A Multi-Level Analyses of Charges and Cost of Fall-Related Hospitalizations Among Older Adults: Individual, Hospital, and Geospatial Variation.

The growing population of older adults has attracted concern from policymakers due in part to the fact that they are at higher risk of costly and potentially injurious falls. Responding to this concern, this study investigated fall-related hospitalizations among those aged 65 and older. Hospitalizations rose from 49,299 to 58,931, with charges and costs (estimated based on charges) increasing from $2.5 billion to $3.6 billion and under $900 million to over $1.1 billion, respectively. The intraclass correlation coefficients from linear mixed-effect models (with charges and costs serving as dependent variables) indicated differences in hospitals accounted for nearly half or more of medical cost variation among older adults suffering a fall-related hospitalization. Nonmetropolitan residence, being aged 65-69 (versus older), and higher risk-of-mortality on admission indicated higher costs. Identifying trends of fall-related hospitalizations over time allows for key stakeholders to not only track the burden of falls among older adults but to also use this information to attract funding for fall prevention strategies from policy makers at various levels (e.g., locally, at the state). Further, identifying characteristics of individuals (e.g., age, race, sex) and places (e.g., rural areas) that carry a higher relative cost can serve to inform the targeted allocation of finite resources including local, state, or federal funding, but also existing evidence-based practices such as community and clinical interventions.

Effects of the Chronic Disease Self-Management Program on medication adherence among older adults.

Despite many interventions to promote medication adherence in older adults, we know little about how medication adherence has improved as a result of such interventions. The purpose of this study was to examine the long-term program impacts on medication adherence from participating in the Chronic Disease Self-Management Program (CDSMP). Secondary data used for this study included the CDSMP participants' sociodemographic characteristics and their baseline and 6- and 12-month follow-up assessments on health-related indicators, including medication adherence, self-rated health, depression, and patient communication skills. This study included those who were 65 years or older, had one or more chronic conditions, and attended at least the first or second session. Linear mixed models were used to analyze the impacts of short-term (6 months) changes in health-related indicators on long-term (12 months) changes in medication nonadherence. The subset analyses were performed among participants with self-rated major depression at baseline. This study included 687 participants. Self-reported medication adherence did not improve significantly at 6-month follow-up assessment but significantly improved at 12-month follow-up assessment. Among those with self-reported major depression at baseline assessment, the short-term improvements in depression and self-rated health were associated with long-term changes in medication adherence. The long-term impacts of the CDSMP on medication adherence were influenced by the short-term program impacts on health-related indicators. More targeted interventions are needed for patients with major depression, and programs such as the CDSMP can be particularly helpful among the population.

Attitudes, Beliefs, and Cost-Related Medication Nonadherence Among Adults Aged 65 or Older With Chronic Diseases.

INTRODUCTION: Cost-related medication nonadherence (CRN) can negatively affect chronic disease prevention and management in an aging population. Limited data are available on the interacting influences among such factors as availability of financial resources, attitudes and beliefs of patients, and CRN. The objective of this study was to examine the causal paths among financial resource availability, patient attitudes and beliefs, and CRN. METHODS: We used a nationally representative sample (n = 4,818) from the 2015 National Health Interview Survey; selected respondents were aged 65 or older, had a diagnosis of hypertension or diabetes or both, and were prescribed medication for at least 1 of these conditions. We performed structural equation modeling to examine whether perceived medication affordability, access to health care, and patient satisfaction influenced the effects of financial resource availability on CRN (skipped doses, took less medicine, or delayed filling a prescription to save money). RESULTS: Six percent of respondents reported CRN in the previous 12 months. The model showed a good to fair fit, and all paths were significant (P < .05) except for age. The effects of financial resource availability on CRN was mediated through perceived medication affordability, access to health care, and patient satisfaction with health care services. CONCLUSION: This study suggests that patients' attitudes and beliefs can mediate the effects of financial resource availability on CRN. We call for senior-friendly public health interventions that can address these modifiable barriers to reduce CRN among older adults with chronic conditions.

Multilevel Comparisons of Hospital Discharge among Older Adults with a Fall-Related Hospitalization.

