (47.3%). Persons with chronic conditions from participating GPs reported significantly better patient-centred coordinated care (p = 0.017), overall experiences with the GP office the last 12 months (p = 0.004), mental well-being (p = 0.039) and mental health (p = 0.013) than patients from non-participating GPs. The raw differences between participating and non-participating GPs on patient-reported experiences and - outcomes varied from 1.5 to 2.9 points on a 0-100 scale, and from 2.2 to 3.0 after adjustment for case-mix.

CONCLUSIONS

The Norwegian field trial indicates that estimates based on participants in the PaRIS survey may modestly overestimate patient-reported experiences and -outcomes at the aggregated level and the need for more research within and across countries to identify and address this potential bias.

Healthcare on the brink: navigating the challenges of an aging society in the United States

The US healthcare system is at a crossroads. With an aging population requiring more care and a strained system facing workforce shortages, capacity issues, and fragmentation, innovative solutions and policy reforms are needed. This paper aims to spark dialogue and collaboration among healthcare stakeholders and inspire action to meet the needs of the aging population. Through a comprehensive analysis of the impact of an aging society, this work highlights the urgency of addressing this issue and the importance of restructuring the healthcare system to be more efficient, equitable, and responsive.

Algorithmic identification of persons with dementia for research recruitment: ethical considerations

Underdiagnosis, misdiagnosis, and patterns of social inequality that translate into unequal access to health systems all pose barriers to identifying and recruiting diverse and representative populations into research on Alzheimer's disease and Alzheimer's disease related dementias. In response, some have turned to algorithms to identify patients living with dementia using information that is associated with this condition but that is not as specific as a diagnosis. This paper explains six ethical issues associated with the use of such algorithms including the generation of new, sensitive, identifiable medical information for research purposes without participant consent, issues of justice and equity, risk, and ethical communication. It concludes with a discussion of strategies for addressing these issues and prompting valuable research.

User-reported quality of care: findings from the first round of the People's Voice Survey in 14 countries

High-quality care is essential for improving health outcomes, although many health systems struggle to maintain good quality. We use data from the People's Voice Survey-a nationally representative survey conducted in 14 high-income, middle-income, and low-income countries-to describe user-reported quality of most recent health care in the past 12 months. We described ratings for 14 measures of care competence, system competence, and user experience and assessed the relationship between visit quality factors and user recommendation of the facility. We disaggregated the data by high-need and underserved groups. The proportion of respondents rating their most recent visit as high quality ranged from 25% in Laos to 74% in the USA. The mean facility recommendation score was 7·7 out of 10. Individuals with high needs or who are underserved reported lower-quality services on average across countries. Countries with high health expenditure per capita tended to have better care ratings than countries with low health expenditure. Visit quality factors explained a high proportion of variation in facility recommendations relative to facility or demographic factors. These results show that user-reported quality is low but increases with high national health expenditure. Elevating care quality will require monitoring and improvements on multiple dimensions of care quality, especially in public systems.

Hereditary angioedema in older adults: Understanding the patient perspective

BACKGROUND

Hereditary angioedema (HAE) is a rare condition characterized by potentially fatal, recurrent episodes of painful swelling. Whereas there are limited studies evaluating the quality of life of individuals with HAE, none have evaluated the impact of HAE on older adults.

OBJECTIVE

To evaluate the effect of HAE on older adults through qualitative methodology.

METHODS

A group of 3 physicians with extensive research and clinical experience in HAE developed a focus group guidebook highlighting issues of importance to older adults. A total of 17 patients with HAE (type I or II) aged 60 years and older participated in focus groups. Three independent reviewers coded each focus group transcript using a thematic saturation approach.

RESULTS

Reviewers identified 7 core themes from the focus groups. The themes identified encompassed the following: (1) challenges with securing medications and insurance concerns; (2) the experience of living with HAE before the advent of newer and more effective therapeutic options; (3) a worsening of HAE attack frequency and severity with aging; (4) the effects of comorbid conditions such as arthritis, memory loss, and irritable bowel syndrome; (5) changes in HAE with menopause; and (6) changing perspective on HAE with age, the effect of HAE on interpersonal relationships including the decision to have children, and goals for future care and research including support groups and a desire to be included in clinical trials.

CONCLUSION

Older adults with HAE have specific challenges and concerns that may be unique compared with younger populations. Health care providers should address these to provide optimal care.

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.

Preventing autonomy loss with multicomponent geriatric interventions: A resource-saving strategy? Evidence from the SPRINT-T study

Background

The objective of healthy aging strategies is to support interventions targeting autonomy loss prevention, with the assumption that these interventions are likely to be efficient by simultaneously improving clinical outcomes and saving costs.

Methods

We compare the economic impact of two interventions targeting frailty prevention in older European populations: a multicomponent intervention including physical activity monitoring, nutrition management, information and communications technology use and a relatively simple healthy aging lifestyle education program based on a series of workshops. Our sample includes 1,519 male and female participants from 11 European countries aged 70 years or older. Our econometric model explores trends in several outcomes depending on intervention receipt and frailty status at baseline.

Results

Implementing a multicomponent intervention among frail older people does not lead to a lower use of care and do not prevent quality of life losses associated with aging. However, it impacts older people's sense of priorities and interest in the future. We find no statistically significant differences between the two interventions, suggesting that the implementation of a multicomponent intervention may not be the most efficient strategy. The impact of the interventions does not differ by frailty status at baseline.

Conclusions

Our results show the need to implement healthy aging strategies that are more focused on people's interests.

Factors associated with delaying medical care: cross-sectional study of Nebraska adults

BACKGROUND

Delayed medical care may result in adverse health outcomes and increased cost. Our purpose was to identify factors associated with delayed medical care in a primarily rural state.

METHODS

Using a stratified random sample of 5,300 Nebraska households, we conducted a cross-sectional mailed survey with online response option (27 October 2020 to 8 March 2021) in English and Spanish. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals.

