A natural experiment: The opening of a supermarket in a public housing community and impacts on children's dietary patterns.

Objective: The aim of the present study is to utilize a natural experiment and examine changes in dietary patterns of predominantly low-income, racial and ethnic minority children who live in a public housing community following the opening of a new supermarket. Methods: Data comes from the Watts Neighborhood Health Study (WNHS), an ongoing study in South Los Angeles, United States, that follows residents of Jordan Downs, a public housing community undergoing redevelopment. Surveys were administered to children aged 9-17 years (n = 297), as well as an adult in the household. The second baseline data collection was conducted June-December 2019, and follow-up was conducted June 2020-April 2021, shortly after the introduction of the new supermarket in January 2020. ANCOVA linear regression models were estimated to examine the association between children's proximity to the new supermarket with dietary outcomes at follow-up. Interactions with barriers to food access were also explored. Results: Living close to the new supermarket was not significantly associated with dietary outcomes at follow-up. However, for children who lived in households with no vehicle access, living close to the new supermarket was associated with increased fruit and vegetable consumption, compared to children in the comparison group. Conclusion: Proximity to the new supermarket was not associated with improved dietary outcomes among children unless they had transportation barriers. This adds to the growing body of literature that suggests that the effects of neighborhood food environments may be modified by individuals' mobility, and that comprehensive interventions are needed.

Heterogeneity in COVID-19 vaccine uptake within low-income minority communities: evidence from the watts neighborhood health study.

BACKGROUND: The literature on disparities in COVID-19 vaccine uptake focuses primarily on the differences between White versus non-White individuals or differences by socioeconomic status. Much less is known about disparities in vaccine uptake within low-income, minority communities and its correlates. METHODS: This study investigates disparities in COVID-19 vaccination uptake within racial and ethnic minoritized communities with similar socioeconomic backgrounds and built environments, specifically focusing on Black-Hispanic disparities and disparities within the Hispanic community by country of origin. Data are analyzed from the fourth wave (June 2021- May 2022) of the Watts Neighborhood Health Study, a cohort study of public housing residents in south Los Angeles, CA. Linear probability models estimated the association between vaccine uptake and participants' race/ethnicity, sequentially adding controls for sociodemographic characteristics, health care access and insurance, prior infection, and attitudes towards COVID-19 vaccines. Differences in reasons for vaccination status by race/ethnicity were also tested. RESULTS: Mexican Hispanic and non-Mexican Hispanic participants were 31% points (95% CI: 0.21, 0.41, p < 0.001) and 44% points (95% CI: 0.32, 0.56, p < 0.001) more likely to be vaccinated than non-Hispanic Black participants, respectively. The disparity between Black and Hispanic participants was reduced by about 40% after controlling for attitudes towards COVID-19 vaccines. Among Hispanic participants, non-Mexican participants were 13% points (95% CI: 0.03, 0.24, p = 0.01) more likely to be vaccinated than Mexican participants, however, these differences were no longer significant after controlling for individual and household characteristics (ß = 0.04, 95% CI: -0.07, 0.15, p = 0.44). CONCLUSION: There are sizeable racial and ethnic COVID-19 vaccination disparities even within low-income and minoritized communities. Accounting for this heterogeneity and its correlates can be critically important for public health efforts to ensure vaccine equity.

Postacute Care for Medicare Advantage Enrollees Who Switched to Traditional Medicare Compared With Those Who Remained in Medicare Advantage.