OBJECTIVE: We examined multilevel factors associated with hospital discharge status among older adults suffering a fall-related hospitalization. DATA SOURCES: The 2011-2013 (n = 131,978) Texas Inpatient Hospital Discharge Public-Use File was used. STUDY DESIGN/METHODS: Multilevel logistic regression analyses estimated the likelihood of being discharged to institutional settings versus home. PRINCIPAL FINDINGS: Factors associated with a greater likelihood of being discharged to institutional settings versus home/self-care included being female, white, older, having greater risk of mortality, receiving care in a non-teaching hospital, having Medicare (versus Private) coverage, and being admitted from a non-health care facility (versus clinical referral). CONCLUSIONS: Understanding risk factors for costly discharges to institutional settings enables targeted fall-prevention interventions with identification of at-risk groups and allows for identifying policy-related factors associated with discharge status.

Does Parents' Social Cohesion Influence Their Perception of Neighborhood Safety and Their Children's Active Commuting to and From School?

BACKGROUND: The role of parents' perceptions of the neighborhood environment in determining children's active commuting to and from school (ACS) is understudied. This study examined the association between parents' perceptions of neighborhood social cohesion, perceived neighborhood safety, and their children's ACS. METHODS: This cross-sectional analysis (n = 857 from 81 elementary schools in Texas) examined baseline data from the Texas Childhood Obesity Prevention Policy Evaluation project. Participants had a mean age of 9.6 (0.6) years, and 50% were girls. Mixed effects logistic regression models were used to assess gender-stratified associations between parent's perceived social cohesion and children's ACS and their perception of neighborhood safety. RESULTS: A positive significant association was observed between levels of perceived social cohesion and children's ACS for boys (P = 0.047); however, an inverse significant association was observed among girls (P = 0.033). Parents of boys living in neighborhoods with medium to high social cohesion were more likely to perceive their neighborhood as safe compared with parents living in neighborhoods with low social cohesion, though nonsignificant. Perceived neighborhood safety for walking and biking was associated with greater ACS among boys (P = 0.003). CONCLUSIONS: Our study findings indicate that both social and physical environments are important factors in determining ACS among boys.

Obesity-specific neural cost of maintaining gait performance under complex conditions in community-dwelling older adults.

BACKGROUND: Recent evidence of obesity-related changes in the prefrontal cortex during cognitive and seated motor activities has surfaced; however, the impact of obesity on neural activity during ambulation remains unclear. The purpose of this study was to determine obesity-specific neural cost of simple and complex ambulation in older adults. METHODS: Twenty non-obese and obese individuals, 65years and older, performed three tasks varying in the types of complexity of ambulation (simple walking, walking+cognitive dual-task, and precision walking). Maximum oxygenated hemoglobin, a measure of neural activity, was measured bilaterally using a portable functional near infrared spectroscopy system, and gait speed and performance on the complex tasks were also obtained. FINDINGS: Complex ambulatory tasks were associated with ~2-3.5 times greater cerebral oxygenation levels and ~30-40% slower gait speeds when compared to the simple walking task. Additionally, obesity was associated with three times greater oxygenation levels, particularly during the precision gait task, despite obese adults demonstrating similar gait speeds and performances on the complex gait tasks as non-obese adults. INTERPRETATION: Compared to existing studies that focus solely on biomechanical outcomes, the present study is one of the first to examine obesity-related differences in neural activity during ambulation in older adults. In order to maintain gait performance, obesity was associated with higher neural costs, and this was augmented during ambulatory tasks requiring greater precision control. These preliminary findings have clinical implications in identifying individuals who are at greater risk of mobility limitations, particularly when performing complex ambulatory tasks.