RESULTS

The overall response rate was 20.8% (n = 1,101). Approximately 37.8% of Nebraskans ever delayed healthcare (cost-related 29.7%, transportation-related 3.7%), with 22.7% delaying care in the past year (10.1% cost-related). Cost-related ever delay was associated with younger age [< 45 years aOR 6.17 (3.24-11.76); 45-64 years aOR 2.36 (1.29-4.32)], low- and middle-income [< $50,000 aOR 2.85 (1.32-6.11); $50,000-$74,999 aOR 3.06 (1.50-6.23)], and no health insurance [aOR 3.56 (1.21-10.49)]. Transportation delays were associated with being non-White [aOR 8.07 (1.54-42.20)], no bachelor's degree [≤ high school aOR 3.06 (1.02-9.18); some college aOR 4.16 (1.32-13.12)], and income < $50,000 [aOR 8.44 (2.18-32.63)]. Those who did not have a primary care provider were 80% less likely to have transportation delays [aOR 0.20 (0.05-0.80)].

CONCLUSIONS

Delayed care affects more than one-third of Nebraskans, primarily due to financial concerns, and impacting low- and middle-income families. Transportation-related delays are associated with more indicators of low socio-economic status. Policies targeting minorities and those with low- and middle-income, such as Medicaid expansion, would contribute to addressing disparities resulting from delayed care.

Examine Race/Ethnicity Disparities in Perception, Intention, and Screening of Dementia in a Community Setting: Scoping Review

BACKGROUND

Delayed detection and diagnosis of Alzheimer's Disease and related dementia (ADRD) can lead to suboptimal care and socioeconomic burdens on individuals, families, and communities. Our objective is to investigate dementia screening behavior focusing on minority older populations and assess whether there are ethnic differences in ADRD screening behavior.

METHODS

The scoping review method was utilized to examine ADRD screening behavior and contributing factors for missed and delayed screening/diagnosis focusing on race/ethnicity.

RESULTS

2288 papers were identified, of which 21 met the inclusion criteria. We identified six dimensions of ADRD screening behavior: Noticing Symptoms, Recognizing a problem, Accepting Screen, Intending Screen, Action, and Integrating with time. Final findings were organized into study race/ethnicity, theoretical background, the methods of quantitative and qualitative studies, description and measures of ADRD screening behavior, and racial/ethnic differences in ADRD screening behavior.

CONCLUSIONS

A trend in ethnic disparities in screening for ADRD was observed. Our findings point to the fact that there is a scarcity of studies focusing on describing ethnic-specific ADRD screening behavior as well as a lack of those examining the impact of ethnicity on ADRD screening behavior, especially studies where Asian Americans are almost invisible.

Barriers to accessing and engaging in healthcare as potential modifiers in the association between polyvictimization and mental health among Black transgender women

BACKGROUND

Black transgender women endure pervasive polyvictimization (experiencing multiple forms of violence throughout the lifespan). Polyvictimization is associated with poor mental health. Black transgender women also face barriers in access to healthcare, but the extent that such barriers modify the association between polyvictimization and poor mental health has not been described using convergent mixed-methods analysis.

METHODS

This convergent mixed-methods secondary analysis employs an intersectional lens and integrates two inter-related datasets to describe barriers to healthcare and the extent that such barriers modify the association between polyvictimization and mental health among Black transgender women. Investigators used survey data (n = 151 participants) and qualitative interview data (n = 19 participants) collected from Black transgender women (age 18 years and older) in Baltimore, MD and Washington, DC between 2016 and 2018. Analyses include thematic content analysis, bivariate analysis, joint display, and multivariate linear regression analysis examining mediation and moderation.

RESULTS

Joint display illuminated three domains to describe how barriers to healthcare present among Black transgender women-Affordability, Accessibility, and Rapport and Continuity. Independent t-tests revealed significantly higher polyvictimization, Post Traumatic Stress Disorder (PTSD), and depression scores among participants who reported at least one barrier to healthcare (BHI) compared to those who reported no barriers. BHI significantly moderated and partially mediated the association between polyvictimization and PTSD symptom severity and BHI fully mediated the association between polyvictimization and depressive symptom severity-when accounting for age and location.

DISCUSSION

Findings highlight the importance of access to healthcare in modifying the association between polyvictimization and PTSD and depression symptom severity among Black transgender women. Findings call for immediate interventions aimed at reducing barriers to healthcare and improved training for clinical providers serving Black transgender women.

Value assessment frameworks: who is valuing the care in healthcare?

Many healthcare agencies are producing evidence-based guidance and policy that may determine the availability of particular healthcare products and procedures, effectively rationing aspects of healthcare. They claim legitimacy for their decisions through reference to evidence-based scientific method and the implementation of just decision-making procedures, often citing the criteria of 'accountability for reasonableness'; publicity, relevance, challenge and revision, and regulation. Central to most decision methods are estimates of gains in quality-adjusted life-years (QALY), a measure that combines the length and quality of survival. However, all agree that the QALY alone is not a sufficient measure of all relevant aspects of potential healthcare benefits, and a number of value assessment frameworks have been suggested. I argue that the practical implementation of these procedures has the potential to lead to a distorted assessment of value. Undue weight may be ascribed to certain attributes, particularly those that favour commercial or political interests, while other attributes that are highly valued by society, particularly those related to care processes, may be omitted or undervalued. This may be compounded by a lack of transparency to relevant stakeholders, resulting in an inability for them to participate in, or challenge, the decisions. The makes it likely that costly new technologies, for which inflated prices can be justified by the current value frameworks, are displacing aspects of healthcare that are highly valued by society.

Impact of financial barriers on health status, healthcare utilisation and economic burden among individuals with cognitive impairment: a national cross-sectional survey

OBJECTIVE

To study the impact of financial barriers to healthcare on health status, healthcare utilisation and costs among patients with cognitive impairment.

DESIGN

Cross-sectional.

SETTING

National Health Interview Survey (NHIS), 2011-2017.

