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The purpose of the study was to assess whether the effects of a mobile predictive intervention used by Service Coordinators (SCs) reduce hospital utilization in a Medicaid Long-Term Services and Supports (LTSS) population in Baltimore city during a 5-month intervention. SC participants ( n = 11) were recruited to treatment or control groups. LTSS clients ( n = 420) followed their SC randomization assignment. Utilization data were obtained from the Maryland Chesapeake Regional Information System for our Patients (CRISP) Health Information Exchange (HIE) system and linked to service coordination records. Study groups were similar in age, gender, race, and years receiving LTSS. SCs’ satisfaction with use of the mobile tool was surveyed. SC perceptions were neutral (mean scores ranged from 2.3 to 3.3 on a 5-point scale). No significant differences between groups were observed for all utilization metrics. The mobile technology software system used in this study did not improve health care utilization for a LTSS population needing ongoing clinical and social services coordinated care.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

BACKGROUND: The U.S. clinical research enterprise in nursing homes was unprepared to mount clinical trials in nursing homes to address urgent questions relevant to prevention and treatment during the COVID-19 pandemic. We identify priorities essential for establishing a supportive environment for future clinical trials in nursing homes. METHODS: Two cross-sectional online questionnaires were administered between January-February 2021. One was administered to nursing home providers, researchers, and policymakers; respondents rated the importance of attributes of researchers, facilities, leaders and staff for conducting clinical trials in nursing homes. Because importance may depend on trial type, respondents rated each attribute for efficacy trials (testing an intervention in ideal circumstances) and effectiveness trials (testing an intervention in “real world” circumstances). We calculated the attribute rating means and standard deviations, and used content analysis to characterize open-ended responses. The second questionnaire for resident family members and advocates included open-ended questions about nursing home research, and factors influencing willingness to participate. RESULTS: The attributes rated as most essential for conducting efficacy and effectiveness trials in nursing homes are research team attributes, i.e., that researchers recognize regulatory constraints; understand and adapt to nursing home workflow; and work collaboratively with nursing home leaders to identify priorities. Resident and facility diversity emerged as essential for effectiveness trials; important dimensions included resident race, ethnicity and income, as well as nursing home urban/rural location, quality ratings, geography, staffing ratios, size, and profit status. Caregivers and resident advocates stressed the importance of communication among participants, researchers, and nursing home leadership and staff at all stages of a trial. CONCLUSION: Developing a robust U.S. clinical research enterprise capable of efficiently mounting future clinical trials in nursing homes will require a reimagining of the relationships that exist between researchers, facilities, nursing home leaders, and residents, with a research infrastructure specifically focused on supporting and fostering these connections.

Purpose The purpose of the study was to explore the influences of the neighborhood environment on physical activity (PA) among people living with type 2 diabetes mellitus (T2DM) in a community with limited resources. Methods Participants were adults with T2DM and their family members or friends who help in the management of T2DM and who were living in a low-income African American (AA) community. Health care providers working in the neighborhood were also included. Using an emergent design, qualitative data were collected through 7 focus group discussions (N = 63) and 13 in-depth interviews. Verbatim transcriptions were analyzed via thematic coding to explore contextual factors that limit PA and meaning around neighborhood features that promote or discourage PA. Results Levels of PA were strongly limited by neighborhood insecurity and a lack of recreational facilities in the neighborhood. People with T2DM and physical/mobility disabilities were more affected by the neighborhood environment than those without disabilities, particularly due to perceived safety concerns and social stigma. Despite socioeconomic inequalities within neighborhoods, participants showed resilience and made efforts to overcome social-environmental barriers to PA, applied various coping strategies, and received social support. Conclusions Results suggested that in an underserved neighborhood, individual barriers to physical activity were amplified by neighborhood-level factors such as crime, especially among individuals who have T2DM and disabilities. Socioeconomic inequalities should be addressed further to improve management of T2DM and its complications.

Telemedicine has shown promise in inflammatory bowel disease (IBD). The objective of this study was to compare disease activity and quality of life (QoL) in a 1 year randomized trial of IBD patients receiving telemedicine versus standard care. Patients with worsening symptoms in the prior 2 years were eligible for randomization to telemedicine (monitoring via texts EOW or weekly) or standard care. The primary outcomes were the differences in change in disease activity and QoL between the groups; change in health care utilization among groups was a secondary aim. 348 participants were enrolled (117 control group, 115 TELE-IBD EOW, and 116 TELE-IBD weekly). 259 (74.4%) completed the study. Age was 38.9 ± 12.3 years, 56.6% were women, 91.9% were Caucasian, 67.9% had Crohn’s disease (CD) and 42.5% had active disease at baseline. In CD, all groups experienced a decrease in disease activity (control −5.2 ± 5.0 to 3.7 ± 3.6, TELE-IBD EOW 4.7 ± 4.1 to 4.2 ± 3.9, and TELE-IBD weekly 4.2 ± 4.2 to 3.2 ± 3.4, p