Importance: Medicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM. Objective: To estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes. Design, Setting, and Participants: This was a cohort study using Medicare data on 4613 hospitalizations among retired Ohio state employees and 2 comparison groups in 2015 and 2016. The study investigated the association of a policy change with use of postacute care and outcomes. The policy changed state retiree health benefits in Ohio from a mandatory MA plan to subsidies for either supplemental TM coverage or an MA plan. After policy implementation, approximately 75% of retired Ohio state employees switched to TM. Hospitalizations for 3 high-volume conditions that usually require postacute rehabilitation were assessed. Data from the Medicare Provider Analysis and Review files were used to identify all hospitalizations in short-term acute care hospitals. Difference-in-difference regressions were used to estimate changes for retired Ohio state employees compared with other 2015 MA enrollees in Ohio and with Kentucky public retirees who were continuously offered a mandatory MA plan. Data analyses were performed from September 1, 2019, to November 30, 2023. Exposures: Enrollment in Ohio state retiree health benefits in 2015, after which most members shifted to TM. Main Outcomes and Measures: Received care in an inpatient rehabilitation facility, skilled nursing facility, or home health, or any postacute care; the occurrence of any hospital readmission; the number of days in the community during the 30 days after hospital discharge; and mortality. Results: The study sample included 2373 hospitalizations for Ohio public retirees, 1651 hospitalizations for other Humana MA enrollees in Ohio, and 589 hospitalizations for public retirees in Kentucky. After the 2016 policy implementation, the percentage of hospitalizations covered by MA decreased by 70.1 (95% CI, -74.2 to -65.9) percentage points (pp), inpatient rehabilitation facility admissions increased by 9.7 (95% CI, 4.7 to 14.7) pp, use of only home health or skilled nursing facility care fell by 8.6 (95% CI, -14.6 to -2.6) pp, and days in the community fell by 1.6 (95% CI, -2.9 to -0.3) days for Ohio public retirees compared with other Humana MA enrollees in Ohio. There was no change in 30-day mortality or hospital readmissions; similar results were found by comparisons using Kentucky public retirees as a control group. Conclusions and Relevance: The findings of this cohort study indicate that after a change in retiree health benefits, most Ohio public retirees shifted from MA to TM and received more intensive postacute care with no significant change in measured short-term postdischarge outcomes. Future work should consider additional measures of postacute functional status over a longer follow-up period.

The Impact of State Dementia Training Requirements for Nursing Homes on Antipsychotic Medication Use.

OBJECTIVES: Nursing home (NH) staff often report not having adequate dementia-specific knowledge to effectively care for these residents. Between 2011 and 2019, 9 states in the United States implemented dementia training requirements for NH staff. This study evaluated whether the state-mandated dementia training for NH staff was associated with improving resident outcomes. DESIGN: Compared trends in antipsychotic medication before and after implementation of state training requirements to trends in states without requirements. SETTING AND PARTICIPANTS: NHs. METHODS: Data from Care Compare for NHs and LTCFocus were linked to state policy data. We excluded 14 states that had implemented training requirements before the start of the study period in 2011. We estimated difference-in-differences models that compared trends in antipsychotic medication use before and after implementation of training requirements in states that have newly implemented requirements to trends in states without requirements. We also investigated whether the impact of training was larger in states with more stringent training requirements (eg, specifying a minimum number of training hours) and in NHs with a special care unit for dementia and examined similar analyses for restraint use and falls. RESULTS: We found that training requirements were associated with a 0.59-percentage point reduction (95% CI -0.91 to -0.27) in antipsychotics use. Effects were larger in NHs with a special care unit for dementia and in states that had stricter training requirements. We also found that training requirements were associated with a 0.17-percentage point reduction (95% CI -0.26 to -0.07) in restraint use measure and had no impact on falls. CONCLUSIONS AND IMPLICATIONS: State requirements for NH staff dementia training were associated with a small, but significant, reduction in the use of antipsychotic medication and physical restraints.

Evaluating non-pharmacological approaches to nursing home dementia care: A protocol.

