The relationship between Medicaid policy and realized access to home- and community-based services

Medicaid funding for home- and community-based services (HCBS) has increased substantially in recent decades. Prior research has investigated the effects of this expansion on outcomes for individuals as well as costs to Medicaid, often using state policy as a proxy for access to HCBS or implicitly assuming that more generous policies affect outcomes through access, an assumption that may not hold. In this study, using survey data linked to Medicaid claims, we assess the extent to which common measures of state Medicaid HCBS generosity correspond to increased individual use of HCBS among older adults with potential needs. We find several measures to have strong predictive power, but only with relatively large changes in policy generosity. Our findings imply that increased funding of HCBS is not sufficient to ensure access to services and that researchers should be careful when using state policy generosity as a proxy for access

Expression of HIF1α, BNIP3, and beclin-1 in the brain of newborn and adult yaks (Bos grunniens)

Introduction. As a main consumer of energy, the brain is particularly susceptible to the effects of hypoxia. However, during long-term evolution, the brain of the plateau yak developed adaptive mechanisms enabling it to maintain normal physiological conditions. Material and methods. A total of 20 male yaks belonging to two age groups [newborns (1–6 days old; n = 10) and adults (3–5 years old; n = 10)] were obtained, and the brain tissue was fixed and processed by standard methods. RT-qPCR, ELISA and IHC assays were used to investigate the expression and localization of HIF1α, BNIP3 and beclin-1 in the hippocampus, cerebral cortex, thalamus, medulla oblongata and cerebellum of newborn and adult yak brains and to explore their potential neuroprotective role. Results. We found that the expression levels of HIF1α, BNIP3 and beclin-1 at the mRNA and protein levels varied in the different regions of yak brain, with the highest expression observed in the hippocampus, followed by the cerebral cortex, thalamus, medulla oblongata and the cerebellum. Moreover, the HIF1α, BNIP3 and beclin-1 expression were significantly higher in the newborn yaks’ brains than in the adult yak. The IHC results showed that HIF1α, BNIP3 and beclin-1 were mainly distributed in the neurons of the cerebral cortex, hippocampus, thalamus, medulla oblongata and cerebellum. In particular, HIF1α accumulated in the nucleus and cytoplasm. Furthermore, the immunoreactivity of BNIP3 and beclin-1 was concentrated in the cytoplasm. Conclusions. The results indicate that the yak hippocampus and cerebral cortex may be more resistant to hypoxia than thalamus, medulla oblongata and cerebellum, and the expression of BNIP3 and beclin-1 may be regulated by HIF1α to serve a neuroprotective role in the yak’s brain to adaptation to hypoxia. Additionally, the brain of adult yaks may have a higher tolerance to hypoxia than the brain of newborn yaks

Home- and community-based care in the new generation of Medicaid administrative data

This study aimed to assess the quality of Home and Community-Based Services (HCBS) data elements within the Transformed Medicaid Statistical Information System Analytical File (TAF) and to devise strategies for improving its research usability. Analyzing Medicaid TAF data from 2016 to 2018, we conducted a retrospective data quality analysis, focusing specifically on HCBS-related data elements. Through secondary data analysis, we identified significant challenges, including considerable missingness and inconsistencies that hamper the effective use of TAF for research purposes. Despite these issues, we developed three approaches that enabled us to identify 94% of known 1915(c) waiver claims as HCBS. Our study also revealed considerable cross-state variations in data quality, prompting specific recommendations for utilizing HCBS data within TAF. Ultimately, the study concludes that while challenges exist, applying our recommended strategies can yield data of acceptable quality for most states, particularly in identifying HCBS usage and classifying them into service categories. Given the growing importance of home-based care, there is a pressing need to prioritize improvements in TAF’s HCBS data quality to better inform policy and practice

Rural-urban differences in health outcomes, healthcare use, and expenditures among older adults under universal health insurance in China.

Rural-urban inequalities in health status and access to care are a significant issue in China, especially among older adults. However, the rural-urban differences in health outcomes, healthcare use, and expenditures among insured elders following China's comprehensive healthcare reforms in 2009 remain unclear. Using the Chinese Longitudinal Healthy Longevity Surveys data containing a sample of 2,624 urban and 6,297 rural residents aged 65 and older, we performed multivariable regression analyses to determine rural-urban differences in physical and psychological functions, self-reported access to care, and healthcare expenditures, after adjusting for individual socio-demographic characteristics and health conditions. Nonparametric tests were used to evaluate the changes in rural-urban differences between 2011 and 2014. Compared to rural residents, urban residents were more dependent on activities of daily living (ADLs) and instrumental ADLs. Urban residents reported better adequate access to care, higher adjusted total expenditures for inpatient, outpatient, and total care, and higher adjusted out-of-pocket spending for outpatient and total care. However, rural residents had higher adjusted self-payment ratios for total care. Rural-urban differences in health outcomes, adequate access to care, and self-payment ratio significantly narrowed, but rural-urban differences in healthcare expenditures significantly increased from 2011 to 2014. Our findings revealed that although health and healthcare access improved for both rural and urban older adults in China between 2011 and 2014, rural-urban differences showed mixed trends. These findings provide empirical support for China's implementation of integrated rural and urban public health insurance systems, and further suggest that inequalities in healthcare resource distribution and economic development between rural and urban areas should be addressed to further reduce the rural-urban differences

Hospital Readmissions Among Post-acute Nursing Home Residents: Does Obesity Matter?

