Supplemental Nutrition Assistance Program Participation and Health Care Use in Older Adults : A Cohort Study

Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients

OBJECTIVE

Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death.

DATA SOURCES, STUDY SETTING, AND STUDY DESIGN

Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models.

PRINCIPAL FINDINGS

Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures.

CONCLUSIONS

In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.

Longitudinal Associations of Diet, Food Insecurity, and Supplemental Nutrition Assistance Program Use with Global Cognitive Performance in Middle-Aged and Older Adults

BACKGROUND

Diet quality, food access, and food assistance policies may be key modifiable factors related to cognitive decline.

OBJECTIVE

We aimed to evaluate whether diet quality, food insecurity, and Supplemental Nutrition Assistance Program (SNAP) use are associated with longitudinal changes in cognition among older adults in the United States.

METHODS

Food intake data from the Health Care and Nutrition Study were linked with longitudinal health information from 5 waves of the Health and Retirement Study (2012-2020). The analytic sample (n = 6968) included community-dwelling United States adults aged ≥51 y without cognitive impairment. Global cognition was measured using a telephone-based cognitive status interview (range: 0-27). Diet quality was measured with the Healthy Eating Index, using participants' average intake of 13 dietary components. Questions regarding food access and affordability were used to determine food insecurity and use of SNAP benefits. Linear mixed-effects regression models were used to estimate longitudinal associations between diet-related factors and cognitive score changes.

RESULTS

Poorer diets [β: -0.24; 95% confidence interval (CI): -0.33, -0.15], food insecurity (β: -1.08; 95% CI: -1.31, -0.85), and SNAP use (β: -0.57; 95% CI: -0.82, -0.32) were associated with lower baseline cognitive scores. Poorer diets (β: -0.17; 95% CI: -0.29, -0.05) and food insecurity (β: -0.23; 95% CI: -0.47, -0.01) were associated with significantly steeper declines in cognitive scores over time, after 8 and 2 y of follow-up, respectively; however, SNAP use was not significantly associated with the rate of cognitive decline over time. Estimates were qualitatively similar when restricting the sample to participants aged ≥65 y.

CONCLUSIONS

Results suggest that food access and adherence to healthy diet recommendations may be important elements to maintain cognitive health in aging. SNAP benefits may be insufficient to prevent negative cognitive effects of poor diet and limited access to nutritious foods.

Instrumental variables for implementation science: exploring context-dependent causal pathways between implementation strategies and evidence-based interventions

BACKGROUND

The impact of both implementation strategies (IS) and evidence-based interventions (EBI) can vary across contexts, and a better understanding of how and why this occurs presents fundamental but challenging questions that implementation science as a field will need to grapple with. We use causal epidemiologic methods to explore the mechanisms of why sharp distinctions between implementation strategies (IS) and efficacy of an evidence-based intervention (EBI) may fail to recognize that the effect of an EBI can be deeply intertwined and dependent on the context of the IS leading to its uptake.

METHODS

We explore the use of instrumental variable (IV) analyses as a critical tool for implementation science methods to isolate three relevant quantities within the same intervention context when exposure to an implementation strategy is random: (1) the effect of an IS on implementation outcomes (e.g., uptake), (2) effect of EBI uptake on patient outcomes, and (3) overall effectiveness of the IS (i.e., ~ implementation*efficacy). We discuss the mechanisms by which an implementation strategy can alter the context, and therefore effect, of an EBI using the underlying IV assumptions. We illustrate these concepts using examples of the implementation of new ART initiation guidelines in Zambia and community-based masking programs in Bangladesh.

RESULTS

Causal questions relevant to implementation science are answered at each stage of an IV analysis. The first stage assesses the effect of the IS (e.g., new guidelines) on EBI uptake (e.g., same-day treatment initiation). The second stage leverages the IS as an IV to estimate the complier average causal effect (CACE) of the EBI on patient outcomes (e.g., effect of same-day treatment initiation on viral suppression). The underlying assumptions of CACE formalize that the causal effect of EBI may differ in the context of a different IS because (1) the mechanisms by which individuals uptake an intervention may differ and (2) the subgroup of individuals who take up an EBI may differ. IV methods thus provide a conceptual framework for how IS and EBIs are linked and that the IS itself needs to be considered a critical contextual determinant. Moreover, it also provides rigorous methodologic tools to isolate the effect of an IS, EBI, and combined effect of the IS and EBI.

DISCUSSION

Leveraging IV methods when exposure to an implementation strategy is random helps to conceptualize the context-dependent nature of implementation strategies, EBIs, and patient outcomes. IV methods formalize that the causal effect of an EBI may be specific to the context of the implementation strategy used to promote uptake. This integration of implementation science concepts and theory with rigorous causal epidemiologic methods yields novel insights and provides important tools for exploring the next generation of questions related to mechanisms and context in implementation science.

