Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan.

BACKGROUND: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown. OBJECTIVE: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan. DESIGN: Cross-sectional. SETTING: National MA plan. PARTICIPANTS: Humana MA beneficiaries in 2022 (n = 2 435 519). MEASUREMENTS: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status. RESULTS: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]). LIMITATION: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability. CONCLUSION: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries. PRIMARY FUNDING SOURCE: Humana, under a collaborative research agreement with Johns Hopkins University.

A cohort study to assess risk of cutaneous small vessel vasculitis among users of different oral anticoagulants.

PURPOSE: Cutaneous small vessel vasculitis (CSVV) was identified as a safety signal among patients treated with direct oral anticoagulants (DOAC). This study aimed to determine if CSVV risk differed among patients with atrial fibrillation (Afib) who newly initiated warfarin or a DOAC. METHODS: We identified enrollees aged ≥21 years diagnosed with Afib who newly initiated rivaroxaban, dabigatran, apixaban, and warfarin in the Sentinel Distributed Database from October 19, 2010 to February 29, 2020. We selected and followed patients who did not have evidence of the following in the 183 days prior to initiating treatment: CSVV diagnosis, dispensing of other study drugs, select autoimmune diseases or autoimmune medications, cancer diagnoses or chemotherapeutic treatment, kidney dialysis or transplant, alternative anticoagulation indications, or an institutional (nursing home, hospice, hospital) stay on the treatment initiation date (index date) until CSVV outcome or pre-specified censoring. We conducted 1:1 propensity score matching in six comparisons. RESULTS: CSVV incidence rates for DOACs and warfarin ranged from 3.3 to 5.6 per 10 000-person years in our matched Afib population. The adjusted CSVV hazard ratio (HR) and 95% confidence interval (CI) was 0.94 (0.64, 1.39) for rivaroxaban versus warfarin; 1.17 (0.67, 2.06) for dabigatran vs. warfarin; 0.85 (0.62, 1.16) for apixaban vs. warfarin; 0.86 (0.49, 1.50) for rivaroxaban vs. dabigatran; 0.99 (0.68, 1.45) for rivaroxaban versus apixaban; and 1.70 (0.90, 3.21) for dabigatran versus apixaban. CONCLUSION: We did not find significant evidence of differential CSVV risk in pair-wise comparisons of DOACs and warfarin.

Complementary Use of U.S. FDA's Adverse Event Reporting System and Sentinel System to Characterize Direct Oral Anticoagulants-Associated Cutaneous Small Vessel Vasculitis.

BACKGROUND: Cutaneous small vessel vasculitis (CSVV) has been reported after exposure to direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and edoxaban. OBJECTIVE: We used the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) to describe clinical characteristics associated with CSVV among DOAC-exposed patients. Furthermore, we characterized this signal in the Sentinel System to relate the clinical data from the individual FAERS cases to population-based electronic healthcare data. METHODS: We queried FAERS for all cases of CSVV associated with DOACs from U.S. approval date of each DOAC through March 16, 2018. Within the Sentinel System, we identified incident CSVV cases using ICD-9 and ICD-10 diagnosis codes among adults aged ≥ 30 years who received a DOAC in the prior 90 days between January 1, 2010, and June 30, 2018. We excluded patients with evidence of select autoimmune diagnoses in the 183 days prior to their CSVV diagnoses and reported patient characteristics in the 183-day period prior to CSVV diagnoses. RESULTS: In FAERS, we identified 50 cases of CSVV reported with rivaroxaban (n=26), apixaban (n=14), dabigatran (n=9), and edoxaban (n=1). Approximately 50% of the cases reported time to onset within 10 days after DOAC exposure. When specified, the predominant type of CSVV reported was leukocytoclastic vasculitis (n=31), followed by Henoch-Schonlein purpura (n=4). Hospitalization occurred in most of the cases (n=37). Switching of the offending agent after the development of CSVV was reported (n=26). Three rivaroxaban (n=3) cases and one dabigatran case (n=1) reported positive rechallenge. In the Sentinel system, we identified 3659 CSVV cases with prior DOAC exposure, with 85% of events occurring within 10 days. CONCLUSIONS: The assessment of FAERS cases, combined with the temporal clustering of the Sentinel System cases suggest a possible causal relationship of DOACs and CSVV. Future efforts should characterize the risk of CSVV among the various DOAC users.

Diagnosed prevalence of Alzheimer's disease and related dementias in Medicare Advantage plans.