Background: The COVID-19 pandemic has underscored the daily challenges nursing home (NH) staff face caring for the residents living with Alzheimer's Disease and Related Dementias (ADRD). Non-pharmacological approaches are prioritized over off-label medication to manage the behavioral and psychological symptoms of ADRD. Yet, it is not clear how to best equip NH staff and families with the knowledge and strategies needed to provide non-pharmacological approaches to these residents. Methods: This clustered randomized trial will compare team- and problem-based approaches to non-pharmacological ADRD care. The team-based approach includes core training for all NH staff using a common language and strategies to support continuity and sustainability. The problem-based approach capitalizes on the expertise of the professional healthcare providers to target issues that arise. A convergent mixed methods design will be used to examine (a) comparative effectiveness of the two approaches on long-term NH resident outcomes and (b) whether either approach is protective against the negative consequences of COVID-19. The primary outcome is the percentage of ADRD residents with off-label antipsychotic medication use, which will be evaluated with an intent-to-treat approach. Staff and family caregiver perspectives will be explored using a multiple case study approach. Conclusion: This trial will be the first-ever evaluation of team- and problem-based approaches to ADRD care across multiple NHs and geographic regions. Results can provide health system leaders and policymakers with evidence on how to optimize ADRD training for staff in an effort to enhance ADRD care delivery.

Potentially Inappropriate Medication Use in Community-Dwelling Older Adults Living with Dementia.

BACKGROUND: The Beers Criteria identifies potentially inappropriate medications (PIMs) that should be avoided in older adults living with dementia. OBJECTIVE: The aim of this study was to provide estimates of the prevalence and persistence of PIM use among community-dwelling older adults living with dementia in 2011-2017. METHODS: Medicare claims data were used to create an analytic dataset spanning from 2011 to 2017. The analysis included community-dwelling Medicare fee-for-service beneficiaries aged 65 and older who were enrolled in Medicare Part D plans, had diagnosis for dementia, and were alive for at least one calendar year. Dementia status was determined using Medicare Chronic Conditions Date Warehouse (CCW) Chronic Condition categories and Charlson Comorbidity Index. PIM use was defined as 2 or more prescription fills with at least 90 days of total days-supply in a calendar year. Descriptive statistics were used to report the prevalence and persistence of PIM use. RESULTS: Of 1.6 million person-year observations included in the sample, 32.7% used one or more PIMs during a calendar year in 2011-2017. Breakdown by drug classes showed that 14.9% of the sample used anticholinergics, 14.0% used benzodiazepines, and 11.0% used antipsychotics. Conditional on any use, mean annual days-supply for all PIMs was 270.6 days (SD = 102.7). The mean annual days-supply for antipsychotic use was 302.7 days (SD = 131.2). CONCLUSION: Significant proportion of community-dwelling older adults with dementia used one or more PIMs, often for extended periods of time. The antipsychotic use in the community-dwelling older adults with dementia remains as a significant problem.

Understanding drivers of micro-level disparities in childhood body mass index, overweight, and obesity within low-income, minority communities.

The focus of childhood obesity disparities has been mainly on macro-level disparities, such as, between lower versus higher socioeconomic groups. But, less is known about micro-level disparities, that is disparities within minority and low-income populations. The present study examines individual and family level predictors of micro-level obesity disparities. We analyze data on 497 parent-child dyads living in public housing communities in Watts, Los Angeles. Cross-sectional multivariable linear and logistic regression models were estimated to examine whether individual and family level factors predict children's BMI z-scores, overweight, and obesity in the sample overall and separately by child's gender and age group. Child characteristics of our study sample included mean age 10.9 years, 74.3% Hispanic, 25.7% Non-Hispanic Black, 53.1% female, 47.5% with household income below $10,000, 53.3% with overweight or obesity, and 34.6% with obesity. Parental BMI was the strongest and most consistent predictor of child zBMI, overweight, and obesity, even after controlling for parent's diet and activity behaviors and home environment. The parenting practice of limiting children's screentime was also protective of unhealthy BMI in younger children and females. Home environment, parental diet and activity behaviors, and parenting practices related to food and bedtime routines were not significant predictors. Overall, our findings show that there is considerable heterogeneity in child BMI, overweight, and obesity even within low-income communities with similar socioeconomic and built environments in their neighborhoods. Parental factors play an important role in explaining micro-level disparities and should be an integral part of obesity prevention strategies in low-income minority communities.

