A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes

In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.

Lower Leg Power and Grip Strength Are Associated With Increased Fall Injury Risk in Older Men: The Osteoporotic Fractures in Men Study

BACKGROUND

Past research has not investigated both lower-extremity power and upper-extremity strength in the same fall injury study, particularly nonfracture fall injuries.

METHODS

In the Osteoporotic Fractures in Men Study (baseline: N = 5 994; age 73.7 ± 5.9 years; 10.2% non-White), fall injuries (yes/no) were assessed prospectively with questionnaires approximately every 3 years over 9 years. Maximum leg power (Watts) from Nottingham single leg press and maximum grip strength (kg) from handheld dynamometry were assessed at baseline and standardized to kg body weight. Physical performance included gait speed (6-m usual; narrow walk) and chair stands speed.

RESULTS

Of men with ≥1/4 follow-ups (N = 5 178; age 73.4 ± 5.7 years), 40.4% (N = 2 090) had ≥1 fall injury. In fully adjusted repeated-measures logistic regressions, lower power/kg and grip strength/kg had higher fall injury risk (trend across quartiles: both p < .0001), with lower quartiles at significantly increased risk versus highest Q4 except for grip strength Q3 versus Q4. Fall injury risk was 19% higher per 1 standard deviation (SD) lower power/kg (95% confidence interval [CI]: 1.12-1.26) and 16% higher per SD lower grip strength/kg (95% CI: 1.10-1.23). In models including both leg power/kg and grip strength/kg, odds ratios (ORs) were similar and independent of each other and physical performance (leg power/kg OR per SD = 1.13, 95% CI: 1.06-1.20; grip strength/kg OR per SD = 1.11, 95% CI: 1.05-1.17).

CONCLUSIONS

Lower leg power/kg and grip strength/kg predicted future fall injury risk in older men independent of physical performance. Leg power potentially identifies fall injury risk better than grip strength at higher muscle function, though grip strength may be more suitable in clinical/practice settings.

Professional agency vs consumer directed care workers: Outcomes in managed care

Direct care workers are a major part of the long-term services and supports (LTSS) needed to address the health of individuals and accounted for $112 billion in United States spending in 2015. Direct care workers are hired within professional agency models (PAMs) or consumer-directed models (CDMs) where workers (including family) are contracted by the individual to obtain services. We sought to identify differences in cost and utilisation outcomes between PAM and CDM participants. Data were obtained from the University of Pittsburgh Medical Center (UPMC) Insurance Services Division from the participants enrolled in UPMC Community HealthChoices in Pennsylvania during 2018. A retrospective, observational cohort study design was performed using claims data. Utilisation outcomes were assessed using multivariate logistic regression and cost outcomes by linear regression. The 3,232 participants met the inclusion criteria. Of these, 69% (N = 2,217) were in a PAM, 23% (N = 752) were in a CDM, and 8% (N = 263) used a combination of services. PAM groups were older (mean 62.4 years vs 54.1 years), more likely to be women (69.0% vs 62.8%), and had more healthcare needs. Hospital utilisation was the same among groups. However, total cost was lower in CDM groups due to differences in LTSS costs between CDM and PAM services. Among dually eligible Medicare and Medicaid beneficiaries receiving LTSS, there are significant differences in age, gender, race and health needs. While hospital utilisation was not different between groups, CDM groups had lower total costs of care compared to PAM. These findings have implications for families, policymakers and insurers in helping to govern community LTSS while supporting member autonomy.

Associations between novel jump test measures, grip strength, and physical performance: the Osteoporotic Fractures in Men (MrOS) Study

BACKGROUND/AIMS

Weight-bearing jump tests measure lower extremity muscle power, velocity, and force, and may be more strongly related to physical performance than grip strength. However, these relationships are not well described in older adults.

METHODS

Participants were 1242 older men (mean age 84 ± 4 years) in the Osteoporotic Fractures in Men (MrOS) Study. Jump peak power (Watts/kg body weight), force (Newton/kg body weight) at peak power, and velocity (m/s) at peak power were measured by jump tests on a force plate. Grip strength (kg/kg body weight) was assessed by hand-held dynamometry. Physical performance included 400 m walk time (s), 6 m usual gait speed (m/s), and 5-repeated chair stands speed (#/s).

RESULTS

In adjusted Pearson correlations, power/kg and velocity moderately correlated with all performance measures (range r = 0.41-0.51; all p < 0.001), while correlations for force/kg and grip strength/kg were weaker (range r = 0.20-0.33; all p < 0.001). Grip strength/kg moderately correlated with power/kg (r = 0.44; p < 0.001) but not velocity or force/kg. In adjusted linear regression with standardized βs, 1 SD lower power/kg was associated with worse: 400 m walk time (β = 0.47), gait speed (β = 0.42), and chair stands speed (β = 0.43) (all p < 0.05). Associations with velocity were similar (400 m walk time: β = 0.42; gait speed: β = 0.38; chair stands speed: β = 0.37; all p < 0.05). Force/kg and grip strength/kg were more weakly associated with performance (range β = 0.18-0.28; all p < 0.05).