Digital health is capturing the attention of the healthcare community. This paradigm whereby healthcare meets the internet uses sensors that communicate wirelessly along with software residing on smartphones to deliver data, information, treatment recommendations, and in some cases control over an effector device. As artificial intelligence becomes more widely used, this approach to creating individualized treatment plans will increase the opportunities for patients, even if they are in remote settings, to communicate with and learn from healthcare professionals. Simple design is needed to promote use of these tools, especially for the purpose of increased adherence to treatment. Widespread adoption by the healthcare industry will require better outcomes data, which will most likely be in the form of safety and effectiveness results from robust randomized controlled trials, as well as evidence of privacy and security. Such data will be needed to convince investors to direct resources into and regulators to clear new digital health tools. Diabetes Technology Society and Sansum Diabetes Research Institute launched the Digital Diabetes Congress in 2017 because of great interest in determining the potential benefits, metrics of success, and appropriate components of mobile applications for diabetes. The second annual meeting in this series took place on May 22-23, 2018 in San Francisco. This report contains summaries of the meeting’s 4 plenary lectures and 10 sessions. This meeting report presents a summary of how 55 panelists, speakers, and moderators, who are leaders in healthcare technology, see the current and future landscape of digital health tools applied to diabetes.

Background Depression is common in patients with inflammatory bowel disease (IBD) and is known to be associated with poor adherence in the usual care setting. In the last decade, there has been an increase in the use of information technology (IT) for the delivery of IBD care, but the association between depressive symptoms (DS) and adherence to self-testing in this context is not known. We aimed to investigate this association among IBD patients managed via a text messaging-based telemedicine system. Methods This was a prospective study of participants in the 2 intervention arms of the Telemedicine for Patients with IBD (TELE-IBD) trial. Depressive symptoms were measured at baseline, and then participants received periodic text messages to initiate IBD-specific self-testing. Treatment plans were similarly conveyed, and adherence to self-testing was evaluated at the end of 1 year. Regression analyses were performed, and age-stratified models were constructed to evaluate for effect modification. Results Of the 193 study participants, 48% had DS at baseline. Overall, there was no significant association between DS and adherence to self-testing. However, upon stratification by age, adherence increased with depressive symptoms in those that were 40 years and younger (P = 0.02), but there was no association between depressive symptoms and adherence in the older group (P = 0.53). Conclusions Younger IBD patients with DS have high adherence when managed in a text messaging-based telemedicine program. Telemedicine interventions have the potential to improve health outcomes in this demographic-a group that is often thought to be difficult to manage due to nonadherence.

Background Effective treatments are available for patients with inflammatory bowel disease (IBD); however, suboptimal outcomes occur and are often linked to patients’ limited disease knowledge. The aim of this analysis was to determine if delivery of educational messages through a telemedicine system improves IBD knowledge. Methods TELEmedicine for Patients with IBD (TELE-IBD) was a randomized controlled trial with visits at baseline, 6 months, and 12 months; patient knowledge was a secondary aim of the study. Patients were randomized to receive TELE-IBD every other week (EOW), weekly (TELE-IBD W), or standard of care. Knowledge was assessed at each visit with the Crohn’s and Colitis Knowledge (CCKNOW) survey. The primary outcome was change in CCKNOW score over 1 year compared between the TELE-IBD and control groups. Results This analysis included 219 participants. Participants in the TELE-IBD arms had a greater improvement in CCKNOW score compared with standard care (TELE-IBD EOW +2.4 vs standard care +1.8, P = 0.03; TELE-IBD W +2.0 vs standard care +1.8, P = 0.35). Participants with lower baseline CCKNOW scores had a greater change in their score over time (P < 0.01). However, after adjusting for race, site, and baseline knowledge, there was no difference in CCKNOW score change between the control and telemedicine arms. Conclusions Telemedicine improves IBD-specific knowledge through text messaging, although the improvement is not additive with greater frequency of text messages. However, after adjustment for confounding variables, telemedicine is not superior to education given through standard visits at referral centers. Further research is needed to determine if revised systems with different modes of delivery and/or frequency of messages improve disease knowledge.