Heterogeneity in grocery shopping patterns among low-income minority women in public housing.

BACKGROUND: Public housing residents, who tend to be predominantly female and racial/ethnic minorities, are at a particularly high risk for chronic health conditions. Prior studies have suggested that a lack of access to healthy and affordable food may be an important barrier in public housing communities, but evidence is mixed on the association between the neighborhood food environment and dietary quality, suggesting the need to examine food access patterns in low-income, minority communities more deeply. The purpose of this study was to examine the variability in grocery shopping patterns, and the factors that predict them, among low-income minority women in public housing. METHODS: Interviewer-administered surveys and body composition measurements were collected in the Watts Neighborhood Health Study, an ongoing longitudinal cohort study of low-income urban public housing residents located in South Los Angeles. Descriptive analyses were conducted to understand the variation in grocery shopping patterns among women. Logistic and ordered logistic regression models were estimated to examine the association between resident characteristics and grocery shopping patterns. RESULTS: There was considerable variability in grocery shopping patterns, including the types of grocery stores accessed, distance travelled, frequency of shopping, and reasons behind grocery store choice. Grocery shopping patterns were associated with several participant characteristics, including race/ethnicity, working status, access to a car, income, and education. Hispanic participants were less likely to shop at a supermarket, travel further distances to shop, shop more frequently, and were more likely to prioritize price in their choice of primary grocery store than non-Hispanic Black women participants. CONCLUSIONS: There was considerable variability in grocery shopping patterns, even within this low-income, minority community despite access to the same neighborhood food environment. Convenience and quality, in addition to price, were priorities for choice of primary grocery store, and differences by race/ethnicity suggest that initiatives to improve the neighborhood food environment should consider quality of food, cultural factors, and availability of foods desired by the surrounding community, in addition to price and proximity of grocery stores.

Standardized assessment of cognitive function of post-acute care patients.

BACKGROUND: The assessment of cognitive function in post-acute care (PAC) settings is important for understanding an individual's condition and care needs, developing better person-directed care plans, predicting resource needs and understanding case mix. Therefore, we tested the feasibility and reliability of cognitive function assessments, including the Brief Interview for Mental Status (BIMS), Confusion Assessment Method (CAM©), Expression and Understanding, and Behavioral Signs and Symptoms for patients in PAC under the intent of the IMPACT Act of 2014. METHODS: We conducted a national test of assessments of four standardized cognitive function data elements among patients in PAC. One hundred and forty-three PAC settings (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. At least one of four cognitive function data elements were assessed in 3026 patients. We assessed descriptive statistics, percent of missing data, time to complete, and interrater reliability between paired research nurse and facility staff assessors, and assessor feedback. RESULTS: The BIMS, CAM©, Expression and Understanding, and Behavioral Signs and Symptoms demonstrated low rates of missing data (less than 2%), high percent agreement, and substantial support from assessors. The prevalence of Behavioral Signs and Symptoms was low in our sample of PAC settings. CONCLUSION: Findings provide support for feasibility of implementing standardized assessment of all our cognitive function data elements for patients in PAC settings. The BIMS and CAM© were adopted into federal Quality Reporting Programs in the fiscal year/calendar year 2020 final rules. Future work could consider implementing additional cognitive items that assess areas not covered by the BIMS and CAM©.

Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate.