CONCLUSIONS/DISCUSSION

Jump power and velocity had stronger associations with physical performance than jump force or grip strength. This suggests lower extremity power and velocity may be more strongly related to physical performance than lower extremity force or upper extremity strength in older men.

Knee Osteoarthritis and the Risk of Medically Treated Injurious Falls Among Older Adults: A Community-Based US Cohort Study

OBJECTIVE

The risk of falls among adults with knee osteoarthritis (OA) has been documented, yet, to our knowledge no studies have examined knee OA and the risk of medically treated injurious falls (overall and by sex), which is an outcome of substantial clinical and public health relevance.

METHODS

Using data from the Health Aging and Body Composition Knee Osteoarthritis Substudy, a community-based study of white and African American older adults, we tested associations between knee OA status and the risk of injurious falls among 734 participants with a mean ± SD age of 74.7 ± 2.9 years. Knee radiographic OA (ROA) was defined as having a Kellgren-Lawrence grade of ≥2 in at least 1 knee. Knee symptomatic ROA (sROA) was defined as having both ROA and pain symptoms in the same knee. Injurious falls were defined using a validated diagnosis code algorithm from linked Medicare fee-for-service claims. Cox regression modeling was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

RESULTS

The mean ± SD follow-up time was 6.59 ± 3.12 years. Of the 734 participants, 255 (34.7%) had an incident injurious fall over the entire study period. In the multivariate model, compared with those without ROA or pain, individuals with sROA (HR 1.09 [95% CI 0.73-1.65]) did not have a significantly increased risk of injurious falls. Compared with men without ROA or pain, men with sROA (HR 2.57 [95% CI 1.12-5.91]) had a significantly higher risk of injurious falls. No associations were found for women or by injurious fall type.

CONCLUSION

Knee sROA was independently associated with an increased risk of injurious falls in older men, but not in older women.

Normative Values of Muscle Power using Force Plate Jump Tests in Men Aged 77-101 Years: The Osteoporotic Fractures in Men (MrOS) Study

OBJECTIVE

To determine normative values for weight-bearing, countermovement leg extension ("jump") tests in the oldest men and characteristics of those not completing vs. completing tests.

DESIGN

2014-16 cross-sectional exam.

SETTING

Six U.S. sites from the Osteoporotic Fractures in Men (MrOS) Study.

PARTICIPANTS

Community-dwelling men (N=1,841) aged 84.5±4.2 (range: 77-101) years.

INTERVENTIONS

N/A.

MEASUREMENTS

Jump tests on a force plate measured lower-extremity muscle peak power/kg, velocity and force/kg at peak power, with normative values for 5-year age groups and by limitations in moderate-intensity activities of daily living (ADLs) and climbing several flights of stairs.

RESULTS

Jump completion was 68.9% (N=1,268/1,841) and 98% (1,242/1,268) had ≥1 analyzable trial/participant. Exclusions primarily were due to poor mobility and/or balance: 24.8% (456/1,841) prior to and 6.4% (N=117/1,841) after attempting testing. Peak power was 20.8±5.3 W/kg, with 1.2±0.3 m/s for velocity, and 16.7±1.9 N/kg for force at peak power. Each 5-year age group >80 years had subsequently 10% lower power/kg, with 30% lower power/kg at >90 vs. ≤80 years (all p<0.05). Velocity and force/kg at peak power were 24% and 9% lower respectively, at >90 vs. ≤80 years (all p<0.05). Limitations in both moderate ADLs and climbing several flights of stairs were associated with 16% lower age-adjusted power/kg, equivalent to 5-10 years of aging, with 11% and 6% lower age-adjusted velocity and force/kg respectively, vs. those without limitation (all p<0.05). Men not completing vs. completing jumps had older age, higher BMI, lower physical activity, more comorbidities, worse cognition, more IADLs/ADLs and more falls in the past year (all p<0.05). Post-jump pain occurred in 4.6% (58/1,268), with 2 participants stopping testing due to pain. Only 24/1,242 (2%) had all trials/participant without flight (i.e., inability to lift feet), with 323/1,242 having ≥1 trial/participant without flight (total of 28%). No serious adverse safety events (e.g., injury) occurred.

CONCLUSIONS

A multicenter cohort of oldest men with a range of function had higher declines in jump power/kg and velocity vs. force/kg across each 5-year age group >80 years. Future research should examine age- and functional-related declines in jump measures related to physical performance decline, falls, fractures, and disability.