To improve understanding of survival among very elderly male patients with surgically repaired hip fractures, this study applied classification techniques to multiple chronic conditions (MCC) then modeled survival by latent class. Veterans Health Administration (VHA)’s electronic medical records on male inpatients age 85–100 years (n=896) with hip fracture diagnosis and repair were used. MCC defined by Charlson and Elixhauser disorders, medications, demographic covariates, and 5 years follow-up survival were included. Latent Class Analysis (LCA) identified three classes based on patterns of MCC, medications, and demographic covariates: Low-comorbidity (16%), High-longevity (55%), and High-comorbidity (29%). Overall, survival censored at 5 years postop averaged 717 days. The Low-comorbidity group was more likely to be Hispanic, less disabled per VHA determination of eligibility for care, with less risk of postoperative emergency department (ED) visit, and taking no prescription medications. The High-longevity group had longer survival. The High-comorbidity group had more MCC, more prescription medications and shorter survival than the other two groups. Accelerated failure time (AFT) modeled associations between MCC and 5-year survival by class. In AFT models, fewer days until first postoperative ED visit was significantly associated with survival across the three classes. About one in male hip fractured veteran patients over the age of 85 had high levels of MCC and ED use and experienced shorter survival. Hip fracture patients with MCC may merit enhanced post-discharge management. Close investigation targeted to MCC and hip fractures is needed to optimize clinical practices for oldest-old patients in community healthcare systems as well as VHA.

Participatory design (PD) is an emerging alternative to existing methods of user-centered design (UCD), and may be a more appropriate approach for designing patient-facing products in the health care sector than conventional UCD. Type 2 Diabetes Mellitus (T2D) is a serious chronic illness that requires life-long treatment and life-long self-management of food intake, physical activity, and self-testing to avoid complications. T2D disproportionately affects low-income minority communities. Using PD, we have developed an app to help T2D patients. Called the Diabetes Networking Tool (DNT), the app is intended to help patients better self-manage by empowering their network of family and friends to better contribute and support the patient’s self-management needs. PD was used to involve a low-income African American community into the process of identifying the specific problems and issues DNT needed to address. We then used multiple complementary analytical methods to condense and abstract the community inputs to yield a functional and user interface design for DNT.

Background Depression is common in patients with inflammatory bowel disease (IBD) and contributes to poor quality of life (QoL). The use of information technology for the remote management of patients with IBD is growing, but little is known about its impact on depressive symptoms (DS) and QoL. We aimed to evaluate the impact of telemedicine on DS and generic QoL in IBD patients. Methods We analyzed data from the Telemedicine for Patients with IBD (TELE-IBD) study. During this 12-month clinical trial, patients were randomized to receive text message-based telemedicine weekly (TELE-IBD W), every other week (TELE-IBD EOW), or to standard care. Depressive symptoms and QoL were assessed over time with the Mental Health Inventory 5 (MHI-5) and the Short Form 12 (SF-12), respectively. We compared the change in MHI-5 and SF-12 (with separate physical (PCS) and mental component summary (MCS) scores) between the study arms. Results A total of 217 participants were included in this analysis. After 1 year, there was no significant difference in the change in MHI-5 (TELE-IBD W +3.0 vs TELE-IBD EOW +0.7 vs standard care +3.4; P = 0.70), MCS (TELE-IBD W +1.4 vs TELE-IBD EOW +1.0 vs standard care +2.5; P = 0.89), and PCS scores (TELE-IBD W +0.4 vs TELE-IBD EOW +0.6 vs standard care +3.7; P = 0.06) between the groups. Conclusions Text message-based telemedicine does not improve DS or QoL when compared with standard care in IBD patients treated at tertiary referral centers. Further studies are needed to determine whether telemedicine improves DS or QoL in settings with few resources., Lay Summary This study showed that, in patients with inflammatory bowel disease, the use of information technology to deliver care via text messaging did not improve depressive symptoms or quality of life when compared with usual healthcare.

Falls are the leading cause of older adult injury and cost $50bn annually. New digital technologies can quantitatively measure falls risk. Objective is to report on a validated wearable sensor-based Timed Up and Go (QTUG) assessment detailing 11 measures of falls risk, frailty and mobility impairment in older adults in six countries in 38 clinical and community settings. Second objective is to generate individual targeted falls prevention programs. 14,611 QTUG records from 8,521 participants (63% female) (72.7±10.7 years) available for analysis. QTUG time was 13.9±7.4 s; gait velocity was 101.9±32.5 cm/s. 25.8% of patients reported falling in previous 12 months; 26.2% of patients were at high fall risk. 21.5% not reporting a fall, were high fall risk. Participants had slow walking speed (29.8%); high gait variability (19.8%); problems with transfers (17.5%). Easily captured and interpreted sensor data is useful in a population-based approach to quantify falls risk stratification.

BACKGROUND: Our Cooling to Help Injured Lungs (CHILL) trial of therapeutic hypothermia in ARDS includes neuromuscular blockade (NMB) as an inclusion criterion to avoid shivering. NMB has been used to facilitate mechanical ventilation in ARDS and was shown to reduce mortality in the ACURASYS trial. To assess the feasibility of a multi-center CHILL trial, we conducted a survey of academic intensivists about their NMB use in patients with ARDS. METHODS: We distributed via email a 16-question survey about NMB use in patients with ARDS including frequency, indications, and dosing strategy. RESULTS: 212 (24.3%) of 871 respondents completed the survey: 94.7% were board-certified in internal medicine, 88% in pulmonary and critical care; 90.3% practiced in academic medical centers, with 87% working in medical ICUs; 96.6% of respondents who treat ARDS use NMB, and 39.7% use NMB in ≥ 50% of these patients. Of 4 listed indications for initiating NMB in ARDS, allowing adherence with lung-protective ventilator strategies and patient–ventilator synchrony were cited as the most important reasons, followed by the results of the ACURASYS trial and facilitating prone positioning. CONCLUSIONS: We conclude that NMB is frequently used by academic intensivists to facilitate mechanical ventilation in patients with moderate to severe ARDS.