BACKGROUND: Assessments of patients have sought to increase the patient voice through direct patient interviews and performance-based testing. However, some patients in post-acute care (PAC) are unable to communicate and cannot participate in interviews or structured cognitive tests. Therefore, we tested the feasibility and reliability of observational assessments of cognitive function, mood, and pain for patients who are unable to communicate in PAC settings. METHODS: We conducted a national test of observational assessments of cognitive function, mood, and pain in 143 PAC facilities (57 home health agencies, 28 Inpatient Rehabilitation Facilities, 28 Long-Term Care Hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. For the 548 patients identified as unable to make themselves understood, we assessed descriptive statistics, percent of missing data, time to complete, and inter-rater reliability (IRR) between paired research nurse and facility staff assessors. RESULTS: Most sampled non-communicative patients were administered all three observational assessments. Among assessed patients, overall missing data was high for some items within the Staff Assessment for Mental Status (2.9% to 33.5%) and Staff Assessment of Patient Mood (12.4% to 44.3%), but not the Observational Assessment of Pain or Distress (0.0% to 4.4%). Average time to complete the data elements ranged from 2.4 to 3.5 min and IRR was good to excellent for all items (kappa range: 0.74-0.98). CONCLUSION: The three observational data elements had acceptable reliability. Although results revealed varying feasibility, there was support for feasibility overall in terms of implementing a standardized observational assessment of pain for patients in PAC settings. Additional work is needed for the Staff Assessment for Mental Status and the Staff Assessment of Patient Mood to improve the observable nature of these data elements and enhance instructions and training for standardizing the assessments.

Developing standardized patient assessment data elements for Medicare post-acute care assessments.

BACKGROUND: To support interoperability and care planning across provider types, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the submission of standardized patient assessment data using the assessment instruments provided by the Centers for Medicare & Medicaid Services (CMS). CMS was tasked with developing standardized assessment data elements (SADEs) within clinical categories named in the IMPACT Act. METHOD: We used environmental scans, subject matter expert, and stakeholder input to identify candidate SADEs; tested candidate data elements in alpha testing; revised SADEs and training protocols based on alpha analyses and stakeholder feedback; tested SADEs across post-acute care (PAC) settings in a national field test that included 3121 patients across 143 home health agencies, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities in 14 markets across the United States; and analyzed data and stakeholder input from national testing. Field testing measured the time required for assessment, percent completion, and inter-rater reliability. We analyzed qualitative feedback from stakeholder focus groups and technical expert panels. We also obtained survey and focus group feedback from data collectors. RESULTS: We developed a mixed-method, multi-stakeholder procedure to identify and gather input on SADE for cross-setting use. This process yielded feasible and reliable SADEs for PAC settings that assess pain, cognitive status, mood, and medication reconciliation. The success of this work depended on working iteratively with diverse stakeholders and providing qualitative as well as quantitative evidence. CONCLUSIONS: The procedures applied in this project for developing and adopting SADEs for PAC, as well as the challenges and strategies to overcome challenges, should be considered in future item and quality measure development.

Assessing impacts of redeveloping public housing communities on obesity in low-income minority residents: Rationale, study design, and baseline data from the Watts Neighborhood Health Study.

INTRODUCTION: Obesogenic built- and social-environments in low-income and minority communities are often blamed for the higher rates of obesity in this population, but existing evidence is based largely on observational studies. This study leverages a natural experiment created by the redevelopment of a public housing community to examine the impact of major improvements to the housing, built, and social environments on obesity among residents. METHODS/DESIGN: The study design is a natural experiment where residents from the redeveloped community (treatment group) will be compared to those from a similar community (control group) in terms of their pre/post changes in primary outcomes using annual longitudinal data on a cohort of residents. Quasi-experimental variation in the timing of exposure to various redevelopment components within the treated community will be further leveraged within a stepped-wedge research design to assess the impact of the redevelopment components. Primary outcome measures include body mass index, overweight, and obese status. RESULTS: A cohort of 868 adults and 704 children (ages 2-17 years) was recruited during 2018-2019 with up to two waves of baseline data. At baseline, the prevalence of obesity (overweight or obesity) was 57.2% (81.3%) in adults and 33.1% (52.4%) among children, with no significant differences by treatment status. No differential trends in primary outcomes were observed by treatment status during the two years of baseline. DISCUSSION: This natural experiment study offers a unique opportunity to assess whether improvements to housing, built, and social environment in low-income minority communities can lead to reductions in obesity.