PARTICIPANTS

Patients with cognitive impairment aged 18 years or older.

INTERVENTIONS

Financial barriers to healthcare were identified using a series of NHIS prompts asking about the affordability of healthcare services.

PRIMARY OUTCOME MEASURES

Health status was based on a survey prompt about respondents' general health. Healthcare utilisation included office visits, home healthcare visits, hospital stays and emergency department (ED) visits. Economic burden was based on the family spending on medical care. Logistic regression models were used to examine the impact of financial barriers to healthcare access on health status, home healthcare visits, office visits, hospital stays and ED visits, respectively.

RESULTS

Compared with cognitively impaired respondents without financial barriers to healthcare access, those with financial barriers were more likely to be unhealthy (OR 0.64, 95% CI 0.57 to 0.72). Cognitively impaired respondents with financial barriers were less likely to have home healthcare (OR 0.69, 95% CI 0.48 to 0.99) and more likely to have hospital stays (OR 1.33, 95% CI 1.19 to 1.48) and ED visits (OR 1.50, 95% CI 1.35 to 1.67). In addition, compared with cognitively impaired respondents without financial barriers to healthcare access, those with the barriers were more likely to have an increased economic burden (OR=1.85, 95% CI 1.65 to 2.07).

CONCLUSION

Financial barriers to healthcare worsened health status and increased use of ED, hospitalisation and economic burden. Policy decision-makers, providers and individuals with cognitive impairment should be aware of the impact of financial barriers and take corresponding actions to reduce the impact.

Digital Multisided Platforms and Women’s Health: An Empirical Analysis of Peer-to-Peer Lending and Abortion Rates

Access to short-term capital remains a pressing problem for many people, especially those facing medical emergencies or needing immediate care. Peer-to-peer lending platforms have the ability to resolve these capital constraints by providing access to small to medium sums of money in an environment that is private and protective of personal information. In this study, we consider how the introduction of P2P lending platforms, and the resulting access to capital, influences local abortion rates, a medical procedure characterized by significant financial barriers and social stigma. We find that the entry of the P2P platform LendingClub is associated with an increase in the rate at which women choose to not carry to term. We argue that the availability of capital through these platforms, when combined with privacy protections, is able to reduce the financial barriers women face when accessing abortion services. This observed effect is stronger in more religious areas and areas with lower levels of education, indicating that social frictions and stigma may be higher in these areas, and also showing where providing an additional channel for funding is more influential.

Delayed medical care due to transportation barriers among adults with atherosclerotic cardiovascular disease

BACKGROUND

In patients with atherosclerotic cardiovascular disease (ASCVD), barriers related to transportation may impair access to care, with potential implications for prognosis. Although few studies have explored transportation barriers among patients with ASCVD, the correlates of delayed care due to transportation barriers have not been examined in this population. We aimed to examine this in U.S. patients with ASCVD using nationally representative data.

METHODS

Using data from the 2009-2018 National Health Interview Survey, we estimated the self-reported prevalence of delayed medical care due to transportation barriers among adults with ASCVD, overall and by sociodemographic characteristics. Logistic regression was used to examine the association between various sociodemographic characteristics and delayed care due to transportation barriers.

RESULTS

Among adults with ASCVD, 4.5% (95% CI; 4.2, 4.8) or ∼876,000 annually reported delayed care due to transportation barriers. Income (low-income: odds ratio [OR] 4.43, 95% CI [3.04, 6.46]; lowest-income: OR 6.35, 95% CI [4.36, 9.23]) and Medicaid insurance (OR 4.53; 95% CI [3.27, 6.29]) were strongly associated with delayed care due to transportation barriers. Additionally, younger individuals, women, non-Hispanic Black adults, and those from the U.S. South or Midwest, had higher odds of reporting delayed care due to transportation barriers.

CONCLUSIONS

Approximately 5% of adults with ASCVD experience delayed care due to transportation barriers. Vulnerable groups include young adults, women, low-income people, and those with public/no insurance. Future studies should analyze the feasibility and potential benefits of interventions such as use of telehealth, mobile clinics, and provision of transportation among patients with ASCVD in the U.S.

Feasibility trial of an integrated treatment "Activate for Life" for physical and mental well-being in older adults

Background

Pain and fatigue are common chronic conditions faced by older adults. Integrated interventions to address pain and fatigue may therefore be particularly useful for older adults, especially those interventions that target mobility and psychosocial well-being. The present study describes feasibility and participant satisfaction for an integrated eHealth treatment to address pain and fatigue in a sample of older adults living in a low-income independent residence facility and their own homes in the community.

Methods

Three treatment combinations were compared in a randomized repeated measures design to determine if adding components of breathing retraining and behavioral activation to the existing Otago program (for strength and balance) affected feasibility and patient satisfaction. Specifically, 30 older adults were randomly allocated to: Arm1: the Otago alone (n = 10); Arm 2: Otago + Gentle Yoga and Yogic Breathing (n = 10); or Arm 3: Otago + Gentle Yoga and Yogic Breathing + Behavioral Activation (combination was named ‘Activate for Life’ n = 10). Feasibility measures included recruitment rate, session completion characteristics, and satisfaction with the program.

Conclusion

Data from this study provide support for the feasibility of an integrated program to address physical and mental well-being of older adults. Future fully powered studies should now focus on assessment of clinical outcomes and refinement of individual components.

Trial registration

Registered in clinicaltrials.gov with the identifier: NCT03853148.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01000-8.