Social networks have the potential to enhance Type 2 Diabetes Mellitus (T2DM) self-management. We used qualitative methods to study if and how mobile application (app) functions that mobilize social resources to improve T2DM management would be desired in a low-income African American community. Data were collected through community discussions and in-depth interviews with 78 participants in 2016&ndash, 2018. Participants included individuals with self-reported pre-diabetes, T2DM, close family members or friends of a T2DM patient, and healthcare providers. Open-ended questions solicited information about challenges with T2DM management and gathered ideas on features of a mobile app that could address them. Data were transcribed and thematically coded by two coders using Atlas-ti. Regarding types of app functions, main themes included: (1) the importance of having support in diabetes self-care, (2) using informal networks to help to each other, and (3) monitoring one another through an app. Suggested app features included reminders for and transportation to medical visits, sharing information and exercise companionship, and providing opportunities for monitoring by friends/family members, especially in case of emergencies. Participants viewed an app as a potential vehicle for reinforcing accomplishments in T2DM self-management. Future research should implement and test an app with these features in this or similar communities.

Background: Evaluation of digital health applications to support older adults’ independence and family caregiving is needed. Digital health is increasingly providing opportunities for older adults and their family caregivers to educate, engage, and share health information across digital platforms. Few apps have documented evidence of usability by older adults and their caregivers. Objective: The objective of this study was to determine the usability of a mobile app in a community-based older adult population aged ≥65 years. The app was designed to improve engagement of the patient-informal caregiver team. Methods: This observational usability study was conducted in participants’ homes and independent living facilities in Baltimore, Maryland. Community-dwelling older adults aged ≥65 years and their caregivers enrolled as a dyad (n=24, 12 dyads). The usability evaluation was a mobile and Web-based app that allowed older adult users to record social and health information and share this information with their caregivers. The older adult-caregiver dyad downloaded the app to a smart phone or accessed the Web version, participated in training and onboarding, and used the app for a 1-month period. Participants responded to weekly surveys sent by app push notifications and to the usability and satisfaction surveys at the end of the study. Participant satisfaction and usability were assessed using the Modified Mobile Application Rating Scale (M-MARS) and the System Usability Scale (SUS). Results: The final sample comprised 16 people (8 dyads). Responses to the M-MARS were comparable between older adults and caregiver respondents in terms of engagement and functionality. Caregivers rated aesthetics slightly higher (mean 3.7) than older adult participants did (mean 3.3). Although most responses to the SUS were around the mean (2.3-3.4), older adults and their caregivers differed with regard to integration of app features (mean 3.7 vs 2.8) and the need to learn more before using the app (mean 2.3 vs 3.1). Conclusions: Technology ownership and use among older adults and caregivers was high. Usability and engagement of the mobile app was average. Additional training is recommended for older adults and their caregivers, including that on targeted behaviors for digital health record keeping.

BACKGROUND Inflammatory bowel diseases (IBD), comprising Crohn’s disease and ulcerative colitis, affects 1 to 3 million people in the United States. Telemedicine has shown promise in IBD. The objective of the parent study, TELE-IBD, was to compare disease activity and quality of life (QoL) in a one-year randomized clinical trial of IBD patients receiving telemedicine versus standard care. Treatment groups experienced improvements in disease activity and QoL but there was not significant differences between groups. Study adherence to the text-based intervention was less than the 80% of the targeted goal. OBJECTIVE To understand adherence to remote monitoring, the goal of this qualitative assessment was to obtain TELE-IBD trial participants’ perceptions of the TELE-IBD system, including their recommendations for future TELE-IBD monitoring. METHODS In the parent study, patients attending three tertiary referral centers with worsening IBD symptoms in the previous two years were eligible for randomization to remote monitoring via texts every other week (EOW), weekly (W) or standard care. Participants (n=348) were evenly enrolled in the treatment groups and 259 (74.4%) completed the study. For this study, a purposive sample of adherent (N=15) and non-adherent (N=14) patients was drawn from the TELE-IBD trial population. Adherence was defined as the completion of 80% or more of the W or EOW self-assessments. Semi-structured interviews conducted by phone surveyed 1) the strengths and benefits of TELE-IBD; 2) challenges associated with using TELE-IBD; and 3) how to improve the TELE-IBD intervention. Interviews were recorded, professionally transcribed, and coded based on a priori concepts and emergent themes with the aid of ATLAS.ti qualitative data analysis software. RESULTS Participants' discussions centered on three elements of the intervention: 1) self-assessment questions, 2) action plans, and 3) educational messages. Participants also commented on: text-based platform, depression and adherence, TELE-IBD system in place of office visit, and their recommendations for future TELE-IBD systems. Adherent and non-adherent participants prefer a flexible system that is personalized, including targeted education messages, and they perceive TELE-IBD as effective in facilitating IBD self-management. CONCLUSIONS Participants identified clear benefits to the TELE-IBD system, including obtaining a better understanding of the disease process, monitoring their symptoms, and feeling connected to their health care provider. Participants' perceptions obtained in this qualitative study will assist in improving the TELE-IBD system to be more responsive to patients with IBD. CLINICALTRIAL NCT01692743