Predictive Utility of Alternate Measures of Physical Activity and Diet for Overweight and Obesity in Low-Income Minority Women.

PURPOSE: The purpose is to compare the predictive utility of alternate measures of diet and physical activity for overweight and obesity among low-income minority women. DESIGN: Cross-sectional analysis of baseline data from a cohort study. SETTING: Three public housing developments in South Los Angeles.Subjects: Adult women (N = 425). MEASURES: Primary outcome-weight status (normal BMI, overweight, or obese). Primary predictors- diet: 24-hour dietary recalls (Healthy Eating Index), dietary screener (intake of specific food groups), and single-item survey question (diet quality); physical activity: accelerometry (minutes/day of moderate-to-vigorous activity), short recall questionnaire (minutes/week of moderate and vigorous activity), and single-item questions (days per week did exercise; self-assessment of overall activity level). ANALYSIS: Multinomial logistic regression models, controlling for socio-demographic covariates. Models are built up starting with least resource-intensive measures of diet and physical activity (single items) and sequentially adding more resource-intensive measures. Model performance is assessed via information-based model selection indices. RESULTS: Adjusted relative risk for obesity for single-item measures ranged from .61 to .64 for diet (P < .01) and from .80 to .81 for physical activity (P <.05). The added value of resource-intensive measures was negligible for physical activity and at best small for diet. CONCLUSION: Single-item questions for diet and physical activity can provide valuable information about risk for overweight and obesity in low-income minority women when more resource-intensive assessments are infeasible.

The effects of vertically integrated care on health care use and outcomes in inpatient rehabilitation facilities.

OBJECTIVE: To understand the effects of receiving vertically integrated care in inpatient rehabilitation facilities (IRFs) on health care use and outcomes. DATA SOURCES: Medicare enrollment, claims, and IRF patient assessment data from 2012 to 2014. STUDY DESIGN: We estimated within-IRF differences in health care use and outcomes between IRF patients admitted from hospitals vertically integrated with the IRF (parent hospital) vs patients admitted from other hospitals. For hospital-based IRFs, the parent hospital was defined as the hospital that owned the IRF and co-located with the IRF. For freestanding IRFs, the parent hospital(s) was defined as the hospital(s) that was in the same health system. We estimated models for freestanding and hospital-based IRFs and for fee-for-service (FFS) and Medicare Advantage (MA) patients. Dependent variables included hospital and IRF length of stay, functional status, discharged to home, and hospital readmissions. DATA EXTRACTION METHODS: We identified Medicare beneficiaries discharged from a hospital to IRF. PRINCIPAL FINDINGS: In adjusted models with hospital fixed effects, our results indicate that FFS patients in hospital-based IRFs discharged from the parent hospital had shorter hospital (-0.7 days, 95% CI: -0.9 to -0.6) and IRF (-0.7 days, 95% CI: -0.9 to -0.6) length of stay were less likely to be readmitted (-1.6%, 95% CI: -2.7% to -0.5%) and more likely to be discharged to home care (1.4%, 95% CI: 0.7% to 2.0%), without worse patient clinical outcomes, compared to patients discharged from other hospitals and treated in the same IRFs. We found similar results for MA patients. However, for patients in freestanding IRFs, we found little differences in health care use or patient outcomes between patients discharged from a parent hospital compared to patients from other hospitals. CONCLUSIONS: Our results indicate that receiving vertically integrated care in hospital-based IRFs shortens institutional length of stay while maintaining or improving health outcomes.

The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery.

BACKGROUND: Comprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons. METHODS: Seventy-three (of 104) orthopedic surgeon members of the Hip Society, a national professional organization of hip surgeons, completed the survey. RESULTS: Surgeons practicing in CJR hospitals were more likely to report that their hospital had implemented programs focused on improving posthospitalization care or reducing costs. Surgeons in CJR hospitals were significantly more likely to report that the hospital had a narrow network of skilled nursing facilities to enhance care and limit length of stay in skilled nursing facilities (83% vs 47%, P < .01). Surgeons in CJR hospitals were also more likely to report the hospital provides incentives or some type of gainsharing. There were no statistically significant differences in implementation of having programs to reduce costs or improve care during hospitalization. CONCLUSION: Participation in CJR is associated with higher utilization of hospital practices aimed at improving postdischarge care and higher utilization of linking surgeon compensation to cost and quality.