Age-Based Disparities in Metastatic Melanoma Patients Treated in the Immune Checkpoint Inhibitors (ICI) Versus Non-ICI Era: A Population-Based Study

Immune checkpoint inhibitors (ICIs) have revolutionized metastatic melanoma treatment, but our knowledge of ICI activity across age groups is insufficient. Patients in different age groups with advanced melanoma were selected based on the ICI approval time in this study. Patients with melanoma were identified in the Surveillance, Epidemiology, and End Result (SEER) database program 2004-2016. The results showed that 4,040 patients had advanced melanoma before the advent of ICI (referred to as the "non-ICI era"), whereas there were 6,188 cases after ICI approval (referred to as the "ICI era"). In all age groups, the cases were dominated by men. The differences between the first (20-59 years) and second (60-74 years) age groups in both eras were significant in terms of surgery performance and holding of insurance policies (p = 0.05). The first and second groups (20-59 and 60-70 years old, respectively) showed no difference in survival (median = 8 months) during the non-ICI era, but the difference was evident in the first, second, and third age groups in the ICI era, with the younger group (20-59 years) having significantly better survival (median = 18, 14, and 10 months, respectively, p = 0.0001). Multivariate analysis of the first group (the youngest) in the ICI era revealed that surgery was significantly associated with an increase in survival among patients compared with those who did not undergo surgery (p < 0.0001). Furthermore, having an insurance policy among all age groups in the ICI era was associated with favorable survival in the first (20-59 years) and second (60-74 years) age groups (p = 0.0001), while there were no survival differences in the older ICI group (>74 years). Although there were differences in survival between the ICI era and the non-ICI era, these results demonstrate that ICI positively affected the survival of younger patients with advanced melanoma (first age group) than it had beneficial effects on older patients. Moreover, having had cancer surgery and holding an insurance policy were positive predictors for patient survival. This study emphasizes that adequate clinical and preclinical studies are important to enhance ICI outcomes across age groups.

Healthy by Association: The relationship between social participation and self-rated physical and psychological health

This paper investigates the relationship between social participation and subjective health. Using individual-level data from the British Household Panel Survey, we show that being an active member of a social or sport organisation increases self-rated physical and psychological health. For men, the benefits of social interaction work primarily via physical pathways, while women report a more psychosocial channel. We separate the main results by occupation and document some heterogeneity. Manual workers find more physical and psychological relief via social involvement, whereas non-manual workers are more likely to take relief from sport participation. Interestingly, as the number of associations in which the individual is active increases, the incremental increase in social benefits diminishes. Our findings point to the importance of promoting social and sport activities in health communication and policy making.

Older Adults Engage With Personalized Digital Coaching Programs at Rates That Exceed Those of Younger Adults

Background: The US population is aging and has an expanding set of healthcare needs for the prevention and management of chronic conditions. Older adults contribute disproportionately to US healthcare costs, accounting for 34% of total healthcare expenditures in 2014 but only 15% of the population. Fully automated, digital health programs offer a scalable and cost-effective option to help manage chronic conditions. However, the literature on technology use suggests that older adults face barriers to the use of digital technologies that could limit their engagement with digital health programs. The objective of this study was to characterize the engagement of adults 65 years and older with a fully automated digital health platform called Lark Health and compare their engagement to that of adults aged 35-64 years. Methods: We analyzed data from 2,169 Lark platform users across four different coaching programs (diabetes prevention, diabetes care, hypertension care, and prevention) over a 12-month period. We characterized user engagement as participation in digital coaching conversations, meals logged, and device measurements. We compared engagement metrics between older and younger adults using nonparametric bivariate analyses. Main Results: Aggregate engagement across all users during the 12-month period included 1,623,178 coaching conversations, 588,436 meals logged, and 203,693 device measurements. We found that older adults were significantly more engaged with the digital platform than younger adults, evidenced by older adults participating in a larger median number of coaching conversations (514 vs. 428) and logging more meals (174 vs. 89) and device measurements (39 vs. 28) all p ≤ 0.01. Conclusions: Older adult users of a commercially available, fully digital health platform exhibited greater engagement than younger adults. These findings suggest that despite potential barriers, older adults readily adopted digital health technologies. Fully digital health programs may present a widely scalable and cost-effective alternative to traditional telehealth models that still require costly touchpoints with human care providers.

Health care Affordability and Associated Concerns Among Adults Aged 65 and above in Florida

OBJECTIVE

This study assessed affordability of care in a diverse sample of Floridians aged ≥ 65 to ascertain concerns about health care costs.

METHODS

We surveyed 170 adults (40.6% white, 27.6% black, and 31.8% Hispanic) and conducted three race/ethnic-stratified focus groups (n = 27).

RESULTS

Most participants had Medicare (97.1%). Among whites, 11.6% reported problems paying medical bills in the past 12 months versus 14.9% of blacks and 24.1% of Hispanics. In addition, 13% of whites, 19.2% of blacks, and 20.4% of Hispanics reported not getting needed prescription drugs because of costs. The most frequently identified concerns from the focus groups were the cost of prescription drugs, out-of-pocket expenses, and medical billing. Concerns about medical billing included understanding bills, transparency, timely postings, and uncertainty about who to contact about problems.

DISCUSSION

Our findings suggest that practices that help older adults effectively manage medical bills and costs may alleviate their concerns and guard against financial burdens.

Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions

Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

Community health worker interventions for older adults with complex health needs: A systematic review

BACKGROUND/OBJECTIVES

The number of older adults with complex health needs is growing, and this population experiences disproportionate morbidity and mortality. Interventions led by community health workers (CHWs) can improve clinical outcomes in the general adult population with multimorbidity, but few studies have investigated CHW-delivered interventions in older adults.

DESIGN

We systematically reviewed the impact of CHW interventions on health outcomes among older adults with complex health needs. We searched for English-language articles from database inception through April 2020 using seven databases. PROSPERO protocol registration CRD42019118761.

SETTING

Any U.S. or international setting, including clinical and community-based settings.

PARTICIPANTS

Adults aged 60 years or older with complex health needs, defined in this review as multimorbidity, frailty, disability, or high-utilization.

INTERVENTIONS

Interventions led by a CHW or similar role consistent with the American Public Health Association's definition of CHWs.

MEASUREMENTS

Pre-defined health outcomes (chronic disease measures, general health measures, treatment adherence, quality of life, or functional measures) as well as qualitative findings.