INTRODUCTION: Limitations in inflammatory bowel disease (IBD) care necessitate greater patient activation and self-efficacy, measures associated with positive health outcomes. METHODS: We assessed change in patient activation and general self-efficacy from baseline to 12 months through our TELEmedicine for IBD trial, a multicenter, randomized controlled trial consisting of a web-based monitoring system that interacts with participants via text messaging. A total of 222 adults with IBD who had experienced an IBD flare within 2 years prior to the trial were randomized into either a control arm that received standard care (SC) or an intervention arm that completed self-testing through the TELE-IBD system every other week (EOW) or weekly (W). RESULTS: Changes in self-efficacy scores were not significantly different between control and experimental groups. Patient activation scores were significantly different between standard care and the TELE-IBD EOW group only (p = 0.03). CONCLUSIONS: Use of remote monitoring did not improve self-efficacy or patient activation compared to routine care.

BackgroundType 2 diabetes (T2D) is a major chronic condition requiring management through lifestyle changes and recommended health service visits. Mobile health (mHealth) is a promising tool to encourage self-management, but few studies have investigated the impact of mHealth on health care utilization. ObjectiveThe objective of this analysis was to determine the change in 2-year health service utilization and whether utilization explained a 1.9% absolute decrease in glycated hemoglobin (HbA1c) over 1-year in the Mobile Diabetes Intervention Study (MDIS). MethodsWe used commercial claims data from 2006 to 2010 linked to enrolled patients’ medical chart data in 26 primary care practices in Maryland, USA. Secondary claims data analyses were available for 56% (92/163) of participants. In the primary MDIS study, physician practices were recruited and randomized to usual care and 1 of 3 increasingly complex interventions. Patients followed physician randomization assignment. The main variables in the analysis included health service utilization by type of service and change in HbA1c. The claims data was aggregated into 12 categories of utilization to assess change in 2-year health service usage, comparing rates of usage pre- and posttrial. We also examined whether utilization explained the 1.9% decrease in HbA1c over 1 year in the MDIS cluster randomized clinical trial. ResultsA significant group by time effect was observed in physician office visits, general practitioner visits, other outpatient services, prescription medications, and podiatrist visits. Physician office visits (P=.01) and general practitioner visits (P=.02) both decreased for all intervention groups during the study period, whereas prescription claims (P

BACKGROUND Evaluation of digital health applications to support older adults’ independence and family caregiving is needed. Digital health is increasingly providing opportunities for older adults and their family caregivers to educate, engage, and share health information across digital platforms. Few apps have documented evidence of usability by older adults and their caregivers. OBJECTIVE The objective of this study was to determine the usability of a mobile app in a community-based older adult population aged ≥65 years. The app was designed to improve engagement of the patient-informal caregiver team. METHODS This observational usability study was conducted in participants’ homes and independent living facilities in Baltimore, Maryland. Community-dwelling older adults aged ≥65 years and their caregivers enrolled as a dyad (n=24, 12 dyads). The usability evaluation was a mobile and Web-based app that allowed older adult users to record social and health information and share this information with their caregivers. The older adult-caregiver dyad downloaded the app to a smart phone or accessed the Web version, participated in training and onboarding, and used the app for a 1-month period. Participants responded to weekly surveys sent by app push notifications and to the usability and satisfaction surveys at the end of the study. Participant satisfaction and usability were assessed using the Modified Mobile Application Rating Scale (M-MARS) and the System Usability Scale (SUS). RESULTS The final sample comprised 16 people (8 dyads). Responses to the M-MARS were comparable between older adults and caregiver respondents in terms of engagement and functionality. Caregivers rated aesthetics slightly higher (mean 3.7) than older adult participants did (mean 3.3). Although most responses to the SUS were around the mean (2.3-3.4), older adults and their caregivers differed with regard to integration of app features (mean 3.7 vs 2.8) and the need to learn more before using the app (mean 2.3 vs 3.1). CONCLUSIONS Technology ownership and use among older adults and caregivers was high. Usability and engagement of the mobile app was average. Additional training is recommended for older adults and their caregivers, including that on targeted behaviors for digital health record keeping.