Evaluating the Influence of the Revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Allocation Package on Healthy Food Availability, Accessibility, and Affordability in Texas.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was implemented to improve the health of pregnant women and children of low socioeconomic status. In 2009, the program was revised to provide a wider variety of healthy food choices (eg, fresh fruits, vegetables, and whole-grain items). OBJECTIVES: The purpose of this study was to evaluate (1) the impact of the revised WIC Nutrition Program's food allocation package on the availability, accessibility, and affordability of healthy foods in WIC-authorized grocery stores in Texas; and (2) how the impact of the policy change differed by store types and between rural and urban regions. DESIGN: WIC-approved stores (n=105) across Texas were assessed using a validated instrument (88 items). Pre- (June-September 2009) and post-new WIC package implementation (June-September 2012) audits were conducted. Paired-sample t tests were conducted to compare the differences between pre- and post-implementation audits on shelf width and number of varieties (ie, availability), visibility (ie, accessibility), and inflation-adjusted price (ie, affordability). RESULTS: Across the 105 stores, post-implementation audits showed increased availability in terms of shelf space for most key healthy food options, including fruit (P<0.001), vegetables (P<0.01), cereal (P<0.001), and varieties of vegetables (P<0.001). Food visibility increased for fresh juices (P<0.001). Visibility of WIC labeling improved for foods such as fruits (P<0.05), WIC cereal (P<0.05), and whole-grain or whole-wheat bread (P<0.01). Inflation-adjusted prices decreased only for bread (P<0.001) and dry grain beans (P<0.001). The positive effects of the policy change on food availability and visibility were observed in stores of different types and in different locations, although smaller or fewer effects were noted in small stores and stores in rural regions. CONCLUSIONS: Implementation of the revised WIC food package has generally improved availability and accessibility, but not affordability, of healthy foods in WIC-authorized stores in Texas. Future studies are needed to explore the impact of the revised program on healthy food option purchases and consumption patterns among Texas WIC participants.

Food-shopping environment disparities in Texas WIC vendors: a pilot study.

OBJECTIVE: To identify differences in food-shopping environments of Texas WIC vendors using a culturally adapted instrument. METHODS: A survey tool was developed for measuring food availability, accessibility, and affordability in 111 WIC vendors in Texas. Two-tailed t-tests and Mann-Whitney tests were used for rural/urban and Texas-Mexico border/non-border area comparisons. RESULTS: Prices were higher in rural areas than in urban areas for 2 key foods, fruits (p = .024) and milk (p = .007); non-border vendors had overall better food availability than border vendors; non-border vendors had better accessibility for fruits (p = .007) than border vendors. CONCLUSION: In Texas, disparities in food-shopping environments are evident and can be assessed using a culturally adapted survey tool.

Parental safety concerns and active school commute: correlates across multiple domains in the home-to-school journey.

BACKGROUND: Empirical evidence of the relationship between safety concerns and walking to school (WTS) is growing. However, current research offers limited understanding of the multiple domains of parental safety concerns and the specific mechanisms through which parents articulate safety concerns about WTS. A more detailed understanding is needed to inform environmental and policy interventions. This study examined the relationships between both traffic safety and personal safety concerns and WTS in the U.S. METHODS: This cross-sectional analysis examined data from the Texas Childhood Obesity Prevention Policy Evaluation (T-COPPE) project, an evaluation of state-wide obesity prevention policy interventions. All study data were from the survey (n=830) of parents with 4th grade students attending 81 elementary schools across Texas, and living within two miles from their children's schools. Traffic safety and personal safety concerns were captured for the home neighborhood, en-route to school, and school environments. Binary logistic regression analysis was used to assess the odds of WTS controlling for significant covariates. RESULTS: Overall, 18% of parents reported that their child walked to school on most days of the week. For traffic safety, students were more likely to walk to school if their parent reported favorable perceptions about the following items in the home neighborhood environment: higher sidewalk availability, well maintained sidewalks and safe road crossings. For the route to school, the odds of WTS were higher for those who reported "no problem" with each one of the following: traffic speed, amount of traffic, sidewalks/pathways, intersection/crossing safety, and crossing guards, when compared to those that reported "always a problem". For personal safety in the en-route to school environment, the odds of WTS were lower when parents reported concerns about: stray or dangerous animals and availability of others with whom to walk. CONCLUSIONS: Findings offered insights into the specific issues that drive safety concerns for elementary school children's WTS behaviors. The observed associations between more favorable perceptions of safety and WTS provide further justification for practical intervention strategies to reduce WTS barriers that can potentially bring long-term physical activity and health benefits to school-aged children.