RESULTS

Of 5671 unique records, nine studies met eligibility criteria, including four randomized controlled trials, three quasi-experimental studies, and two qualitative studies. Target population and intervention characteristics were variable, and studies were generally of low-to-moderate methodological quality. Outcomes included mood, functional status and disability, social support, well-being and quality of life, medication knowledge, and certain health conditions (e.g., falls, cognition). Results were mixed with several studies demonstrating significant effects on mood and function, including one high-quality RCT, while others noted no significant intervention effects on outcomes.

CONCLUSION

CHW-led interventions may have benefit for older adults with complex health needs, but additional high-quality studies are needed to definitively determine the effectiveness of CHW interventions in this population. Integration of CHWs into geriatric clinical settings may be a strategy to deliver evidence-based interventions and improve clinical outcomes in complex older adults.

Subjective Well-Being, Depression, and Delays in Care Among Older Adults: Dual-Eligible Versus Medicare-Only Beneficiaries

We aimed to (a) determine the role of subjective well-being and depression in care delays among Medicare beneficiaries and (b) examine whether subjective well-being and depression play a differential role among Medicare-only and dual-eligible beneficiaries. A nationally representative sample of 1,696 older adults participated in the study. Roughly, 22% of participants reported often or sometimes experiencing care delays, with more delays among dual eligibles. We found that higher levels of subjective well-being were significantly related to less frequent care delays. In contrast, higher levels of depression were significantly related to more frequent care delays. Moreover, as depression increased, the predicted probability of delays increased to a greater extent among dual eligibles than Medicare-only beneficiaries. These findings signify the importance of identifying and implementing strategies to enhance subjective well-being and reduce depression in older adults, particularly dual eligibles, to improve access to timely care.

Primary care experience among older adults in the United States: a retrospective cross-sectional study

BACKGROUND

While the importance of primary care becomes more imminent for older adults to manage multi-morbidities, the perception of primary care among this group is not well examined.

AIM

To evaluate the primary care experience among older adults in the United States (US).

METHODS

We conducted a retrospective cross-sectional study examining four domains of primary care: first contact, longitudinality, comprehensiveness, and coordination. Using survey responses from Medical Expenditure Panel Survey (MEPS), we used propensity score matching method to compare the percentage of geriatric (≥65 years old) and non-geriatric (< 65 years old) who answered favorably to questions that supported each domain from 2014 to 2016. Using multivariate regression, we also assessed the impact of each domain on various demographic and perceived need for care features of older adults.

RESULTS

A total of 12,982 surveys were analyzed for geriatric, compared to 62,694 surveys for non-geriatric. Overall, older adults answered more favorably than younger adults for all four domains. However, uninsured older adults, Black older adults and older adults with limitation in activities, cognitive impairments, and multiple comorbidities were more likely to have difficulties in accessing their usual source of care (USC). Additionally, Black, Hispanic, and Asian older adults and cognitively impaired adults perceived less contribution in their own treatment management.

CONCLUSION

Older adults in the US generally experience good quality of primary care, compared to younger adults. However, establishing and maintaining access (first contact) and being involved in disease management (coordination) were perceived as poor by several cohorts of older adults.

The Money Smart for Older Adults Program: A Qualitative Study of the Participants' Financial Well-Being

The Money Smart for Older Adults is a program that is tailored to older adults to raise awareness for the risk of financial exploitation and teach them how to plan and make informed financial decisions. The purpose of this study was to examine financial circumstances of older adults in the program and to explore how the program could better support their financial well-being. Individual, in-depth interviews were conducted with 29 older adults who attended the program provided by a local agency in northern Texas. Three themes emerged when exploring financial circumstances of the participants: (1) victims of financial fraud scams, (2) struggles with money management, and (3) inability to make ends meet. The program has been serving older adults, particularly ethnically diverse older adults and low-income older adults who may not have access to financial education workshops or seminars provided by private financial institutions. The Money Smart for Older Adults Program was perceived as helpful among the participants because it raised awareness of the importance of their financial well-being and it also supported their financial decision making.

Comparison of Mobile Health Technology Use for Self-Tracking Between Older Adults and the General Adult Population in Canada: Cross-Sectional Survey

Background

The burden of population aging and chronic conditions has been reported worldwide. Older adults, especially those with high needs, experience social isolation and have high rates of emergency visits and limited satisfaction with the care they receive. Mobile health (mHealth) technologies present opportunities to address these challenges. To date, limited information is available on Canadian older adults’ attitudes toward and use of mHealth technologies for self-tracking purposes—an area that is increasingly important and relevant during the COVID-19 era.

Objective

This study presents contributions to an underresearched area on older adults and mHealth technology use. The aim of this study was to compare older adults’ use of mHealth technologies to that of the general adult population in Canada and to investigate the factors that affect their use.

Methods

A cross-sectional survey on mHealth and digital self-tracking was conducted. A web-based questionnaire was administered to a national sample of 4109 Canadian residents who spoke either English or French. The survey instrument consisted of 3 sections assessing the following items: (1) demographic characteristics, health status, and comorbidities; (2) familiarity with and use of mHealth technologies (ie, mobile apps, consumer smart devices/wearables such as vital signs monitors, bathroom scales, fitness trackers, intelligent clothing); and (3) factors influencing the continued use of mHealth technologies.

Results

Significant differences were observed between the older adults and the general adult population in the use of smart technologies and internet (P<.001). Approximately 47.4% (323/682) of the older adults in the community reported using smartphones and 49.8% (340/682) indicated using digital tablets. Only 19.6% (91/463) of the older adults using smartphones/digital tablets reported downloading mobile apps, and 12.3% (47/383) of the older adults who heard of smart devices/wearables indicated using them. The majority of the mobile apps downloaded by older adults was health-related; interestingly, their use was sustained over a longer period of time (P=.007) by the older adults compared to that by the general population. Approximately 62.7% (428/682) of the older adults reported tracking their health measures, but the majority did so manually. Older adults with one or more chronic conditions were mostly nontrackers (odds ratio 0.439 and 0.431 for traditional trackers and digital trackers, respectively). No significant differences were observed between the older adults and the general adult population with regard to satisfaction with mHealth technologies and their intention to continue using them.