BACKGROUND Type 2 diabetes is a major chronic condition requiring management through lifestyle changes and recommended health service visits. Mobile health is a promising tool to encourage self-management, but few studies have investigated the impact of mobile health on health care utilization. OBJECTIVE In the current analysis, we aimed to determine change in two-year health service utilization and whether utilization explained a 1.9% absolute decrease in HbA1c over one-year in the Mobile Diabetes Intervention Study (MDIS). METHODS We used commercial claims data from 2006-2010 linked with enrolled patients’ medical chart data in 26 primary care practices in Maryland. Secondary claims data analysis was available for 56% of participants (n=92). In the primary MDIS study, physician practices were recruited and randomized to usual care and one of three increasingly complex interventions. Patients followed physician randomization assignment. Main variables in the analysis include health service utilization by type of service and change in HbA1c. The claims data was aggregated into 12 categories of utilization to assess change in two-year health service utilization. We also examined whether utilization explained the 1.9% decrease in HbA1c over one-year in a mobile diabetes cluster randomized clinical trial. RESULTS A significant group by time effect was observed in physician office visits (P CONCLUSIONS Claims data analyses identified patterns of utilization relevant to mobile health interventions. Findings may encourage patients and health providers to discuss utilization of treatment-recommended services, lab tests, and prescribed medications.

New reimbursement and managed care models demonstrate the need to reduce avoidable Emergency Department (ED) use and limit preventable inpatient admissions for older adults in Skilled Nursing Facilities (SNF). The objective was to develop an ED telemedicine consultation intervention for SNF residents with acute medical problems. Secondary objectives including evaluation of health care utilization, provider satisfaction. Demonstration evaluation in three urban SNFs, telemedicine linked to university medical center ED. Mobile telemedicine cart equipment assessed SNF residents for any change in condition. ED physicians used tablets with secure access to conduct the resident assessment. Provider satisfaction measures imbedded in EMRs were completed at consultation visit end. 460 patients had changes in condition, 327 resulted in 911 calls, 85 deemed eligible for telemedicine consult. Conducted 57 telehealth consults. Forty (70%) telemedicine consult residents remained in the SNF. Fourteen residents were transferred to the ED. Average satisfaction scores were 5.8/7 for SNF nurses (n=49) and 5.6 for ED physicians (n=45). Lower-rated items related to technical equipment problems. ED physicians reported residents transferred to ED after telehealth visit had better continuity of care. The intervention was effective in preventing or delaying transfer of acutely ill, medically complex SNF residents. Implementation of the intervention identified need for SNF admission policy and procedure changes; weekly telemedicine training; SNF clinical advocates; on-site tracking and linkage of EMRs across providers; HIPAA shared medical record concerns. Future research plans include analyses of detailed SNF resident characteristics and business case assessment for reduction of transfers, ED and hospital utilization.

The purpose of this study was to evaluate participant self-efficacy and use of a mobile phone diabetes health intervention for older adults during a 4-week period. Participants included seven adults (mean age, 70.3 years) with type 2 diabetes cared for by community-based primary care physicians. Participants entered blood glucose data into a mobile phone and personalized patient Internet Web portal. Based on blood glucose values, participants received automatic messages and educational information to self-manage their diabetes. Study measures included prior mobile phone/Internet use, the Stanford Self-Efficacy for Diabetes Scale, the Stanford Energy/Fatigue Scale, the Short Form-36, the Patient Health Questionnaire-9 (depression), the Patient Reported Diabetes Symptom Scale, the Diabetes Stages of Change measure, and a summary of mobile system use. Participants had high self-efficacy and high readiness and confidence in their ability to monitor changes to control their diabetes. Participants demonstrated ability to use the mobile intervention and communicate with diabetes educators.

Background Inflammatory bowel diseases (IBD), comprised of ulcerative colitis and Crohn's disease, are chronic disorders characterized by worsening of symptoms followed by symptom-free periods. Symptoms have a profound negative impact on quality of life and are associated with increased health care utilization. Despite effective treatments, outcomes are suboptimal secondary to nonadherence, medication intolerance, inconsistent monitoring, poor patient knowledge and limited access to care. Objectives Compare disease activity and quality of life over 1 year in a randomized trial of IBD patients receiving standard care versus telemedicine. Methods Patients evaluated at 3 IBD referral centers with worsening symptoms within the last 2 years are eligible for randomization to one of two interventions or standard care. The interventions consist of either every other week or weekly assessment of symptoms, side effects, weight and delivery of medication prompts and education via texts to the participant's mobile phone. Individualized alerts and action plans are created on a secure portal. Participants in the standard care group undergo routine and urgent follow-up visits and telephone calls. The primary outcomes group comparisons of changes in disease activity and quality of life scores from baseline to 6 and 12 months. Conclusions Methods such as telemedicine are needed to improve monitoring, adherence, self-efficacy, and patient knowledge in IBD. If effective, telemedicine should decrease symptoms, improve quality of life, and decrease health care utilization. The burden associated with use of telemedicine for patients and providers needs to be assessed. The trial is ongoing and will be completed in July 2016.

