OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Transportation barriers are often cited as barriers to healthcare access. Transportation barriers lead to rescheduled or missed appointments, delayed care, and missed or delayed medication use. These consequences may lead to poorer management of chronic illness and thus poorer health outcomes. However, the significance of these barriers is uncertain based on existing literature due to wide variability in both study populations and transportation barrier measures. The authors sought to synthesize the literature on the prevalence of transportation barriers to health care access. A systematic literature search of peer-reviewed studies on transportation barriers to healthcare access was performed. Inclusion criteria were as follows: (1) study addressed access barriers for ongoing primary care or chronic disease care; (2) study included assessment of transportation barriers; and (3) study was completed in the United States. In total, 61 studies were reviewed. Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured. Additional research needs to (1) clarify which aspects of transportation limit health care access (2) measure the impact of transportation barriers on clinically meaningful outcomes and (3) measure the impact of transportation barrier interventions and transportation policy changes.

/pdf/traveling-towards-disease-transportation-barriers-to-health-2jfktgxy3s.pdf

Traveling Towards Disease: Transportation Barriers to Health Care Access

Objectives
To estimate medical expenditures attributable to older adult falls using a methodology that can be updated annually to track these expenditures over time.

Design
Population data from the National Vital Statistics System (NVSS) and cost estimates from the Web-based Injury Statistics Query and Reporting System (WISQARS) for fatal falls, quasi-experimental regression analysis of data from the Medicare Current Beneficiaries Survey (MCBS) for nonfatal falls.

Setting
U.S. population aged 65 and older during 2015.

Participants
Fatal falls from the 2015 NVSS (N=28,486); respondents to the 2011 MCBS (N=3,460).

Measurements
Total spending attributable to older adult falls in the United States in 2015, in dollars.

Results
In 2015, the estimated medical costs attributable to fatal and nonfatal falls was approximately $50.0 billion. For nonfatal falls, Medicare paid approximately $28.9 billion, Medicaid $8.7 billion, and private and other payers $12.0 billion. Overall medical spending for fatal falls was estimated to be $754 million.

Conclusion
Older adult falls result in substantial medical costs. Measuring medical costs attributable to falls will provide vital information about the magnitude of the problem and the potential financial effect of effective prevention strategies.

/pdf/medical-costs-of-fatal-and-nonfatal-falls-in-older-adults-6j50p0s8l0.pdf

Medical Costs of Fatal and Nonfatal Falls in Older Adults.

“North Star” goals toward an ideal integrated behavioral health and ambulatory care setting Tips, resources, and real-world examples of how others are doing it What not to do, or the pitfalls to avoid when integrating behavioral health An interactive integration self-assessment checklist with immediate feedback linked to guidance Access to the Academy Community, an online forum for peer-topeer networking and sharing

Agency for Healthcare Research and Quality (AHRQ)

Exposing some important barriers to health care access in the rural USA

Context: Many rural elders experience limited access to health care. The majority of what we know about this issue has been based upon quantitative studies, yet qualitative studies might offer additional insight into individual perceptions of health care access. Purpose: To examine what barriers rural elders report when accessing needed health care, including how they cope with the high cost of prescription medication. Methods: During Spring 2001, thirteen 90-minute focus groups were conducted in 6 rural West Virginia communities. A total of 101 participants, aged 60 years and older, were asked several culminating questions about their perceptions of health care access. Findings: Five categories of barriers to health care emerged from the discussions: transportation difficulties, limited health care supply, lack of quality health care, social isolation, and financial constraints. In addition, 6 diverse coping strategies for dealing with the cost of prescription medication were discussed. They included: reducing dosage or doing without, limiting other expenses, relying on family assistance, supplementing with alternative medicine, shopping around for cheapest prices, and using the Veteran's Administration. Conclusions: Overall, rural older adults encounter various barriers to accessing needed health care. Qualitative methodology allows rural elders to have a voice to expound on their experiences. Research can contribute valuable information to shape policy by providing a forum where older adults can express their concerns about the current health care delivery system.

Perceived Barriers to Health Care Access Among Rural Older Adults: A Qualitative Study

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.

Emerging services for community-based long-term care in urban China: a systematic analysis of Shanghai's community-based agencies.

Purpose: This study examined the contribution of facility-level and area market-level attributes to variations in hospitalization rates among nursing home residents. Design and Methods: Three years (1991–1994) of state quarterly Medicaid case-mix reimbursement data from 527 nursing homes (NH) in Massachusetts were linked with Medicare Provider Analysis and Review hospital claims and nursing facility attribute data to produce a longitudinal, analytical file containing 72,319 person-quarter observations. Logistic regression models were used to estimate the influence of facility-level and market-level factors on hospital use, after controlling for individuallevel resident attributes, including: NH diagnoses, resident-level quality of care indicators, and diagnostic cost grouping classification from previous hospital stays. Results: Multivariate findings suggest that resident heterogeneity alone does not account for the wide variations in hospitalization rates across nursing homes. Instead, facility characteristics such as profit status, nurse staffing patterns, NH size, chain affiliation, and percentage of Medicaid and Medicare reimbursed days significantly influence NH residents’ risk of hospitalization. Broader area market factors also appear to contribute to variations in hospitalization rates. Implications: Variations in hospitalization rates may reflect underutilization, as well as overutilization. Continued efforts toward identifying medically necessary hospitalizations are needed.

Variations in Hospitalization Rates Among Nursing Home Residents: The Role of Facility and Market Attributes

This study explores whether nursing home residents with Alzheimer's disease and related dementias (ADRD) are affected differently by facility-level risk factors of ambulatory care-sensitive (ACS) c...

https://journals.sagepub.com/doi/pdf/10.1177/153331750502000605

Vulnerable populations at risk of potentially avoidable hospitalizations: the case of nursing home residents with Alzheimer's disease.

This study examined patient-level, facility-level, and area market-level factors affecting ambulatory care-sensitive hospitalization (ACSH) rates among nursing home residents. Although ACSH has long been used to monitor accessibility to health care services among community-dwelling populations, the use of ACSH rates as an indicator of potential quality-of-care problems affecting nursing home residents has not been employed. METHODS. Three years of quarterly Medicaid reimbursement data from more than 500 nursing homes were linked to 4 years of Medicare Provider Analysis and Review hospital claims data, nursing facility attribute data, and Area Resource File data to investigate the relative contribution of patient-, facility-, and market-level risk factors to ACSH among nursing home residents. RESULTS. Logistic regression results indicate that facility-level factors and nursing home quality-of-care indicators significantly contribute to the risk of ACSH. DISCUSSION. Findings underscore the need for continuing efforts to improve quality-of-care practices in nursing homes, particularly with respect to associations between quality-of-care indicators and facility structural/organizational characteristics with ACSHs.

Mary W. Carter

Papers

Perceived Barriers to Health Care Access Among Rural Older Adults: A Qualitative Study

Emerging services for community-based long-term care in urban China: a systematic analysis of Shanghai's community-based agencies.

Variations in Hospitalization Rates Among Nursing Home Residents: The Role of Facility and Market Attributes

Vulnerable populations at risk of potentially avoidable hospitalizations: the case of nursing home residents with Alzheimer's disease.

Factors associated with ambulatory care--sensitive hospitalizations among nursing home residents.