Parental Deployment, Adolescent Academic and Social-Behavioral Maladjustment, and Parental Psychological Well-being in Military Families.

OBJECTIVE: Increases in the frequency and length of military deployments have raised concerns about the well-being of military families. We examined the relationship between a military parent's deployment and (1) adolescent academic and social-behavioral maladjustment and (2) parental psychological well-being. METHODS: We collected data from April 2013 through January 2014 from 1021 families of enlisted US Army personnel with children aged 12 or 13 during the Military Teenagers' Environments, Exercise, and Nutrition Study. Through online parent surveys, we collected data on deployment, adolescent academic and social-behavioral maladjustment, and parental psychological well-being. We estimated adjusted logistic and linear regression models for adolescents (all, boys, girls), military parents (all, fathers, mothers), and civilian parents. RESULTS: Compared with no or short deployments, long deployments (>180 days in the past 3 years) were associated with significantly higher odds of decreases in adolescent academic performance (adjusted odds ratio [AOR] = 1.54), independence (AOR = 2.04), and being responsible (AOR = 1.95). These associations were also significant for boys but not for girls. Among parents, long deployments were associated with significantly higher odds of being depressed (AOR = 2.58), even when controlling for adolescent maladjustment (AOR = 2.54). These associations did not differ significantly between military and civilian parents and were significant for military fathers but not military mothers. Recent deployment (in the past 12 months) was not associated with either adolescent or parent outcomes. CONCLUSION: Long deployments are associated with adolescents' academic and social-behavioral maladjustments and diminished parental well-being, especially among boys and military fathers.

Implementing exercise programs to prevent falls: systematic descriptive review.

BACKGROUND: The United States Preventive Services Task Force recommends exercise to prevent falls in community-dwelling adults aged ≥ 65 years at increased fall risk. However, little is known about how best to implement exercise programs in routine care when a patient's need for exercise is identified within the healthcare system. METHODS: Using a qualitative approach, we reviewed the literature to determine how exercise programs to prevent falls are implemented from the vantage point of a health care setting. We synthesized descriptive information about each program with data on program features and implementation difficulties and facilitators. RESULTS: We found that programs sponsored by primary care providers (PCPs) or specialists may help with recruitment into exercise programs. PCPs have the opportunity to identify people at risk and promote participation since most older adults regularly visit, and inquire about exercise from, their physicians. In terms of referral options, both home-based and group-based exercise programs have been shown effective in preventing falls; however, each approach carries strengths and limitations. Home-based programs can include participants who are reluctant or unable to attend group classes and can be individually tailored, but provide less opportunity for supervision and socialization than classes. Adherence to programs can be encouraged, and attrition minimized, through positive reinforcement. Successful programs ranged in expense for exercise sessions: a weekly class combined with exercises at home cost < $2 per participant per week, while frequent individual sessions cost > $100 per participant per week. CONCLUSIONS: With increasing attention to population-based health management in the United States, clinicians and health system leaders need a deeper understanding of how to link patients in their healthcare systems with appropriate community programs. This review identifies key characteristics of successful fall prevention exercise programs that can be used to determine which local options conform to clinical evidence. In addition, we highlight tradeoffs between program options, such as home versus group exercise programs, to allow referrals to be tailored to local conditions and patient preferences. Finally, our work highlights the key role of the PCP in recruiting patients to participate in exercise programs, and identifies options, such as registries, to support referrals to the community.

The Role of School Environments in Explaining Racial-Ethnic Disparities in Body Mass Index Among U.S. Adolescents.