Creating a tipping point: Texas obesity policy actions in review, 2000-2010.

This paper discusses the historical context and current challenges of obesity prevention and control initiatives in Texas to understand how the obesity epidemic has been addressed by multiple interacting stakeholders over the past decade. By reviewing state reports and interviewing key decision makers, this paper chronicles recent efforts in Texas by highlighting health policy initiatives and champions who helped to create the foundation for obesity prevention and control. The findings outline the sentinel policy approaches that were implemented by public/private sector partnerships over the last decade, as well as the public figures that have been singular champions in creating the momentum for these changes. The efforts to address obesity with a collaborative approach in Texas have shown initial promise in creating a tipping point to control the obesity epidemic. These strategies can also serve as a model for obesity prevention and control at the national level.

TCOPPE school environmental audit tool: assessing safety and walkability of school environments.

BACKGROUND: Several environmental audit instruments have been developed for assessing streets, parks and trails, but none for schools. This paper introduces a school audit tool that includes 3 subcomponents: 1) street audit, 2) school site audit, and 3) map audit. It presents the conceptual basis and the development process of this instrument, and the methods and results of the reliability assessments. METHODS: Reliability tests were conducted by 2 trained auditors on 12 study schools (high-low income and urban-suburban-rural settings). Kappa statistics (categorical, factual items) and ICC (Likert-scale, perceptual items) were used to assess a) interrater, b) test-retest, and c) peak vs. off-peak hour reliability tests. RESULTS: For the interrater reliability test, the average Kappa was 0.839 and the ICC was 0.602. For the test-retest reliability, the average Kappa was 0.903 and the ICC was 0.774. The peak-off peak reliability was 0.801. Rural schools showed the most consistent results in the peak-off peak and test-retest assessments. For interrater tests, urban schools showed the highest ICC, and rural schools showed the highest Kappa. CONCLUSIONS: Most items achieved moderate to high levels of reliabilities in all study schools. With proper training, this audit can be used to assess school environments reliably for research, outreach, and policy-support purposes.

Advanced practice nurses' perspectives on the use of health optimization strategies for managing chronic disease among older adults in different care settings: pushing the boundaries of self-management programs.

This study examines the intention of advanced practice nurses (APNs) to utilize health optimization programs (HOPs) for addressing clients' chronic disease in various work settings (i.e., nursing homes or other care settings). A paper-based survey was administered to 270 APNs at a continuing education conference to determine their intentions to refer patients to HOPs for chronic disease management. APNs working in nursing homes were 0.23 times as likely to utilize HOPs for management of their patients' chronic disease compared with their counterparts working in other care settings (odds ratio = 0.23, confidence interval = 0.06-0.80, P = .021). APNs who had previously used a HOP for management of their patients' chronic disease were 5.2 times as likely to do so again relative to those who had not previously used a HOP for management of their patients' chronic disease (odds ratio = 5.17, confidence interval = 1.78-14.99, P = .002). Educational and organizational interventions are recommended to disseminate further HOPs for chronic disease in nursing home settings as part of an overall health optimization strategy.

Sustainability of evidence-based community-based physical activity programs for older adults: lessons from Active for Life.

Program sustainability in community and healthcare settings is critical to realizing the translation of research into practice. The purpose of this study is to describe the implementation and assessment of an intervention to increase organizational maintenance of evidence-based physical activity programs and the factors that impede or facilitate sustainability. All organizations implemented a sustainability action plan that included identifying factors related to sustainability, examining resources available, identifying program modifications to enhance sustainability, and long-term action planning. A mixed methods approach was used. Organizational (n = 12 sites) ability to demonstrate program effectiveness, align priorities with the organizational mission, and integrate the program within the existing infrastructure were strengths related to sustainability. Sites were more optimistic about program sustainability when they had less reliance on internal financial, but more reliance on internal human resources to run the program post-funding. The study resulted in a number of tools that can help community organizations plan for sustainability of physical activity programs.

Understanding the challenges encountered and adaptations made by community organizations in translation of evidence-based behavior change physical activity interventions: a qualitative study.