INTRODUCTION: One-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA). Yet, little is known about MA beneficiaries diagnosed with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD). METHODS: We calculated the prevalence of AD/ADRD diagnoses in 2014 and 2016 in three MA plans. We determined the demographic characteristics of beneficiaries diagnosed with AD/ADRD, and whether they disenrolled from the MA plan for any reason within 364 days from the index date. RESULTS: In 2014 and 2016, the overall prevalence of AD/ADRD diagnoses was 5.6% and 6.5%, respectively. In 2016, AD/ADRD beneficiaries were on average 82.4 (SD = 7.4) years of age, 61.8% female, and had multiple comorbidities. By 364 days post-index date, 32% of beneficiaries with AD/ADRD had disenrolled from their plan. The demographic characteristics of 2014 beneficiaries with diagnosed AD/ADRD were similar to their 2016 counterparts. DISCUSSION: The prevalence of AD/ADRD diagnosis in MA is lower than rates reported in Medicare fee-for-service.

Proton pump inhibitors and the risk of severe cognitive impairment: The role of posttraumatic stress disorder.

INTRODUCTION: Proton pump inhibitors (PPIs), a common treatment for gastroesophageal reflux disease (GERD), were recently associated with increased risk of dementia. However, severe or chronic stress including, for example, posttraumatic stress disorder (PTSD) was not accounted for. This study examined whether PPI use was associated with severe cognitive impairment (SCI) and whether PTSD explained this association in a cohort of World Trade Center (WTC) responders. METHOD: A prospective cohort study of 3779 WTC responders attending a university-based monitoring and treatment program. Prescriptions for PPIs and SCI determined using the Montreal Cognitive Assessment were the focus of the analysis. RESULTS: Overall, 1451 (38.4%) responders were dispensed PPIs, and 83 (2.2%) had SCI. Bivariable analyses revealed significant associations between being-dispensed PPIs in relation to SCI. After adjusting for PTSD, major depressive disorder, WTC exposures, age, and sex, being-dispensed PPIs were significantly associated with odds of SCI (adjusted odds ratio = 1.67 95% confidence interval = 1.054-2.643). CONCLUSIONS: Being-dispensed PPIs were associated with SCI in this analysis of WTC responders. Results suggest that clinicians treating GERD seek to both understand patients' mental health history and monitor cognitive functioning when designing treatment routines. Overall, results confirmed that this is an important area of investigation with potential direct clinical implications.

Show Me the Money: A Systematic Exploration of Manipulations, Moderators, and Mechanisms of Priming Effects.

A major challenge for accumulating knowledge in psychology is the variation in methods and participant populations across studies in a single domain. We offer a systematic approach to addressing this challenge and implement it in the domain of money priming. In three preregistered experiments ( N = 4,649), participants were exposed to one of a number of money manipulations before completing self-report measures of money activation (Study 1); engaging in a behavioral-persistence task (Study 3); completing self-report measures of subjective wealth, self-sufficiency, and communion-agency (Studies 1-3); and completing demographic questions (Studies 1-3). Four of the five manipulations we tested activated the concept of money, but, contrary to what we expected based on the preponderance of the published literature, no manipulation consistently affected any dependent measure. Moderation by sociodemographic characteristics was sparse and inconsistent across studies. We discuss implications for theories of money priming and explain how our approach can complement recent efforts to build a reproducible, cumulative psychological science.

Effects of Power on Mental Rotation and Emotion Recognition in Women.

Based on construal-level theory (CLT) and its view of power as an instance of social distance, we predicted that high, relative to low power would enhance women's mental-rotation performance and impede their emotion-recognition performance. The predicted effects of power emerged both when it was manipulated via a recall priming task (Study 1) and environmental cues (Studies 2 and 3). Studies 3 and 4 found evidence for mediation by construal level of the effect of power on emotion recognition but not on mental rotation. We discuss potential mediating mechanisms for these effects based on both the social distance/construal level and the approach/inhibition views of power. We also discuss implications for optimizing performance on mental rotation and emotion recognition in everyday life.

An ironic effect of monitoring closeness.

