Clinical Assistant Professor, Medicine - Primary Care and Population Health
Paid Care Services and Transitioning out of the Community Among Black and White Older Adults With Dementia.
The journals of gerontology. Series B, Psychological sciences and social sciences
2023; 78 (Supplement_1): S91-S100
Paid care provided in the home includes important support services for older adults with dementia such as cleaning and personal care assistance. By reducing unmet needs, these services could delay the transition to residential long-term care, but access may differ across racial groups. This study examined the relationship between paid care and transitioning out of the community among Black and White older adults with dementia.Using data from 303 participants (29.4% Black) with probable dementia in the 2011 National Health and Aging Trends Study, competing risk hazards models estimated the association between receiving paid care at baseline and the probability of transitioning out of the community over 8 years (through 2019). Covariate selection was guided by the Andersen model of health care utilization.Paid care was associated with lower risk of transitioning out of the community (subhazard ratios [SHR] = 0.70, 95% CI [0.50, 0.98]). This effect was similar after controlling for predisposing factors and most prominent after controlling for enabling and need for services factors (SHR = 0.65, 95% CI [0.44, 0.95]). There was no racial difference in the use of paid care despite evidence of greater care needs in Blacks. Furthermore, Black participants were less likely to transition out of the community than Whites.Paid care services may help delay transitions out of the community. Future research should seek to explain racial differences in access to and/or preferences for home-based, community-based, and residential care.
View details for DOI 10.1093/geronb/gbac117
View details for PubMedID 36075074
Role of Home Health for Community-Dwelling Older Adults Near the End of Life: A Resource Beyond Hospice?
JOURNAL OF PALLIATIVE MEDICINE
Background: Medicare home health could be leveraged to care for those near the end of life (EOL), especially for those who cannot access nor desire the Medicare hospice benefit. It is unknown what role home health currently has either preceding or as an alternative to hospice use. Objective: The aim of this study is to compare populations served and visit patterns of Medicare beneficiaries receiving home health/hospice/both near the EOL. Design: Nationally representative cohort study of National Health and Aging Trends Study (NHATS) respondents. Setting/Subjects: A total of 1,057 U.S. decedents in NHATS from 2012 to 2017 with linked Medicare claims were included in this study. Measurements: Measurements included the proportion of decedents who received home health/hospice/both/neither (yes/no) in the last six months of life (EOL) and mean number of visits by discipline (nurse/therapist [physical/occupational speech-language pathologist]/social worker/home health aide) per 30 eligible days at home for home health/hospice/both at the EOL. The primary independent variable was the clinician discipline providing services (nurse/therapist/social worker/aide). Results: In our sample, 19.9% received home health only, 25.8% hospice only, 18.8% both, and 35.6% neither at the EOL. These populations varied in their demographic, region, and clinical characteristics. Decedents who received home health only compared with hospice only were younger (44.1% over age 85 vs. 58.4%), members of a racially/ethnically diverse group (19.7% vs. 10.9%), and with less disability (37.2% required no assistance with activities of daily living vs. 22.7%), all p values <0.05. In adjusted models, those receiving home health versus hospice received similar numbers of visits per 30 days (average 5.4/30 vs. 6.6/30), while those receiving both received more visits (10.5/30). Home health provided more therapy visits, while hospice provided more social work and aide visits. Conclusions: More than one in three Medicare decedents nationwide received home health at the EOL. Home health has the potential to serve a population not reached by hospice and improve the quality of end-of-life care.
View details for DOI 10.1089/jpm.2022.0272
View details for Web of Science ID 000892086000001
View details for PubMedID 36137095
Front-Line Hospice Staff Perceptions of Barriers and Opportunities to Discussing Advance Care Planning With Hospice Patients and Their Families
JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION
2022; 23 (7): 1205-+
To understand the facilitators and barriers to hospice staff engagement of patients and surrogates in advance care planning (ACP) conversations.Qualitative study conducted with purposive sampling and semistructured interviews using ATLAS.ti software to assist with template analysis.Participants included 51 hospice professionals (31 clinicians, 13 leaders, and 7 quality improvement administrators) from 4 geographically distinct nonprofit US hospices serving more than 2700 people.Interview domains were derived from the implementation science framework of Capability, Opportunity, Motivation, and Behavior (COM-B), with additional questions soliciting recommendations for behavior change. Differences in themes were reconciled by consensus. The facilitator, barrier, and recommendation themes were organized within the COM-B framework.Capability was facilitated by interdisciplinary teamwork and specified clinical staff roles and inhibited by lack of self-perceived skill in engaging in ACP conversations. Opportunities for ACP occurred during admission to hospice, acute changes, or deterioration in patient condition. Opportunity-related environmental barriers included time constraints such as short patient stay in hospice and workload expectations that prevented clinicians from spending more time with patients and families. Motivation to discuss ACP was facilitated by the employee's goal of providing personalized, patient-centered care. Implicit assumptions about patients' and families' preferences reduced staff's motivation to engage in ACP. Hospice staff made recommendations to improve ACP discussions, including training and modeling practice sessions, earlier introduction of ACP concepts by clinicians in prehospice settings, and increasing workforce diversity to reflect the patient populations the organizations want to reach and cultural competency.Even hospice staff can be uncomfortable discussing death and dying. Yet staff were able to identify what worked well. Solutions to increase behavior of ACP engagement included staff training and modeling practice sessions, introducing ACP prior to hospice, and increasing workforce diversity to improve cultural competency.