PURPOSE: Designing programs for mid-life to older adults whose sedentary behaviors are associated with increased health risks is crucial. The U.S. Task Force on Community Preventive Services strongly recommends individually adapted behavior change programs as one approach to increasing physical activity in communities. The purpose of this study is to report challenges organizations faced when translating two evidence-based programs in real-world settings, adaptations made, and whether or not fidelity was negatively impacted by these adaptations. DESIGN: A grounded theory approach to qualitative research was used. SETTING AND PARTICIPANTS: Nine community organizations across the country participated. Two organizations had more than one site participating, for a total of 12 sites from nine organizations. Within those organizations, 2796 participants were part of the program during the first 2 years. Participants were underactive (i.e., not meeting Centers for Disease Control and Prevention and American College of Sports Medicine recommendations) mid- to older-aged adults. METHODS: Community organizations participated in monthly conference calls, and program information was entered into an electronic database regularly. Data obtained from the calls and database were used for analyses. RESULTS: Challenges and adaptations emerged in three categories: (1) program logistics, (2) program theory, and (3) program philosophy. CONCLUSION: Challenges were present for community organizations; however, with some level of adaptation, the community organizations were able to effectively deliver and maintain fidelity in two evidence-based physical activity programs to a large and diverse group of mid- to older-aged adults.

Active for life: final results from the translation of two physical activity programs.

BACKGROUND: Most evidence-based programs are never translated into community settings and thus never make a public health impact. DESIGN: Active for Life (AFL) was a 4-year translational initiative using a pre-post, quasi-experimental design. Data were collected from 2003 to 2007. Analyses were conducted in 2005 and 2008. SETTING/PARTICIPANTS: Nine lead organizations at 12 sites participated. Active Choices participants (n=2503) averaged 65.8 years (80% women, 41% non-Hispanic white). Active Living Every Day (ALED) participants (n=3388) averaged 70.6 years (83% women, 64% non-Hispanic white). INTERVENTION: In AFL, Active Choices was a 6-month telephone-based and ALED a 20-week group-based lifestyle behavior change program designed to increase physical activity, and both were grounded in social cognitive theory and the transtheoretical model. The interventions were evaluated in Years 1, 3, and 4. An adapted shortened ALED program was evaluated in Year 4. MAIN OUTCOME MEASURE: Moderate- to vigorous-intensity physical activity, assessed with the CHAMPS self-reported measure. RESULTS: Posttest survey response rates were 61% for Active Choices and 70% for ALED. Significant increases in moderate- to vigorous-intensity physical activity, total physical activity, and satisfaction with body appearance and function, and decreases in BMI were seen for both programs. Depressive symptoms and perceived stress, both low at pretest, also decreased over time in ALED. Results were generally consistent across years and sites. CONCLUSIONS: Active Choices and ALED were successfully translated across a range of real-world settings. Study samples were substantially larger, more ethnically and economically diverse, and more representative of older adult's health conditions than in efficacy studies, yet the magnitude of effect sizes were comparable.

Results of the first year of active for life: translation of 2 evidence-based physical activity programs for older adults into community settings.

OBJECTIVES: Translating efficacious interventions into practice within community settings is a major public health challenge. We evaluated the effects of 2 evidence-based physical activity interventions on self-reported physical activity and related outcomes in midlife and older adults. METHODS: Four community-based organizations implemented Active Choices, a 6-month, telephone-based program, and 5 implemented Active Living Every Day, a 20-week, group-based program. Both programs emphasize behavioral skills necessary to become more physically active. Participants completed pretest and posttest surveys. RESULTS: Participants (n=838) were aged an average of 68.4 +/-9.4 years, 80.6% were women, and 64.1% were non-Hispanic White. Seventy-two percent returned posttest surveys. Intent-to-treat analyses found statistically significant increases in moderate-to-vigorous physical activity and total physical activity, decreases in depressive symptoms and stress, increases in satisfaction with body appearance and function, and decreases in body mass index. CONCLUSIONS: The first year of Active for Life demonstrated that Active Choices and Active Living Every Day, 2 evidence-based physical activity programs, can be successfully translated into community settings with diverse populations. Further, the magnitudes of change in outcomes were similar to those reported in the efficacy trials.