ObjectivesTo explore profiles of obese residents who receive post-acute care in nursing homes (NHs) and to assess the relationship between obesity and hospital readmissions and how it is modified by individual comorbidities, age, and type of index hospitalizations.DesignRetrospective cohort study.Setting and participantsMedicare fee-for-service beneficiaries who were newly admitted to free-standing US NHs after an acute inpatient episode between 2011 and 2014 (N = 2,323,019).MeasuresThe Minimum Data Set 3.0 were linked with Medicare data. The outcome variable was 30-day hospital readmission from an NH. Residents were categorized into 3 groups based on their body mass index (BMI): nonobese, mildly obese, moderate-to-severely obese. We tested the relationship between obesity and 30-day readmissions by fixed-effects logit models and stratified analyses by the type of index hospitalization and residents' age.ResultsForty percent of the identified residents were admitted after a surgical episode, and the rest were admitted after a medical episode. The overall relationship between obesity and readmissions suggested that obesity was associated with higher risks of readmission among the oldest old (≥85 years) residents but with lower risks of readmission among the youngest group (65-74 years). After accounting for individual co-covariates, the association between obesity and readmissions among the oldest old residents became weaker; the adjusted odds ratio was 1.061 (P = .049) and 1.004 (P = .829) for moderate-to-severely obese patients with surgical and medical index hospitalizations, respectively. The protective effect of obesity among younger residents reduced after adjusting for covariates.Conclusions/relevanceThe relationship between obesity and hospital readmission among post-acute residents could be affected by comorbidities, age, and the type of index hospitalization. Further studies are also warranted to understand how to effectively measure NH quality outcomes, including hospital readmissions, so that policies targeting at quality improvement can successfully achieve their goals without unintended consequences

Obesity among Nursing Home Residents: Association with Potentially Avoidable Hospitalizations

Background/objectivesStudies show that in nursing homes (NHs), the prevalence of moderate-to-severe obesity has doubled in the last decade and continues to increase. Obese residents are often complex and costly, and this increase in prevalence has come at a time when NHs struggle to decrease hospitalizations, particularly those that are potentially avoidable. This study examined the association between obesity and hospitalizations.DesignWe linked 2011-2014 national data using Medicare NH assessments, hospital claims, and the NH Compare.Setting and participantsIndividuals aged ≥65 years, newly admitted to NHs, who became long-term residents between July 1, 2011 and March 26, 2014. The analytical sample included 490,086 residents.MethodsNH-originating hospitalization was the outcome; a categorical variable defined as no hospitalization, potentially avoidable hospitalization (PAH), and other hospitalization (non-PAH). The main independent variable was body mass index (BMI) defined as normal weight (30 >BMI ≥18.5 kg/m2), mildly obese (35 >BMI ≥30 kg/m2), or moderately-to-severely obese (BMI ≥35 kg/m2). Covariates included individual and NH characteristics. Multinomial models with NH random effects and state dummies were estimated.ResultsAfter adjusting for individual level covariates, the risk of non-PAH for the mildly and moderate/severely obese was not different from normal weight residents. But the risk of PAH remained significantly higher for the moderate/severely obese (relative risk ratio = 1.055; 95% confidence interval 1.018, 1.094). Several NH-level factors also influenced hospitalization risk.Conclusions and implicationsObese residents are more likely to experience PAH but not non-PAH. Efforts to improve care for these residents may need to broadly consider the ability of NHs to commit additional resources to fully integrate care for this growing segment of the population

The role of Medicaid home- and community-based services in use of Medicare post-acute care

Objective: Medicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled. Data sources: National Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018. Study design: We estimated the relationship between prior Medicaid HCBS use and PAC (skilled nursing facilities [SNF] or home health) utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups. Data extraction methods: The primary sample included 887,598 hospital discharges from community-dwelling duals who had an eligible index hospitalization between April 1, 2016, and September 30, 2018. Principal findings: We found HCBS use was associated with a 9 percentage-point increase in the use of home health relative to SNF, conditional on using PAC, and a meaningful reduction in length of stay for those using SNF. In addition, in our primary sample, we found HCBS use to be associated with an overall increase in PAC use, given that the absolute increase in home health use was larger than the absolute decrease in SNF use. In other words, the use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings. Conclusion: Our findings indicate potential synergies between Medicaid-funded HCBS and increased use of home-based PAC, suggesting policymakers should cautiously consider these dynamics in HCBS expansion efforts.</p