View details for DOI 10.1016/j.jamda.2021.07.014
View details for Web of Science ID 000840266400022
View details for PubMedID 34391713
View details for PubMedCentralID PMC8840996
Meaningful Activities and Sources of Meaning for Community-Dwelling People Living with Dementia
JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION
2022; 23 (7): 1191-+
To examine how people living with dementia at home engage in meaningful activities, a critical component of quality of life.Ethnographic study design using semistructured interviews, participant-observation, and ethnographic analysis.Home setting. People living with dementia were recruited through 3 geriatrics programs in the San Francisco Bay Area, along with 1 primary live-in care partner for each. Participants were purposively sampled to maximize heterogeneity of dementia severity and life experience.We asked participants to self-identify and report meaningful activity engagement prior to dementia onset and during the study period using a structured questionnaire, semistructured dyadic interviews, and observed engagement in activities. Home visits were audio-recorded, transcribed, and inductively analyzed using thematic analysis.Twenty-one people living with dementia (mean age 84 years, 38% women) and 20 care partners (59 years, 85% women), including 40% professionals, 35% spouse/partners, and 15% adult children. Overarching theme: specific activities changed over time but underlying sources of meaning and identity remained stable. As dementia progressed, meaningful activity engagement took 3 pathways. Pathway 1: Activities continued with minimal adaptation when engagement demanded little functional or cognitive ability (eg, watching football on TV). Pathway 2: care partners adapted or replaced activities when engagement required greater functional or cognitive abilities (eg, traveling overseas). This pathway was associated with caregiving experience, nursing training, and strong social support structures. Pathway 3: care partners discontinued meaningful activity engagement. Discontinuation was associated with severe caregiver burden, coupled with illness, injury, or competing caregiving demands severe enough to impact their ability to facilitate activities.For people living with dementia at home, underlying sources of meaning and identity remains stable despite changes in meaningful activity engagement. Many of the factors associated with adaptation vs discontinuation over time are modifiable and can serve as targets for intervention.
View details for DOI 10.1016/j.jamda.2021.08.009
View details for Web of Science ID 000840266400020
View details for PubMedID 34481793
View details for PubMedCentralID PMC8888776
Rural and urban differences in the implementation of Virtual Integrated Patient-Aligned Care Teams
JOURNAL OF RURAL HEALTH
2023; 39 (1): 272-278
Workforce shortages contribute to geographic disparities in accessing primary care services. An innovative, clinic-to-clinic videoconferencing telehealth program in the Veterans Health Administration (VHA) called the Virtual Integrated Patient-Aligned Care Teams (V-IMPACT) was designed to increase veterans' access to primary care and relieve workforce shortages in VA primary care clinics, including in many rural areas. This paper describes trends in clinic sites and veteran uptake of the V-IMPACT program, a model that delivered remote, team-based primary care services, from fiscal years (FY)2013-2018.This observational study used VHA administrative data to compare program uptake, measured by the program penetration rate (percent of patients using V-IMPACT services in each site) across sites; and characteristics for V-IMPACT users versus nonusers for 2,155,203 veteran-years in 69 sites across 7 regional networks for FY2013-2018. Regression models assessed the association between V-IMPACT use and veteran characteristics within sites.Across sites, V-IMPACT had higher penetration in rural sites (8%) and primary care community-based outpatient clinics (7%, P<.001). After adjusting for veteran characteristics, rural veterans (aOR = 1.05; P = .02) and veterans with higher comorbidity risk scores (aOR = 1.08; P<.001) were independently associated with V-IMPACT use. Highly rural veterans (OR = 0.60; P<.001) and veterans who lived ≥40 miles from the closest VHA primary care site (OR = 0.86; P<.001) were less likely to be a V-IMPACT user.A clinic-to-clinic telehealth program, such as V-IMPACT, was able to reach many rural sites, rural veterans, and veterans in primary care health professional shortage areas. V-IMPACT has the potential to increase access to team-based primary care.