Food insecurity is associated with chronic pain and high-impact chronic pain in the USA

OBJECTIVE

This study evaluated whether food insecurity (US Adult Food Security Survey) was associated with chronic pain (≥ 3 months) and high-impact chronic pain (i.e. pain that limits work and life) among US adults.

DESIGN

Cross-sectional analysis.

SETTING

Nationally representative sample of non-institutionalised adults in the USA.

PARTICIPANTS

79 686 adults from the National Health Interview Survey (2019-2021).

RESULTS

Marginal, low and very low food security were associated with increased prevalence odds of chronic pain (OR: 1·58 (95 % CI 1·44, 1·72), 2·28 (95 % CI 2·06, 2·52) and 3·37 (95 % CI 3·01, 3·78), respectively) and high-impact chronic pain (OR: 1·28 (95 % CI 1·14, 1·42), 1·55 (95 % CI 1·37, 1·75) and 1·90 (95 % CI 1·65, 2·18), respectively) in a dose-response fashion (P-trend < 0·0001 for both), adjusted for sociodemographic, socio-economic and clinically relevant factors. Participation in Supplemental Nutrition Assistance Program (SNAP) and age modified the association between food insecurity and chronic pain.

CONCLUSIONS

These findings illustrate the impact of socio-economic factors on chronic pain and suggest that food insecurity may be a social determinant of chronic pain. Further research is needed to better understand the complex relationship between food insecurity and chronic pain and to identify targets for interventions. Moreover, the consideration of food insecurity in the clinical assessment of pain and pain-related conditions among socio-economically disadvantaged adults may be warranted.

Impact of the Affordable Care Act on participation in the Supplemental Nutrition Assistance Program among low-income older Medicare beneficiaries

BACKGROUND

The Affordable Care Act (ACA) provisions, especially Medicaid expansion, are believed to have "spillover effects," such as boosting participation in the Supplemental Nutrition Assistance Program (SNAP) among eligible individuals in the United States (US). However, little empirical evidence exists about the impact of the ACA, with its focus on the dual eligible population, on SNAP participation. The current study investigates whether the ACA, under an explicit policy aim of enhancing the interface between Medicare and Medicaid, has improved participation in the SNAP among low-income older Medicare beneficiaries.

METHODS

We extracted 2009 through 2018 data from the US Medical Expenditure Panel Survey (MEPS) for low-income (≤ %138 Federal Poverty Level [FPL]) older Medicare beneficiaries (n = 50,466; aged ≥ 65), and low-income (≤ %138 FPL) younger adults (aged 20 to < 65 years, n = 190,443). MEPS respondents of > %138 FPL incomes, younger Medicare and Medicaid beneficiaries, and older adults without Medicare were excluded from this study. Using a quasi-experimental comparative interrupted time-series design, we examined (1) whether ACA's support for the Medicare-Medicaid dual-eligible program, through facilitating the online Medicaid application process, was associated with an increase in SNAP uptake among low-income older Medicare beneficiaries, and (2) in the instance of an association, to assess the magnitude of SNAP uptake that can be explicitly attributed to the policy's implementation. The outcome, SNAP participation, was measured annually from 2009 through 2018. The year 2014 was set as the intervention point when the Medicare-Medicaid Coordination Office started facilitating Medicaid applications online for eligible Medicare beneficiaries.

RESULTS

Overall, the change in the probability of SNAP enrollment from the pre- to post-intervention period was 17.4 percentage points higher among low-income older Medicare enrollees, compared to similarly low-income, SNAP-eligible, younger adults (β = 0.174, P < .001). This boost in SNAP uptake was significant and more apparent among older White (β = 0.137, P = .049), Asians (β = 0.408, P = .047), and all non-Hispanic adults (β = 0.030, P < .001).

CONCLUSIONS

The ACA had a positive, measurable effect on SNAP participation among older Medicare beneficiaries. Policymakers should consider additional approaches that link enrollment to multiple programs to increase SNAP participation. Further, there may be a need for additional, targeted efforts to address structural barriers to uptake among African Americans and Hispanics.

Supplemental Nutrition Assistance Program Participation and Medication Adherence Among Medicaid-Insured Older Adults Living with Hypertension

BACKGROUND

Food insecurity has been associated with medication non-adherence among individuals living with chronic diseases like hypertension. The relationship between Supplemental Nutrition Assistance Program (SNAP)-a public program that addresses food insecurity-and Medication adherence among older Medicaid-insured adults living with hypertension is not clear.

OBJECTIVE

To analyze the association between patterns of SNAP participation and adherence to antihypertensive medications among older Medicaid-insured individuals.

DESIGN

Retrospective study using linked 2006-2014 state of Missouri's Medicaid claims and Supplemental Nutrition Assistance Program data.

PARTICIPANTS

Older adults (≥ 60 years) who were continuously enrolled in Medicaid for 12 months following their first observed claim for hypertension at or after age 60.