PURPOSE: Policymakers have focused substantial efforts on how school environments can be used to combat obesity. Given this intense focus, this article examined whether disparities in body mass index (BMI) noted among black and Hispanic adolescents relative to whites were explained by the well-documented differences in the school socioeconomic characteristics, and food and physical activity environment. METHODS: Data from the fifth- and eighth-grade waves of the Early Childhood Longitudinal Study-Kindergarten Class were analyzed. Unadjusted linear regression models of BMI percentile that included only indicators for child's race/ethnicity were estimated first followed by adjusted models that iteratively added sets of child, family, and ultimately school covariates. Separate models were estimated by grade and gender. School covariates included detailed indicators for the school socioeconomic characteristics, and the food and physical activity environments. RESULTS: For Hispanic boys and girls and for black boys, substantial shares of the disparities in BMI were explained by differences in birth weight, BMI at school entry, and current child and family characteristics. Substantial disparities in BMI remained among black girls relative to white girls. Characteristics of the child's school during fifth and eighth grade-specifically, the schools' socioeconomic characteristics as well as measures of the food and physical activity environment-did not explain the disparities for any of the demographic groups. CONCLUSIONS: Differences in the school environment had little additional explanatory power suggesting that interventions seeking to reduce BMI disparities should focus on early school years and even before school entry.

Neighborhood and home food environment and children's diet and obesity: Evidence from military personnel's installation assignment.

Research and policy initiatives are increasingly focused on the role of neighborhood food environment in children's diet and obesity. However, existing evidence relies on observational data that is limited by neighborhood selection bias. The Military Teenagers' Environments, Exercise, and Nutrition Study (M-TEENS) leverages the quasi-random variation in neighborhood environment generated by military personnel's assignment to installations to examine whether neighborhood food environments are associated with children's dietary behaviors and BMI. Our results suggest that neither the actual nor the perceived availability of particular food outlets in the neighborhood is associated with children's diet or BMI. The availability of supermarkets and convenience stores in the neighborhood was not associated with where families shop for food or children's dietary behaviors. Further, the type of store that families shop at was not associated with the healthiness of food available at home. Similarly, availability of fast food and restaurants was unrelated to children's dietary behaviors or how often children eat fast food or restaurant meals. However, the healthiness of food available at home was associated with healthy dietary behaviors while eating at fast food outlets and restaurants were associated with unhealthy dietary behaviors in children. Further, parental supervision, including limits on snack foods and meals eaten as a family, was associated with dietary behaviors. These findings suggest that focusing only on the neighborhood food environment may ignore important factors that influence children's outcomes. Future research should also consider how families make decisions about what foods to purchase, where to shop for foods and eating out, how closely to monitor their children's food intake, and, ultimately how these decisions collectively impact children's outcomes.

How will provider-focused payment reform impact geographic variation in Medicare spending?

OBJECTIVES: The Institute of Medicine has recently argued against a value index as a mechanism to address geographic variation in spending and instead promoted payment reform targeted at individual providers. It is unknown whether such provider-focused payment reform reduces geographic variation in spending. STUDY DESIGN: We estimated the potential impact of 3 Medicare provider-focused payment policies-pay-for-performance, bundled payment, and accountable care organizations-on geographic variation in Medicare spending across Hospital Referral Regions (HRRs). We compared geographic variation in spending, measured using the coefficient of variation (CV) across HRRs, between the baseline case and a simulation of each of the 3 policies. METHODS: Policy simulation based on 2008 national Medicare data combined with other publicly available data. RESULTS: Compared with the baseline (CV, 0.171), neither pay-for-performance nor accountable care organizations would change geographic variation in spending (CV, 0.171), while bundled payment would modestly reduce geographic variation (CV, 0.165). CONCLUSIONS: In our models, the bundled payment for inpatient and post acute care services in Medicare would modestly reduce geographic variation in spending, but neither accountable care organizations nor pay-for-performance appear to have an impact.