View details for DOI 10.1111/jrh.12676
View details for Web of Science ID 000799878400001
View details for PubMedID 35611882
Medicare-funded home-based clinical care for community-dwelling persons with dementia: An essential healthcare delivery mechanism
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
2022; 70 (4): 1127-1135
Over the past decade, medical care has shifted from institutions into home settings-particularly among persons with dementia. Yet it is unknown how home-based clinical services currently support persons with dementia, and what factors shape access.Using the National Health and Aging Trends Study linked to Medicare claims 2012-2017, we identified 6664 community-dwelling adults age ≥ 70 years enrolled in fee-for-service Medicare. Annual assessment of dementia status was determined via self-report, cognitive interview, and/or proxy assessment. Receipt of four types of home-based clinical care (home-based medical care (HBMC) (i.e., nurse practitioner, physician, or physician assistant visits), skilled home health care (SHHC), podiatry visits, and other types of home-based clinical services (e.g., behavioral health)) was assessed annually. We compared age-adjusted rates of home-based clinical care by dementia status and determined sociodemographic, health, and environmental characteristics associated with utilization of home-based clinical care among persons with dementia.Nearly half (44.4%) of persons with dementia received any home-based clinical care annually compared to only 14.4% of those without dementia. Persons with dementia received substantially more of each type of home-based clinical care than those without dementia including a 5-fold increased use of HBMC (95% CI = 3.8-6.2) and double the use of SHHC (95% CI = 2.0-2.5). In adjusted models, Hispanic/Latino persons with dementia were less likely to receive HBMC (OR = 0.32; 95% CI = 0.11-0.93). Use of HBMC, podiatry, and other home-based clinical care was significantly more likely among those living in residential care facilities, in the Northeast and in metropolitan areas.Although almost half of community-dwelling persons with dementia receive home-based clinical care, there is significant variation in utilization based on race/ethnicity and environmental context. Increased understanding as to how these factors impact utilization is necessary to reduce potential inequities in healthcare delivery among the dementia population.
View details for DOI 10.1111/jgs.17621
View details for Web of Science ID 000732739900001
View details for PubMedID 34936087
View details for PubMedCentralID PMC8986555
Engagement in Meaningful Activities Among Older Adults With Disability, Dementia, and Depression
JAMA INTERNAL MEDICINE
2021; 181 (4): 560-562
This cross-sectional study examines the association between disability, dementia, and depression and engagement in meaningful activities in community-dwelling older adults.
View details for DOI 10.1001/jamainternmed.2020.7492
View details for Web of Science ID 000612829300010
View details for PubMedID 33492334
View details for PubMedCentralID PMC7835951
Extreme Vulnerability of Home Care Workers During the COVID-19 Pandemic-A Call to Action
JAMA INTERNAL MEDICINE
2020; 180 (11): 1459-1460
View details for DOI 10.1001/jamainternmed.2020.3937
View details for Web of Science ID 000604965700011
View details for PubMedID 32749452
View details for PubMedCentralID PMC7858686
Key Ingredients of an Ideal System for High-Quality Community Care for Persons With Dementia
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
2020; 68 (2): 238-240
View details for DOI 10.1111/jgs.16303
View details for Web of Science ID 000503974800001
View details for PubMedID 31868915
View details for PubMedCentralID PMC8015407
Social Support and Patterns of Institutionalization Among Older Adults: A Longitudinal Study
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
2019; 67 (12): 2622-2627
To identify participants living at home and to estimate the risk of their transition into an institutional setting.Prospective cohort study from the National Health and Aging Trends Study (NHATS), a nationally representative survey of US adults aged 65 and older.US national sample.A total of 4712 NHATS participants were living at home in 2011. Residential transitions were described every year through 2017.The primary outcome was transition time into an institutional setting. Primary predictors were social support factors (living spouse, lives with others, presence of social network, and participation in social activities). Covariates included age, sex, race, cognitive status, functional disability, multimorbidity, and Medicaid enrollment. A Fine and Gray hazards model estimated the risk of transition into an institutional setting, with death before institutionalization considered a competing risk.In 2011, 4712 NHATS participants were living at home (78 ± 8 y; 57% female; 80% white; 10% probable dementia; 7% with three or more activities of daily living disabilities). By 2017, 58% remained at home, 17% had either transitioned to an institution or died in an institution, and 25% died before institutionalization. In multivariable analyses that adjusted for age, sex, race, cognitive status, functional disability, multimorbidity, and Medicaid enrollment, participants were more likely to move out of the home into an institution if they had no social network (0 vs three or more people; subhazard ratio [sHR] = 1.8; 95% confidence interval [CI] = 1.2-2.5; P = .003) or lived alone (sHR = 1.9; 95% CI = 1.6-2.2; P < .0001). Older adults who enjoyed going to the movies, dinner, or the casino and visiting family or friends had a lower probability of institutionalization compared with participants who did not enjoy these activities or did not visit family or friends (adjusted sHR = .7; 95% CI = .6-.9; adjusted sHR = .7; 95% CI = .6-.9, respectively).Policy initiatives should target older adults with limited social support to reduce the risk of moving from home into an institution. J Am Geriatr Soc 67:2622-2627, 2019.
