%0 Journal Article %J Journal of General Internal Medicine %D 2021 %T Patterns of Material Hardship and Food Insecurity Among Older Adults During the COVID-19 Pandemic. %A Claire K. Ankuda %A Fogel, Joyce %A Amy Kelley %A Byhoff, Elena %K COVID-19 %K Food insecurity %K material hardship %K race %X The coronavirus (COVID-19) pandemic has major economic consequences across the USA.1 Along with heightened risk for severe COVID-19,2 older adults have less digital access which may be a barrier to mobilizing supports including grocery delivery.3,4 While people with lower incomes and from racial and ethnic minoritized groups have faced high levels of material hardship due to COVID-19,1 little is known about the experience of older adults. We aim to assess the prevalence and risk factors for material hardship and food insecurity among older adults in the USA. %B Journal of General Internal Medicine %V 36 %P 3639-3641 %G eng %N 11 %R 10.1007/s11606-021-06905-3 %0 Journal Article %J Annals of Internal Medicine %D 2017 %T The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study. %A Tamara B Harris %A Byhoff, Elena %A Chithra R Perumalswami %A Kenneth M. Langa %A Alexi A Wright %A Jennifer J Griggs %K Hospice %K Medicare/Medicaid/Health Insurance %K Obesity %K Older Adults %X

Background: Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown.

Objective: To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life.

Design: Retrospective cohort.

Setting: The HRS (Health and Retirement Study).

Participants: 5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012.

Measurements: Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. BMI was modeled as a continuous variable with a quadratic functional form.

Results: For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3% (95% CI, 36.5% to 40.2%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3% (CI, 59.4% to 63.2%), and total Medicare expenditures were $42 803 (CI, $41 085 to $44 521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, -9.3 to -4.0 percentage points), hospice duration decreased by 3.8 days (CI, -4.4 to -3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, -6.0 to -0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI ≥40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, -19.6 to -10.9 percentage points), hospice duration decreased by 4.3 days (CI, -5.7 to -2.9 days), and in-home death decreased by 6.3 percentage points (CI, -11.2 to -1.5 percentage points) versus decedents with BMI of 20 kg/m2.

Limitation: Baseline data were self-reported, and the interval between reported BMI and time of death varied.

Conclusion: Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life.

Primary Funding Source: Robert Wood Johnson Foundation Clinical Scholars Program.

%B Annals of Internal Medicine %8 2017 Feb 07 %G eng %R 10.7326/M16-0749 %0 Journal Article %J JAMA Internal Medicine %D 2016 %T Characteristics of Decedents in Medicare Advantage and Traditional Medicare %A Byhoff, Elena %A Tamara B Harris %A John Z. Ayanian %K Health Conditions and Status %K Medicare/Medicaid/Health Insurance %K Older Adults %X Approximately 25% of all Medicare expenditures are for care received in the last year of life.1 Much research has been done to understand cost and utilization patterns for Medicare beneficiaries at the end of life (EOL).2 However, when assessing EOL costs, most studies focus on decedents with traditional fee-for-service (FFS) Medicare owing to the lack of cost and utilization data for the 30% of Medicare beneficiaries in Medicare Advantage (MA) plans.3 This gap is a cause for concern because utilization and quality of care may differ between MA and FFS beneficiaries.4- 6 We sought to examine differences in characteristics of decedents in MA and FFS Medicare based on detailed survey data. Methods The Health and Retirement Study (HRS) is a biennial longitudinal survey of a nationally representative cohort of US adults 51 years or older that measures a broad range of questions about health and aging. Between interview cycles, the HRS identifies participants who have died using information from family members and the National Death Index. We included decedents 65 years or older who died between the 1998 and 2012 survey waves and who authorized their HRS responses to be linked to Medicare data. We compared demographic, health, and functional and cognitive characteristics of all HRS decedents enrolled in Medicare FFS and MA plans using χ2 and t test. We performed multivariable ordinal regressions to determine if demographic differences between the Medicare groups explained differences in health, functional, and cognitive status. We used multiple imputation for missing data. The study was exempt from institutional review board approval because the data looked only at decedents. There were no significant differences in results of multivariable analyses using imputed or nonimputed variables (Table 1). Results Of the 9385 decedents included in our analysis, 2280 (24.3%) were continuously enrolled in MA plans for the last 6 months of life and 7105 (75.7%) were continuously enrolled in Medicare FFS. The FFS beneficiaries were significantly older than MA beneficiaries at the time of death, and the 2 groups differed with respect to marital status, race, net worth, and educational attainment (Table 1). The MA decedents were less likely to have supplemental insurance compared with FFS decedents, including Medicaid or private insurance. The MA decedents were more likely to be living in urban areas and in the Northeast or West, whereas FFS decedents resided commonly in the Midwest and South. The MA and FFS decedents did not differ in having an advance directive or having discussed their EOL treatment preferences with their health care proxy. At their last survey before death, FFS beneficiaries were more likely than MA beneficiaries to rate their health as “poor,” to have limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL), and to have dementia. After adjusting for demographic differences between FFS and MA decedents in our sample, differences between FFS and MA decedents in self-rated health, functional limitations, and cognitive status remained significant (Table 2). Discussion The FFS beneficiaries were sicker than MA beneficiaries during the last year of life, with worse functional status, higher rates of dementia, and poorer self-rated health. These are important considerations because policymakers and researchers consider patient-specific factors related to high EOL costs in the Medicare population. Because MA beneficiaries are, on average, younger and more independent at the EOL, their health care utilization and costs may differ from those enrolled in FFS. Prior research6 shows that MA beneficiaries have lower inpatient and Emergency Department utilization at the EOL, and increased hospice enrollment compared with FFS beneficiaries. This pattern may arise from improved EOL management by MA plans but could also reflect a less chronically impaired population, with fewer acute care needs at the EOL owing to better social support and functional and cognitive status. %B JAMA Internal Medicine %V 176 %P 1020 %8 Jan-07-2016 %G eng %U http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.2266 %N 7 %! JAMA Intern Med %R 10.1001/jamainternmed.2016.2266 %0 Journal Article %J Journal of the American Geriatrics Society %D 2016 %T Racial and Ethnic Differences in End-of-Life Medicare Expenditures. %A Byhoff, Elena %A Tamara B Harris %A Kenneth M. Langa %A Theodore J Iwashyna %K African Continental Ancestry Group %K Aged %K Aged, 80 and over %K Cohort Studies %K Comorbidity %K Cross-Cultural Comparison %K Ethnic Groups %K European Continental Ancestry Group %K Female %K Health Care Surveys %K Health Expenditures %K Hispanic Americans %K Humans %K Life Support Care %K Longitudinal Studies %K Male %K Medicare %K Rate Setting and Review %K Social Support %K Socioeconomic factors %K Terminal Care %K United States %X

OBJECTIVES: To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life.

DESIGN: Retrospective cohort study.

SETTING: Health and Retirement Study (HRS).

PARTICIPANTS: Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105).

MEASUREMENTS: Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected.

RESULTS: The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models.

CONCLUSION: Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.

%B Journal of the American Geriatrics Society %V 64 %P 1789-1797 %G eng %N 9 %R 10.1111/jgs.14263