Conclusions

Leveraging mHealth technologies in partnership with health care providers and sharing of health/well-being data with health care professionals and family members remain very limited. A culture shift in the provision of care to older adults is deemed necessary to keep up with the development of mHealth technologies and the changing demographics and expectations of patients and their caregivers.

Case Management Models and Continuing Care: A Literature Review across nations, settings, approaches, and assessments

Older adults accessing continuing care often have multiple chronic conditions. Research suggests that case management is a promising approach to reduce health care expenditure and improve patient outcomes. To optimize healthcare delivery, an examination of existing case management models and their effectiveness is essential. This literature review was conducted using Joanna Briggs Institute (JBI) methods to explore case management models for older adults accessing continuing care services. Searches were conducted in PubMed and CINAHL from 2010 to 2018. A total of 37 articles were included in this review. Approaches to case management are diverse with respect to composition of care providers, method of care provision, and location of care. Findings from 27 quantitative studies demonstrated that nurse-led and interdisciplinary team case management models that include home visits can effectively reduce hospital admission/readmission while lowering costs. Mixed results were found on the impact of case management on patient satisfaction, ED visits, quality of life, length of stay, self-efficacy, social integration and caregiver burden. Among 10 qualitative studies, 3 facilitators for quality case management were identified that include receiving care at home, building trusting relationships, and improving self-efficacy. Based on these findings, we conclude that nurse-led and interdisciplinary team case management can effectively reduce hospital admission of frail older adults while lowering costs, particularly within home care settings.

Connecting Social, Clinical, and Home Care Services for Persons with Serious Illness in the Community

The medical, psychological, cognitive, and social needs of older adults with serious illness are best met by coordinated and team-based services and support. These services are best provided in a seamless care model anchored by integrated biopsychosocial assessments focused on what matters to older adults and their social determinants of health; individualized care plans with shared goals; care provision and management; and quality measurement with continuous improvement. This model requires (1) racially and ethnically diverse healthcare professionals, including mental health and direct service workers, with training in aging and team collaboration; (2) an integrated network of community-based organizations (CBOs) providing in-home services; (3) an electronic communication platform that spans the system of providers and organizations with skilled technology staff; and (4) payment models that incentivize team-based care across the continuum of services, including CBOs, with adequate salaries and academic loan forgiveness to recruit and retain high-quality team members. Assuring that this model is effective requires ongoing quality assurance measures that include not only quality of care and utilization data to demonstrate cost offsets of service integration, but also quality of life for both the older adults and the family members caring for them. Although this may seem a lofty ideal in comparison with our current fragmented system, we review models that provide the key elements effectively and cost efficiently. We then propose an Essential Care Model that defines best practice in meeting the needs of older adults with serious illness and their families. J Am Geriatr Soc 67:S412-S418, 2019.

Transportation Barriers to Health Care in the United States: Findings From the National Health Interview Survey, 1997-2017

Objectives. To quantify the number of people in the US who delay medical care annually because of lack of available transportation and to examine the differential prevalence of this barrier for adults across sociodemographic characteristics and patient populations.Methods. We used data from the National Health Interview Survey (1997-2017) to examine this barrier over time and across groups. We used joinpoint regression analysis to identify significant changes in trends and multivariate analysis to examine correlates of this barrier for the year 2017.Results. In 2017, 5.8 million persons in the United States (1.8%) delayed medical care because they did not have transportation. The proportion reporting transportation barriers increased between 2003 and 2009 with no significant trends before or after this window within our study period. We found that Hispanic people, those living below the poverty threshold, Medicaid recipients, and people with a functional limitation had greater odds of reporting a transportation barrier after we controlled for other sociodemographic and health characteristics.Conclusions. Transportation barriers to health care have a disproportionate impact on individuals who are poor and who have chronic conditions. Our study documents a significant problem in access to health care during a time of rapidly changing transportation technology.

Examining Interprofessional teams structures and processes in the implementation of a primary care intervention (Health TAPESTRY) for older adults using normalization process theory

BACKGROUND

Many countries are engaged in primary care reforms to support older adults who are living longer in the community. Health Teams Advancing Patient Experience: Strengthening Quality [Health TAPESTRY] is a primary care intervention aimed at supporting older adults that involves trained volunteers, interprofessional teams, technology, and system navigation. This paper examines implementation of Health TAPESTRY in relation to interprofessional teamwork including volunteers.

METHODS

This study applied Normalization Process Theory (NPT) and used a descriptive qualitative approach [1] embedded in a mixed-methods, pragmatic randomized controlled trial. It was situated in two primary care practice sites in a large urban setting in Ontario, Canada. Focus groups and interviews were conducted with primary care providers, clinical managers, administrative assistants, volunteers, and a volunteer coordinator. Data was collected at 4 months (June-July 2015) and 12 months (February-March 2016) after intervention start-up. Patients were interviewed at the end of the six-month intervention. Field notes were taken at weekly huddle meetings.

RESULTS

Overall, 84 participants were included in 17 focus groups and 13 interviews; 24 field notes were collected. Themes were organized under four NPT constructs of implementation: 1) Coherence- (making sense/understanding of the program's purpose/value) generating comprehensive assessments of older adults; strengthening health promotion, disease prevention, and self-management; enhancing patient-focused care; strengthening interprofessional care delivery; improving coordination of health and community services. 2) Cognitive Participation- (enrolment/buy-in) tackling new ways of working; attaining role clarity. 3) Collective Action- (enactment/operationalizing) changing team processes; reconfiguring resources. 4) Reflective Monitoring- (appraisal) improving teamwork and collaboration; reconfiguring roles and processes.