View details for DOI 10.1111/jgs.16184
View details for Web of Science ID 000489478700001
View details for PubMedID 31593295
View details for PubMedCentralID PMC7276300
A Gray Area for Reimbursement: Medical Foods for Non-Inborn Errors of Metabolism
AMERICAN JOURNAL OF MANAGED CARE
2018; 24 (8): SP273-+
The use of medical foods (MFs) specifically for non-inborn errors of metabolism (non-IEM) is rising. Concomitantly, evidence for the safety and efficacy of these non-IEM MFs is lacking. We examined the current use and costs of non-IEM MFs and determined whether the scientific evidence supporting their effectiveness and medical utility is adequate to warrant public reimbursement.We employed a qualitative literature review analysis.PubMed and MEDLINE databases were searched for all years using relevant keywords, including names of non-IEM MFs identified in the California Workers' Compensation System (CAWCS) claims dataset from 2011 to 2013. The quality of extracted data was scored with the Delfini Evidence Tool Kit.Only 2 (3.2%) of 62 studies were conducted with scientific rigor. These 2 studies were for dietary management of Alzheimer disease, which does not have a distinctive nutritional requirement necessitating an MF. Seventy-one percent of the studies of MFs used by patients in the CAWCS were considered to have uncertain validity.Most reviewed non-IEM MFs lack evidence to support their safety and efficacy. These non-IEM MFs do not abide by FDA draft guidance, as they do not address a distinct nutritional requirement for a disease and yet often have a National Drug Code or "Rx only" label. Consequently, these products do not meet the statutory definition of an MF. We recommend that CAWCS and other payers not provide insurance coverage for non-IEM MFs until more scientific evidence supports their safety, efficacy, and use for nutritional need of a disease.
View details for Web of Science ID 000439388400002
View details for PubMedID 30020739
Association Between Sponsorship and Findings of Medical Home Evaluations
JAMA INTERNAL MEDICINE
2017; 177 (9): 1375-1376
This analysis of published evaluations of medical home interventions investigates whether there is an association between the findings and whether the evaluators were employed or funded by intervention sponsors.
