THE ROLE OF PUBLIC TRANSPORTATION IN ACCESS TO CARE FOR OLDER ADULTS IN THE UNITED STATES

Among older adults in the United States, transportation is the third most commonly cited barrier to care. Existing research on transportation as a barrier to accessing health services is limited to rural areas and access to private vehicles, yet transportation is as much a barrier to care for older adults living in urban areas. This research addresses three questions on the topic of aged Medicare beneficiaries’ use of public transportation and access to health services. First, whether there is a valid measure of access to public transport. Second, whether access to public transport is associated with its use to travel to a usual source of care. Finally, whether access to public transport is associated with more appropriate use of outpatient health services. We found that two existing measures of public transport accessibility, the Transport Connectivity Index (TCI) and the Transit Access Shed (TAS) are valid measures of public transport accessibility, both for Census block groups and ZIP Code tabulation areas (ZCTAs). Overall, approximately 5% of older adult Medicare beneficiaries take public transportation to get to their usual source of care. Additionally, individuals living in areas with better public transportation are more likely to take public transportation to get to their usual source of care, independent of the other barriers to care or health status. However, I did not find a relationship between access to public transportation and appropriate use of outpatient services. Beneficiaries living in areas with better public transportation were equally likely to have at least one primary care visit during the year, and were hospitalized for ambulatory care sensitive conditions at the same rate as beneficiaries living in areas with worse public transportation. Future research should work to understand how beneficiaries without private vehicles are getting to health services and to evaluate other transportation alternatives

Hospice Use, Hospitalization, and Medicare Spending at the End of Life

OBJECTIVES: Prior studies associate hospice use with reduced hospitalization and spending at the end of life based on all Medicare hospice beneficiaries. In this study, we examine the impact of different lengths of hospice care and nursing home residency on hospital use and spending prior to death across 5 disease groups. METHODS: We compared inpatient hospital days and Medicare spending during the last 6 months of life using hospice versus propensity matched non-hospice beneficiaries who died in 2010, were enrolled in fee for service Medicare throughout the last 2 years of life, and were in at least 1 of 5 disease groups. Comparisons were based on length of hospice use and whether the decedent was in a nursing home during the seventh month prior to death. We regressed a categorical measure of hospice days on outcomes, controlling for observed patient characteristics. RESULTS: Hospice use over 2 weeks was associated with decreased hospital days (1-5 days overall, with greater decreases for longer hospice use) for all beneficiaries; spending was $900-$5,000 less for hospice use of 31-90 days for most beneficiaries not in nursing homes, except beneficiaries with Alzheimer's. Overall spending decreased with hospice use for beneficiaries in nursing homes with lung cancer only, with a $3,500 reduction. DISCUSSION: The Medicare hospice benefit is associated with reduced hospital care at the end of life and reduced Medicare expenditures for most enrollees. Policies that encourage timely initiation of hospice and discourage extremely short stays could increase these successes while maintaining program goals

The Five‐Star Skilled Nursing Facility Rating System and Care of Disadvantaged Populations

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146941/1/jgs15629.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146941/2/jgs15629_am.pd

THE ROLE OF PUBLIC TRANSPORTATION IN ACCESS TO CARE FOR OLDER ADULTS IN THE UNITED STATES

Among older adults in the United States, transportation is the third most commonly cited barrier to care. Existing research on transportation as a barrier to accessing health services is limited to rural areas and access to private vehicles, yet transportation is as much a barrier to care for older adults living in urban areas. This research addresses three questions on the topic of aged Medicare beneficiaries’ use of public transportation and access to health services. First, whether there is a valid measure of access to public transport. Second, whether access to public transport is associated with its use to travel to a usual source of care. Finally, whether access to public transport is associated with more appropriate use of outpatient health services. We found that two existing measures of public transport accessibility, the Transport Connectivity Index (TCI) and the Transit Access Shed (TAS) are valid measures of public transport accessibility, both for Census block groups and ZIP Code tabulation areas (ZCTAs). Overall, approximately 5% of older adult Medicare beneficiaries take public transportation to get to their usual source of care. Additionally, individuals living in areas with better public transportation are more likely to take public transportation to get to their usual source of care, independent of the other barriers to care or health status. However, I did not find a relationship between access to public transportation and appropriate use of outpatient services. Beneficiaries living in areas with better public transportation were equally likely to have at least one primary care visit during the year, and were hospitalized for ambulatory care sensitive conditions at the same rate as beneficiaries living in areas with worse public transportation. Future research should work to understand how beneficiaries without private vehicles are getting to health services and to evaluate other transportation alternatives

Affective and deliberative processes in risky choice: Age differences in risk taking in the Columbia Card Task