BackgroundSuccessful treatment of diabetes includes patient self-management behaviors to prevent or delay complications and comorbid diseases. On the basis of findings from large clinical trials and professional guidelines, diabetes education programs and health providers prescribe daily regimens of glucose monitoring, healthy eating, stress management, medication adherence, and physical activity. Consistent, long-term commitment to regimens is challenging. Mobile health is increasingly being used to assist patients with lifestyle changes and self-management behaviors between provider visits. The effectiveness of mobile health to improve diabetes outcomes depends on patient engagement with a technology, content, or interactions with providers. ObjectivesIn the current analysis, we aimed to identify patient engagement themes in diabetes messaging with diabetes providers and determine if differences in engagement in the Mobile Diabetes Intervention Study (MDIS) influenced changes in glycated hemoglobin A1c (HbA1c) over a 1-year treatment period (1.9% absolute decrease in the parent study). MethodsIn the primary MDIS study, 163 patients were enrolled into 1 of 3 mobile intervention groups or a usual care control group based on their physician cluster randomization assignment. The control group received care from their physicians as usual. Participants in each intervention group had access to a patient portal where they could record monitoring values for blood glucose, blood pressure, medication changes, or other self-management information while also assigned to varying levels of physician access to patient data. Intervention participants could choose to send and receive messages to assigned certified diabetes educators with questions or updates through the secure Web portal. For this secondary analysis, patient engagement was measured using qualitative methods to identify self-care themes in 4109 patient messages. Mixed methods were used to determine the impact of patient engagement on change in HbA1c over 1 year. ResultsSelf-care behavior themes that received the highest engagement for participants were glucose monitoring (75/107, 70.1%), medication management (71/107, 66.4%), and reducing risks (71/107, 66.4%). The average number of messages sent per patient were highest for glucose monitoring (9.2, SD 14.0) and healthy eating (6.9, SD 13.2). Compared to sending no messages, sending any messages about glucose monitoring (P=.03) or medication (P=.01) led to a decrease in HbA1c of 0.62 and 0.72 percentage points, respectively. Sending any messages about healthy eating, glucose monitoring, or medication combined led to a decrease in HbA1c of 0.54 percentage points compared to not sending messages in these themes (P=.045). ConclusionsThe findings from this study help validate the efficacy of the mobile diabetes intervention. The next step is to determine differences between patients who engage in mobile interventions and those who do not engage and identify methods to enhance patient engagement. Trial RegistrationClinicalTrials.gov: NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by WebCite at http://www.webcitation.org/6wh4ekP4R)

BACKGROUND Diabetes is a complex, demanding disease that requires the constant attention of patients. The burden of self-management, including different medication regimens, routine self-care activities, and provider visits, has an impact on patients’ emotional well-being. Diabetes distress and depression are two important components of emotional well-being that may negatively affect diabetes outcomes. OBJECTIVE The aim was to determine the impact of the 1-year Mobile Diabetes Intervention Study cluster randomized clinical trial on emotional well-being measured by diabetes distress and depression among adults with type 2 diabetes (T2D). METHODS A total of 163 adults with not-well-managed T2D were enrolled from community primary care practices. Primary care practices were cluster randomized into either a usual care control group or intervention group. Intervention participants were given a mobile phone with coaching software including a Web portal to communicate with providers. A priori established secondary outcomes included distress measured by the Diabetes Distress Scale (DDS), with subscales measuring emotional burden, interpersonal distress, physician-related distress, and regimen-related distress, as well as depression measured by the Patient Health Questionnaire (PHQ-9). Linear mixed models were used to calculate the effect of the intervention on diabetes distress levels over time, both overall and separately by sex, and to determine if the intervention affected distress or depression. The impact of total DDS on changes in HbA1c was also studied. RESULTS There were no significant treatment group effects for DDS total (baseline: P=.07; differences over time: P=.38) or for depression (P=.06 over time). Significant declines in total DDS were observed over the 12-month intervention period (P=.01). Regimen-related distress significantly decreased for all study participants (P CONCLUSIONS Although we found no definitive overall or sex-specific effect of the intervention on diabetes distress or depression, this study makes an important contribution to the understanding of mobile health interventions and the impact on emotional health. Our study verified previous work that although diabetes distress and depression are highly correlated, these measures are not evaluating the same construct. Design of future mobile technology provides an opportunity to personalize, contextualize, and intervene in the emotional well-being of persons with diabetes. CLINICALTRIAL Clinicaltrials.gov NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by WebCite at http://www.webcitation.org/6vVgRCLAF)