Immunohistochemical analysis of the thymus in newborn and adult yaks (Bos grunniens)

Introduction. The thymus is the site of development and maturation of functional T lymphocytes and is critically important to the immune system. The purpose of this study was to examine the expression of markers of T lymphocytes, macrophages, dendritic cells, B lymphocytes and plasmocytes in the yak thymus. Materials and methods. Twenty healthy male yaks were divided into newborn (2–4 weeks old, n = 10) and adult (3–4 years old, n = 10) group. qRT-PCR was used to evaluate the mRNA expression level of the main markers of the studied cell types. Immunohistochemistry was used to detect the distribution of CD3+ T lymphocytes, CD68+ macrophages, SIRPα+ dendritic cells, CD79α+ B lymphocytes, IgA and IgG+ plasmocytes. Results. Within the same age group, the mRNA expression of CD3ε was highest (P &lt; 0.05), followed by that of CD68, SIRPα, CD79α, IgG and IgA. Furthermore, CD3ε, CD68, and SIRPα mRNA expression levels were higher in newborn yaks than in the adult ones (P &lt; 0.05), whereas those of CD79α, IgA, and IgG were higher in adults (P &lt; 0.05). Immunohistochemical results showed localization of CD3+ T lymphocytes in the thymic cortex and medulla. CD68+ macrophages, SIRPα+ dendritic cells, CD79α+ B lymphocytes, IgA+ and IgG+ plasmocytes were mainly observed in the cortico-medullary region and medulla. In the same age group, the frequency of CD3+ T lymphocytes was higher than that of CD68+ macrophages and SIRPα+ dendritic cells (P &lt; 0.05), followed by those of CD79α+ B lymphocytes and IgA+ and IgG+ plasmocytes. No significant difference was observed between B lymphocyte and plasmocyte frequencies in the yak thymus in both age groups (P &gt; 0.05). The frequency of CD3+, CD68+ and SIRPα+ cells decreased from newborns to adults (P &lt; 0.05). However, the frequencies of CD79α+, IgA+ and IgG+ cells increased from newborn to adult yaks (P &lt; 0.05). Conclusions: The thymus of newborn yaks is well-developed, with higher numbers of T lymphocytes, macrophages, and dendritic cells than those in the adult thymus. However, higher frequencies of plasmocytes and B lymphocytes were detected in the adult thymus, suggesting that adults may better resist infections through humoral immunity as this organ undergoes involution. Furthermore, there was no significant difference in the number of IgA and IgG plasmocytes, which differs from what is observed in rodents and humans. This difference might be related to the fact that yaks live in low-oxygen plateaus

Expression and Localization of Fas-Associated Factor 1 in Testicular Tissues of Different Ages and Ovaries at Different Reproductive Cycle Phases of Bos grunniens

Fas-associated factor 1 (FAF1), a member of the Fas family, is involved in biological processes such as apoptosis, inflammation, cell proliferation and proteostasis. This study aimed to explore the biological role of FAF1 in testicular tissue at different ages (juveniles (1 and 2 years old), adults (3, 4, 6, and 7 years old) and old-aged animals (11 years old)) and ovaries during different reproductive cycle phases (follicular, luteal, and pregnancy phases). FAF1 mRNA, relative protein expression and protein expression localization were determined in testes and ovaries using real-time quantification, WB and immunohistochemistry (IHC), respectively. Real-time quantification of testis tissues showed that the relative expression of FAF1 mRNA in testis tissues at 3, 4 and 7 years of age was significantly higher than of those in other ages, and in ovarian tissues was significantly higher in luteal phase ovaries than those in follicular and pregnancy phase ovaries; follicular phase ovaries were the lowest. WB of testis tissues showed that the relative protein expression of FAF1 protein was significantly higher at 11 and 7 years of age; in ovarian tissue, the relative protein expression of FAF1 protein was significantly higher in follicular phase ovaries than in luteal and pregnancy phase ovaries, and lowest in luteal phase ovaries. The relative protein expression of FAF1 at 3, 4 and 7 years of age was the lowest. IHC showed that FAF1 was mainly expressed in spermatozoa, spermatocytes, spermatogonia and supporting cells; in ovarian tissue, FAF1 was expressed in ovarian germ epithelial cells, granulosa cells, cumulus cells and luteal cells. The IHC results showed that FAF1 mRNA and protein were significantly differentially expressed in testes of different ages and ovarian tissues of different reproductive cycle phases, revealing the significance of FAF1 in the regulation of male and female B. grunniens reproductive physiology. Furthermore, our results provide a basis for the further exploration of FAF1 in the reproductive physiology of B. grunniens