The authors investigated risk taking and underlying information use in 13- to 16- and 17- to 19-year-old adolescents and in adults in 4 experiments, using a novel dynamic risk-taking task, the Columbia Card Task (CCT). The authors investigated risk taking under differential involvement of affective versus deliberative processes with 2 versions of the CCT, constituting the most direct test of a dual-system explanation of adolescent risk taking in the literature so far. The “hot” CCT was designed to trigger more affective decision making, whereas the “cold” CCT was designed to trigger more deliberative decision making. Differential involvement of affective versus deliberative processes in the 2 CCT versions was established by self-reports and assessment of electrodermal activity. Increased adolescent risk taking, coupled with simplified information use, was found in the hot but not the cold condition. Need-for-arousal predicted risk taking only in the hot condition, whereas executive functions predicted information use in the cold condition. Results are consistent with recent dual-system explanations of risk taking as the result of competition between affective processes and deliberative cognitive-control processes, with adolescents’ affective system tending to override the deliberative system in states of heightened emotional arousal

Efficacy and safety of two neutralising monoclonal antibody therapies, sotrovimab and BRII-196 plus BRII-198, for adults hospitalised with COVID-19 (TICO): a randomised controlled trial

We aimed to assess the efficacy and safety of two neutralising monoclonal antibody therapies (sotrovimab [Vir Biotechnology and GlaxoSmithKline] and BRII-196 plus BRII-198 [Brii Biosciences]) for adults admitted to hospital for COVID-19 (hereafter referred to as hospitalised) with COVID-19. In this multinational, double-blind, randomised, placebo-controlled, clinical trial (Therapeutics for Inpatients with COVID-19 [TICO]), adults (aged ≥18 years) hospitalised with COVID-19 at 43 hospitals in the USA, Denmark, Switzerland, and Poland were recruited. Patients were eligible if they had laboratory-confirmed SARS-CoV-2 infection and COVID-19 symptoms for up to 12 days. Using a web-based application, participants were randomly assigned (2:1:2:1), stratified by trial site pharmacy, to sotrovimab 500 mg, matching placebo for sotrovimab, BRII-196 1000 mg plus BRII-198 1000 mg, or matching placebo for BRII-196 plus BRII-198, in addition to standard of care. Each study product was administered as a single dose given intravenously over 60 min. The concurrent placebo groups were pooled for analyses. The primary outcome was time to sustained clinical recovery, defined as discharge from the hospital to home and remaining at home for 14 consecutive days, up to day 90 after randomisation. Interim futility analyses were based on two seven-category ordinal outcome scales on day 5 that measured pulmonary status and extrapulmonary complications of COVID-19. The safety outcome was a composite of death, serious adverse events, incident organ failure, and serious coinfection up to day 90 after randomisation. Efficacy and safety outcomes were assessed in the modified intention-to-treat population, defined as all patients randomly assigned to treatment who started the study infusion. This study is registered with ClinicalTrials.gov, NCT04501978. Between Dec 16, 2020, and March 1, 2021, 546 patients were enrolled and randomly assigned to sotrovimab (n=184), BRII-196 plus BRII-198 (n=183), or placebo (n=179), of whom 536 received part or all of their assigned study drug (sotrovimab n=182, BRII-196 plus BRII-198 n=176, or placebo n=178; median age of 60 years [IQR 50–72], 228 [43%] patients were female and 308 [57%] were male). At this point, enrolment was halted on the basis of the interim futility analysis. At day 5, neither the sotrovimab group nor the BRII-196 plus BRII-198 group had significantly higher odds of more favourable outcomes than the placebo group on either the pulmonary scale (adjusted odds ratio sotrovimab 1·07 [95% CI 0·74–1·56]; BRII-196 plus BRII-198 0·98 [95% CI 0·67–1·43]) or the pulmonary-plus complications scale (sotrovimab 1·08 [0·74–1·58]; BRII-196 plus BRII-198 1·00 [0·68–1·46]). By day 90, sustained clinical recovery was seen in 151 (85%) patients in the placebo group compared with 160 (88%) in the sotrovimab group (adjusted rate ratio 1·12 [95% CI 0·91–1·37]) and 155 (88%) in the BRII-196 plus BRII-198 group (1·08 [0·88–1·32]). The composite safety outcome up to day 90 was met by 48 (27%) patients in the placebo group, 42 (23%) in the sotrovimab group, and 45 (26%) in the BRII-196 plus BRII-198 group. 13 (7%) patients in the placebo group, 14 (8%) in the sotrovimab group, and 15 (9%) in the BRII-196 plus BRII-198 group died up to day 90. Neither sotrovimab nor BRII-196 plus BRII-198 showed efficacy for improving clinical outcomes among adults hospitalised with COVID-19. US National Institutes of Health and Operation Warp Spee