View details for DOI 10.1001/jamainternmed.2017.3188
View details for Web of Science ID 000410178900034
View details for PubMedID 28759665
View details for PubMedCentralID PMC5818829
Cost-Effectiveness of Nivolumab-lpilimumab Combination Therapy Compared with Monotherapy for First-Line Treatment of Metastatic Melanoma in the United States
JOURNAL OF MANAGED CARE & SPECIALTY PHARMACY
2017; 23 (6): 653-664
The approval of new immunotherapies has dramatically changed the treatment landscape of metastatic melanoma. These survival gains come with trade-offs in side effects and costs, as well as important considerations for third-party payer systems, physicians, and patients.To develop a Markov model to determine the cost-effectiveness of nivolumab, ipilimumab, and nivolumab-ipilimumab combination as firstline therapy in metastatic melanoma, while accounting for differential effectiveness in programmed death-ligand 1 (PD-L1) positive and negative patients.A 3-state Markov model (PD-L1 positive stable disease, PD-L1 negative stable disease, and progression and/or death) was developed using a U.S. societal perspective with a lifetime time horizon of 14.5 years. Transition probabilities were calculated from progression-free (PF) survival data reported in the CheckMate-067 trial. Costs were expressed in 2015 U.S. dollars and were determined using national sources. Adverse event (AE) management was determined using immune-related AE (irAE) data from CheckMate-067, irAE management guides for nivolumab and ipilimumab, and treatment guidelines. Utilities were obtained from published literature, using melanoma-specific studies when available, and were weighted based on incidence and duration of irAEs. Base case, one-way sensitivity, and probabilistic sensitivity analyses were conducted.Nivolumab-ipilimumab combination therapy was not the cost-effective choice ($454,092 per PF quality-adjusted life-year [QALY]) compared with nivolumab monotherapy in a base case analysis at a willingness-to-pay threshold of $100,000 per PFQALY. Combination therapy and nivolumab monotherapy were cost-effective choices compared with ipilimumab monotherapy. PD-L1 positive status, utility of nivolumab and combination therapy, and medication costs contributed the most uncertainty to the model. In a population of 100% PD-L1 negative patients, nivolumab was still the optimal treatment, but combination therapy had an improved incremental cost-effectiveness ratio (ICER) of $295,903 per PFQALY. Combination therapy became dominated by nivolumab, when 68% of the sample was PD-L1 positive. In addition, the cost of ipilimumab would have to decrease to < $21,555 per dose for combination therapy to have an ICER < $100,000 per PFQALY and to < $19,151 (a 42% reduction) to be more cost-effective than nivolumab monotherapy.Nivolumab-ipilimumab combination therapy was not cost-effective compared with nivolumab monotherapy, which was the most cost-effective option. Professionals in managed care settings should consider the pharmacoeconomic implications of these new immunotherapies as they make value-based formulary decisions, and future cost-effectiveness studies are completed.No funding supported this study. Merino was a contractor with EMD Serono at the time of this study but does not have any conflicts of interest and did not receive any funding related to this study. All other authors have no financial disclosures and no conflicts of interest. All the authors contributed to the study concept and design. Tran, McDowell, and Barcelon took the lead in data collection, along with Oh, Keyvani, and Merino. All authors except Merino contributed to data interpretation. The manuscript was written by Oh, Tran, McDowell, and Wilson and revised by Oh, Tran, McDowell, Wilson, and Keyvani. This analysis was presented at Academy of Managed Care Pharmacy Managed Care & Specialty Pharmacy Annual Meeting 2016, April 19-22, 2016, in San Francisco, California, and at the International Society for Pharmacoeconomics and Outcomes Research Annual International Meeting, May 21-25, 2016, in Washington DC.
View details for DOI 10.18553/jmcp.2017.23.6.653
View details for Web of Science ID 000402359700005
View details for PubMedID 28530525
View details for PubMedCentralID PMC5960988
Use of Conjoint Analysis to Determine Patient Preferences for Surgical Treatment of Urethral Stricture Disease.
Journal of participatory medicine
INTRODUCTION: Understanding patient preferences for characteristics of treatments facilitates patient participation and doctor-patient communication and enhances patient-centered care. Patient participation is especially important for urethral stricture disease, which has no definitive treatment guidelines favoring either endoscopic incision or open reconstruction, making patient preference an important factor in treatment choice. However, to date, there have been no studies assessing factors that patients value when choosing a treatment option.METHODS: We employ choice-based conjoint analysis to assess patient preferences in the trade-offs of treatment attributes for urethral stricture disease. Male patients undergoing treatment or follow-up examination for urethral stricture disease were recruited through a University Medical Practice. We included 169 patients in the analysis. Six attributes of both risk and benefit were examined: treatment type, success rate, number of future procedures, post-treatment catheter duration, recovery time, and copayment amount.RESULTS: The treatment success rate was by far the most important attribute. Relative to a 25% success rate (OR = 1) an 85% success rate (OR = 26.72, p<.01) increased patient preference by approximately 27 times. Furthermore, patients are willing to pay a $10,000 copayment to double the success rate from 25% to 50%. Patients demonstrated a strong aversion to time with a urinary catheter. Catheter duration for 1 week or less (OR = .67, p<.01) reduced patient preference by about 1.5 times when compared to requiring no catheter. We also found that patients place low importance on both how invasive the treatment seems and low copayment amounts but are willing to pay $10,000 copayment for an open reconstruction surgery compared with an endoscopic incision procedure.CONCLUSION: The findings highlight the importance of shared and detailed physician/patient discussions of all the risk and benefits of each treatment choice and suggest that conjoint analysis may be helpful as a decision aid to guide discussions with individual patients deciding on a treatment.
View details for PubMedID 32995067