CONCLUSIONS

This study contributes key strategies for effective implementation of interventions involving interprofessional primary care teams. Findings indicate that regular communication among all team members, the development of procedures and/or protocols to support team processes, and ongoing review and feedback are critical to implementation of innovations involving primary care teams.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT02283723 November 5, 2014. Prospectively registered.

Professional Care Networks of Frail Older People: An Explorative Survey Study from the Patient Perspective

BACKGROUND

Frail older people living in the community require multidisciplinary care. Despite the fact that patient participation is high on the public agenda, studies into multidisciplinary care mainly focus on the viewpoints of professionals. Little is known about frail older patients' experiences with care delivered by multidisciplinary teams and their perception of collaboration between professional and informal caregivers.

OBJECTIVE

To gain more insight into the experiences of frail older patients with integrated multidisciplinary care by mapping the care networks of this patient group and their perception of the interconnection between professional and informal caregivers.

METHODS

Survey study to facilitate a care network analysis. Due to the vulnerable health status of the respondents, questionnaires were completed during interviews. Analysis was performed using an iterative process, using both visual and metric techniques.

PARTICIPANTS

44 older persons, considered 'frail' by their general practitioner.

SETTING

Four general practices in The Netherlands.

RESULTS

The networks of the participants consisted of an average of 15 actors connected by 54 ties. General practitioners were the most common actors in the networks, and were well connected to medical specialists and in-home care providers. The participants did not always perceive a connection between their general practitioner and their informal caregiver. The network analyses resulted in the identification of three subtypes: simple star (n = 16), complex star (n = 16), and sub-group networks (n = 12).

CONCLUSIONS

Our findings indicate that the elderly often do not experience the integration of multidisciplinary care as such. This is a real opportunity for MTs to improve their care and to make the patients' experiences better in line with what they are aiming: allowing patients to live at home as healthy and independently as possible for as long as possible. We showed that informal caregivers often form communication bridges between patients and professionals. Having a better knowledge of the patient perspective enables the gaps in professional care networks of frail older people to be filled and facilitates the anticipation of crisis situations.

Health Insurance and Out-of-Pocket Costs in the Last Year of Life Among Decedents Utilizing the ICU

OBJECTIVES

Use of intensive care is increasing in the United States and may be associated with high financial burden on patients and their families near the end of life. Our objective was to estimate out-of-pocket costs in the last year of life for individuals who required intensive care in the months prior to death and examine how these costs vary by insurance coverage.

DESIGN

Observational cohort study using seven waves of post-death interview data (2002-2014).

PARTICIPANTS

Decedents (n = 2,909) who spent time in the ICU at some point between their last interview and death.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two-part models were used to estimate out-of-pocket costs for direct medical care and health-related services by type of care and insurance coverage. Decedents with only traditional Medicare fee-for-service coverage have the highest out-of-pocket spending in the last year of life, estimated at $12,668 (95% CI, $9,744-15,592), second to only the uninsured. Medicare Advantage and private insurance provide slightly more comprehensive coverage. Individuals who spend-down to Medicaid coverage have 4× the out-of-pocket spending as those continuously on Medicaid.

CONCLUSIONS

Across all categories of insurance coverage, out-of-pocket spending in the last 12 months of life is high and represents a significant portion of assets for many patients requiring intensive care and their families. Medicare fee-for-service alone does not insulate individuals from the financial burden of high-intensity care, due to lack of an out-of-pocket maximum and a relatively high co-payment for hospitalizations. Medicaid plays an important role in the social safety net, providing the most complete hospital coverage of all the insurance groups, as well as significantly financing long-term care.

Testing a Musical Game Activity for Community-Dwelling Older Adults

Leisure programs that combine music with active leisure activities are more common than music combined with passive activities. The latter offers alternatives for older adults with health declines. The purpose of this pilot study was to determine the effect of an innovative song bingo game on mood, satisfaction, and acceptability in community-residing older adults. The design was quasi-experimental. A convenience sample of 13 older adults (mean age = 74.4; 53.8% female, 38.5% black) were recruited from a community senior center. The intervention was an innovative song bingo program offered one time with staff assistance. A song list was created from age-appropriate music. Measures included a demographic survey, mood scale, and satisfaction and acceptability items. Data analysis was performed to compute descriptive items and compare mean mood scores before and after the program. Before the program, 33.4% of the participants reported their mood as “very happy” or “happy.” Afterwards, 61.5% reported their mood was either “very happy” or “happy.” When comparing the preprogram and postprogram mean mood scores, mean values increased from 5.0 (standard deviation [ SD] = 1.0) to 5.7 ( SD = 1.4), although the difference was not statistically significant ( t = −1.8, p = .09). Overall participants were satisfied and would play again. This program was cost-effective and improved mood in community-dwelling older adults. Replicating this study in a larger sample and different settings is recommended.

Resetting the Aging Clock: Implications for Managing Age-Related Diseases

Worldwide, individuals are living longer due to medical and scientific advances, increased availability of medical care and changes in public health policies. Consequently, increasing attention has been focused on managing chronic conditions and age-related diseases to ensure healthy aging. The endogenous circadian system regulates molecular, physiological and behavioral rhythms orchestrating functional coordination and processes across tissues and organs. Circadian disruption or desynchronization of circadian oscillators increases disease risk and appears to accelerate aging. Reciprocally, aging weakens circadian function aggravating age-related diseases and pathologies. In this review, we summarize the molecular composition and structural organization of the circadian system in mammals and humans, and evaluate the technological and societal factors contributing to the increasing incidence of circadian disorders. Furthermore, we discuss the adverse effects of circadian dysfunction on aging and longevity and the bidirectional interactions through which aging affects circadian function using examples from mammalian research models and humans. Additionally, we review promising methods for managing healthy aging through behavioral and pharmacological reinforcement of the circadian system. Understanding age-related changes in the circadian clock and minimizing circadian dysfunction may be crucial components to promote healthy aging.