Most theories of goal pursuit underscore the beneficial consequences of monitoring progress towards goals. However, effects of affect labelling and dissociations between experience and meta-consciousness suggest that monitoring may not always facilitate goal pursuit. We predicted that in the case of pursuing interpersonal closeness, intense monitoring of progress would have a detrimental effect. We tested this hypothesis with the intimate conversation procedure, adapted from Aron, Melinat, Aron, Vallone, and Bator (1997). Participants in the closeness-monitoring condition asked themselves every five minutes in the course of a 45-minute interaction with a partner whether they felt any closer to their partner, whereas participants in the control condition monitored the room temperature. As predicted, intense monitoring interfered with achieving a feeling of closeness, as measured by sitting distance between pair members following the intimate conversation procedure. We discuss the possibility that monitoring would also be detrimental for achieving other goals that are internal states.

Here it comes: defined contribution health care.

The Patient Protection and Affordable Care Act includes provisions to make the individual health insurance marketplace one where all Americans, including those with preexisting health conditions, can obtain affordable coverage. At the same time, the act has failed to address, in any significant way, many of the underlying flaws in the current U.S. health care system that have caused costs to spiral out of control. The combination of persistent U.S. health care cost increases and a viable individual health insurance marketplace will cause a sea change in employer-sponsored health care offerings that is similar to that seen among employer-sponsored retirement benefit plans: movement away from defined benefit approaches and toward defined contribution designs. Although the authors show parallels between the evolution of employers' health care and retirement offerings, they explain why certain key developments will need to occur before defined contribution approaches become as prevalent in employer-sponsored health care plans as they are in today's employer-sponsored retirement plans.

The craving to smoke in flight attendants: relations with smoking deprivation, anticipation of smoking, and actual smoking.

In the study, the authors examined the effects of smoking deprivation, anticipation of smoking, and actual smoking on the craving to smoke. Flight attendants who were light to heavy smokers rated their craving to smoke at predetermined time points during a 2-way short flight (each leg 3-5.5 hr) and a 1-way long flight (8-13 hr). In both short and long flights, craving increased gradually and peaked as landing approached. Craving levels at the end of the 1st leg of the short flights were equal to those at the end of the long flight and were much higher than those at the parallel time point in the long flight. In the short flight, craving levels at the beginning of the 2nd leg dropped relative to the end of the 1st leg, both for participants who smoked during the intermission and for those who did not, though the drop was steeper for the former. The results provide additional evidence for the role of psychological factors in determining the craving to smoke in a naturalistic setting.

Preparing for novel versus familiar events: shifts in global and local processing.

Six experiments examined whether novelty versus familiarity influences global versus local processing styles. Novelty and familiarity were manipulated by either framing a task as new versus familiar or by asking participants to reflect upon novel versus familiar events prior to the task (i.e., procedural priming). In Experiments 1-3, global perception was enhanced after novelty priming or framing, whereas familiarity priming facilitated local perception relative to a control group. In Experiment 4, participants used more inclusive categories under novelty priming and narrower categories under familiarity priming. In Experiments 5-6, participants construed actions and products more abstractly when these were framed as novel as compared to familiar. These results support the construal level theory (N. Liberman & Y. Trope, 2008; Y. Trope & N. Liberman, 2003) contention that having less direct experience is associated with using higher construal levels. Implications of the findings for research on mood, processing styles, stereotypes, and consumer research are discussed.

Authoritarianism, perceived threat and exclusionism on the eve of the Disengagement: Evidence from Gaza.

Major political events such as terrorist attacks and forced relocation of citizens may have an immediate effect on attitudes towards ethnic minorities associated with these events. The psychological process that leads to political exclusionism of minority groups was examined using a field study among Israeli settlers in Gaza days prior to the Disengagement Plan adopted by the Israeli government on June 6, 2004 and enacted in August 2005. Lending credence to integrated threat theory and to theory on authoritarianism, our analyses show that the positive effect of religiosity on political exclusionism results from the two-staged mediation of authoritarianism and perceived threat. We conclude that religiosity fosters authoritarianism, which in turn tends to move people towards exclusionism both directly and through the mediation of perceived threat.

The psychological impact of impending forced settler disengagement in Gaza: trauma and posttraumatic growth.

The Israeli government's decision to remove settlers in the Gaza Strip forcibly produced a situation of traumatic stress, resulting from confrontation and conflict for settlers. The authors examined the effects of the Gaza disengagement, that occurred following prolonged terrorist exposure, on rates of probable major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) diagnosis in a representative sample of Gaza settlers (N = 190). Predictors of probable MDD in multivariate models were being female, and experiencing greater economic and psychosocial resource loss. Predictors of probable PTSD were being older and experiencing greater psychosocial resource loss. Posttraumatic growth was significantly related to a reduction in the odds of having probable PTSD. This latter finding is interpreted within our conceptualization of action-focused growth.