MAIN MEASURES

The outcome measure was medication adherence assessed using the proportion of days covered (PDC). The exposure measures were as follows: (1) receipt of SNAP benefits (no [0], yes [1]); (2) SNAP benefits receipt during the 12-month Medicaid continuous enrollment (no [0], yes [1]); (3) duration of SNAP participation during the 12-month continuous Medicaid enrollment; and (4) SNAP participation pattern.

KEY RESULTS

On multivariable analyses, there was a statistically significant association between ever participating in SNAP and medication adherence (β = 0.32; S.E. = 0.011). Compared to those who participated in SNAP for 1-3 months during the 12-month continuous enrollment, there was an increased likelihood of medication adherence among those who were enrolled for 10-12 months (β = 0.44, S.E. = 0.041).

CONCLUSIONS

Medicaid-insured older adults who are SNAP participants or enrolled in SNAP for 10-12 months of a 12-month Medicaid continuous enrollment period are more likely to be adherent to antihypertensive medication compared to non-SNAP participants or those enrolled for 1-3 months, respectively.

Home Modifications for Older Adults: A Systematic Review

While ≧10,000 Americans turn 65 years old every day, only 10% of American homes are "aging ready." Unsafe homes can exacerbate disability, lead to falls, and increase the likelihood of hospitalization. With increased investments in home and community-based services, public health stakeholders are considering home modifications to promote successful aging. While several home modification models exist, there is significant heterogeneity between models and no consensus on critical features. PubMed, EMBASE, and Web of Science were reviewed and twelve randomized controlled trials of home modifications for older adults were identified and evaluated for model structure, reported outcomes, and risk of bias. Overall, occupational therapist-driven home modifications supplemented with clinical, physical activity, and/or behavioral components saw the greatest success. This systematic review discusses the components of these models, highlights particularly effective and frequently used features, and the practice and research needed to create effective next-generation home modification models which promote healthy longevity.

Food Insufficiency, Supplemental Nutrition Assistance Program (SNAP) Status, and 9-Year Trajectory of Cognitive Function in Older Adults: The Longitudinal National Health and Aging Trends Study, 2012-2020

BACKGROUND

Despite findings from cross-sectional studies, how food insecurity experience/Supplemental Nutrition Assistance Program (SNAP) status relates to cognitive decline over time has not been fully understood.

OBJECTIVES

We aimed to investigate the longitudinal associations between food insecurity/SNAP status and cognitive function in older adults (≥65 y).

METHODS

Longitudinal data from the National Health and Aging Trends Study 2012-2020 were analyzed (n = 4578, median follow-up years = 5 y). Participants reported food insecurity experience (5-item) and were classified as food sufficient (FS, no affirmative answer) and food insufficient (FI, any affirmative answer). The SNAP status was defined as SNAP participants, SNAP eligible nonparticipants (≤200% Federal Poverty Line, FPL), and SNAP ineligible nonparticipants (>200% FPL). Cognitive function was measured via validated tests in 3 domains, and the standardized domain-specific and combined cognitive function z-scores were calculated. Mixed-effect models with a random intercept were used to study how FI or SNAP status was associated with combined and domain-specific cognitive z-scores over time, adjusting for static and time-varying covariates.

RESULTS

At baseline, 96.3% of the participants were FS and 3.7% were FI. In a subsample (n = 2832), 10.8% were SNAP participants, 30.7% were SNAP eligible nonparticipants, and 58.6% were SNAP ineligible nonparticipants. Compared with the FS group in the adjusted model (FI vs. FS), FI was associated with faster decline in the combined cognitive function scores [-0.043 (-0.055, -0.032) vs. -0.033 (-0.035, -0.031) z-scores per year, P-interaction = 0.064]. Cognitive decline rates (z-scores per year) in the combined score were similar in SNAP participants (β = -0.030; 95% CI: -0.038, -0.022) and SNAP ineligible nonparticipants (β = -0.028; 95% CI: -0.032, -0.024), both of which were slower than the rate in SNAP eligible nonparticipants (β = -0.043; 95% CI: -0.048, -0.038; P-interaction < 0.0001).

CONCLUSIONS

Food sufficiency and SNAP participation may be protective factors preventing accelerated cognitive decline in older adults.

The Logic of Policies to Address Income-Related Health Inequity: A Problem-Oriented Approach

Policy Points  Income is a fundamental cause of health across the life course. To address income-related health inequities, we need a set of overlapping and complementary policy approaches rather than focusing on a single policy.  During their lives, individuals inhabit different roles with regard to their ability to earn wages, and at any given time, only about 50% of the US population are expected to earn wages, while the rest (e.g., children, older adults, those who are disabled, unemployed, students, and/or caregivers) are not.  Three key "branch points" for designing policy approaches to address income-related health inequity are (1) should the needed good or service be obtained on the market? (2) do policy beneficiaries currently earn income? and (3) have policy beneficiaries earned income previously? The responses to these questions suggest one of four policy approaches: social services, social enfranchisement, social insurance, or social assistance.