Aging and the clock: Perspective from flies to humans

Endogenous circadian oscillators regulate molecular, cellular and physiological rhythms, synchronizing tissues and organ function to coordinate activity and metabolism with environmental cycles. The technological nature of modern society with round-the-clock work schedules and heavy reliance on personal electronics has precipitated a striking increase in the incidence of circadian and sleep disorders. Circadian dysfunction contributes to an increased risk for many diseases and appears to have adverse effects on aging and longevity in animal models. From invertebrate organisms to humans, the function and synchronization of the circadian system weakens with age aggravating the age-related disorders and pathologies. In this review, we highlight the impacts of circadian dysfunction on aging and longevity and the reciprocal effects of aging on circadian function with examples from Drosophila to humans underscoring the highly conserved nature of these interactions. Additionally, we review the potential for using reinforcement of the circadian system to promote healthy aging and mitigate age-related pathologies. Advancements in medicine and public health have significantly increased human life span in the past century. With the demographics of countries worldwide shifting to an older population, there is a critical need to understand the factors that shape healthy aging. Drosophila melanogaster, as a model for aging and circadian interactions, has the capacity to facilitate the rapid advancement of research in this area and provide mechanistic insights for targeted investigations in mammals.

Mirror meetings with frail older people and multidisciplinary primary care teams: Process and impact analysis

OBJECTIVES

To analyse the process and impact of confronting multidisciplinary teams (MTs) in primary care with the experiences of frail older patients through mirror meetings (MMs), with the aim of supporting teams to organize care in a more patient-oriented way.

METHODS

Process and impact analyses were performed using a mixed-method approach. MMs were held with 14 frail older patients and four MTs comprising 23 health-care professionals (HCPs) in primary care in the Netherlands.

RESULTS

Mirror meetings were feasible for frail older people living at home, although their recruitment was time-consuming. Interaction between the patients was scarce, but they valued the opportunity to share their stories. HCPs preferred MMs overwritten reports about patient experiences. An impact analysis revealed four dominant professional areas for improvement: improve alignment with patient goals, improved communication with patients both orally and in writing, developing new pathways to connect with informal caregivers and an increased understanding that most HCPs are relative strangers to their patients.

CONCLUSIONS

Mirror meetings are a relatively simple and promising method for exploring the ways in which frail older patients experience care.

PRACTICE IMPLICATIONS

Given the right conditions, MMs could result in valuable processes to enable MTs to improve their working methods.

Using co-creation and multi-criteria decision analysis to close service gaps for underserved populations

BACKGROUND

Navigating treatment pathways remains a challenge for populations with complex needs due to bottlenecks, service gaps and access barriers. The application of novel methods may be required to identify and remedy such problems.

OBJECTIVE

To demonstrate a novel approach to identifying persistent service gaps, generating potential solutions and prioritizing action.

DESIGN

Co-creation and multi-criteria decision analysis in the context of a larger, mixed methods study.

SETTING AND PARTICIPANTS

Community-dwelling sample of older women living alone (OWLA), residing in Melbourne, Australia (n = 13-37). Convenience sample of (n = 11) representatives from providers and patient organizations.

INTERVENTIONS

Novel interventions co-created to support health, well-being and independence for OWLA and bridge missing links in pathways to care.

MAIN OUTCOME MEASURES

Performance criteria, criterion weights , performance ratings, summary scores and ranks reflecting the relative value of interventions to OWLA.

RESULTS

The co-creation process generated a list of ten interventions. Both OWLA and stakeholders considered a broad range of criteria when evaluating the relative merits of these ten interventions and a "Do Nothing" alternative. Combining criterion weights with performance ratings yielded a consistent set of high priority interventions, with "Handy Help," "Volunteer Drivers" and "Exercise Buddies" most highly ranked by both OWLA and stakeholder samples.

DISCUSSION AND CONCLUSIONS

The present study described and demonstrated the use of multi-criteria decision analysis to prioritize a set of novel interventions generated via a co-creation process. Application of this approach can add community voice to the policy debate and begin to bridge the gap in service provision for underserved populations.

Prevalence of Financial Considerations Documented in Primary Care Encounters as Identified by Natural Language Processing Methods

IMPORTANCE

Quantifying patient-physician cost conversations is challenging but important as out-of-pocket spending by US patients increases and patients are increasingly interested in discussing costs with their physicians.

OBJECTIVE

To characterize the prevalence of financial considerations documented in narrative clinical records of primary care encounters and their association with patient-level features.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study applied natural language processing to narrative clinical notes obtained from electronic health records for adult primary care visits. Participants included patients aged 18 years and older with at least 1 primary care visit for an annual preventive examination at outpatient clinics at a US academic health system between January 2, 2008, and July 30, 2013. Data were analyzed in March 2019.

MAIN OUTCOMES AND MEASURES

Presence of financial content documented in narrative clinical notes.

RESULTS

The data set included 222 457 primary care visits for 46 244 individuals aged 18 years and older; 30 556 patients (60.1%) were female, 27 869 patients (60.3%) were white, and the mean (SD) age was 51.3 (17.7) years. In total, 6058 patients (13.1%) had at least 1 narrative clinical note indicating a financial conversation with their physician. In fully adjusted regression models, the odds of having a financial note were greater among patients with Medicare (odds ratio [OR], 1.27; 95% CI, 1.15-1.41; P < .001) or Medicaid (OR, 1.43; 95% CI, 1.25-1.64; P < .001) insurance, those residing in zip codes with lower median income (OR, 0.97; 95% CI, 0.96-0.98; P < .001), black individuals (OR, 1.40; 95% CI, 1.28-1.53; P < .001), Hispanic individuals (OR, 1.10; 95% CI, 1.01-1.20; P = .03), and those who were unmarried (OR, 1.23; 95% CI, 1.15-1.33; P < .001).

CONCLUSIONS AND RELEVANCE

Cost considerations were more likely to be noted in annual preventive examinations than previously observed in intensive care unit admissions, but still infrequently. Associations with particular patient subgroups may indicate differential financial burden or willingness to discuss financial concerns.