The purpose of this symposium is to present use of technology to translate the assessment of physical functioning in older adults to clinical practice. Previous studies confirm the relationship of physical performance measures to disability onset, hospitalization, nursing home admission, falls, mortality and other outcomes. While performance measures are being used more frequently in aging research, their uptake in clinical practice has been slow, in part because of the added burden in clinical care of geriatric patients. Using technology to improve the simplicity and efficiency of these measures could have a major impact on their use in clinical practice.In this symposium Dr. Charlene Quinn, will provide an overview of the translation of technology to clinical care.Dr. Jack Guralnik will describe the development of a smart phone app for the administration of the Short Physical Performance Battery, a widely used assessment of gait, strength and balance.Dr. W. Jack Rejeski will present the mobility assessment tool-short form (MAT-sf) which uses video animations to improve accuracy and precision measurement of mobility.Dr. Miriam Morey will discuss walking speed in the 6th Vital Sign research project to establish community population walking speed norms and promote walking speed as a vital sign.Dr. Lisa Barry will discuss use of an RFID (small electronic chip) device to measure gait speed in the clinic setting.Dr. Antoine Piau will present the RESPECT study of a shoe insole to monitor frailty, assessing gait characteristics and transmit data for the use of patients and physicians.

Technology enriches and enhances our everyday lives and can support health, wellbeing, and productivity. Unfortunately, barriers exist that prevent many older adults from taking full advantage of the potential of technology. The Center for Research and Education on Aging and Technology Enhancement (CREATE) is dedicated to understanding and overcoming barriers to technology use so these benefits can be realized by everyone, regardless of age. This symposium will focus on technology to support older adults and factors related to older adult technology use and adoption in a variety of contexts. W. Rogers will present an overview of older adult technology use derived from representative U.S. samples and important factors influencing technology adoption. W. Boot will discuss the critical role of technology proficiency in adoption and how to quickly and easily assess proficiency with respect to desktop and tablet-based computers in older adult samples. In the domain of work, J. Sharit will discuss the implications of rapid changes in technology for older workers, and the promises and pitfalls of technology in the workplace. In the domain of medicine, N. Charness will present studies related to the successful adoption of telehealth devices in different populations (healthy older adults and older adults with heart failure). S. Czaja will present CREATE data related to the potential of technology to support social engagement and support for older adults at risk for social isolation. Discussant C. Quinn will highlight common themes across talks and provide additional insight into the potential of technology.

Although prior literature has shown the plausibility of combining the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) items to form an expanded scale for measuring the degree of functional decline, this has not been shown in older adults with diabetes who are disproportionately affected by functional disability. Using the 2009 Medicare Current Beneficiary Survey data, we evaluated the factor structure of the pooled ADL and IADL items. Based on our study comprising 2,158 community-dwelling older adults (≥65 years) with diabetes, the unidimensional model exhibited good fit. Despite well-fitting indices, high correlations were observed between the latent constructs (>.70) of the multi-factor models, suggesting a lack of discriminant validity. These findings provide empirical support for a combined scale that can comprehensively and efficiently characterize the extent of functional disability in older adults with diabetes for research, risk adjustment, and evaluation in patient-centered medical homes.

The purpose of this study was to assess effects of a mobile coaching system on glycated hemoglobin (HbA1c) levels in younger versus older patients over 1 year. Participants ( n = 118) included adult patients with Type 2 diabetes cared for by community physicians. Intervention patients received mobile phone coaching and individualized web portal. Control patients received usual care. Patients were stratified into two age groups: younger (

This manuscript is a secondary analysis of a large multicenter randomized controlled trial. The primary study is Cross RK et al., A Randomized Controlled Trial of TELEmedicine for patients with Inflammatory Bowel Disease (TELE-IBD). Am J Gastroenterol, 2019 Mar.

Creative use of new mobile and wearable health information and sensing technologies (mHealth) has the potential to reduce the cost of health care and improve well-being in numerous ways. These applications are being developed in a variety of domains, but rigorous research is needed to examine the potential, as well as the challenges, of utilizing mobile technologies to improve health outcomes. Currently, evidence is sparse for the efficacy of mHealth. Although these technologies may be appealing and seemingly innocuous, research is needed to assess when, where, and for whom mHealth devices, apps, and systems are efficacious. In order to outline an approach to evidence generation in the field of mHealth that would ensure research is conducted on a rigorous empirical and theoretic foundation, on August 16, 2011, researchers gathered for the mHealth Evidence Workshop at NIH. The current paper presents the results of the workshop. Although the discussions at the meeting were cross-cutting, the areas covered can be categorized broadly into three areas: (1) evaluating assessments; (2) evaluating interventions; and (3) reshaping evidence generation using mHealth. This paper brings these concepts together to describe current evaluation standards, discuss future possibilities, and set a grand goal for the emerging field of mHealth research.

Noninsulin antihyperglycemic agents (NAAs) are the mainstay of treatment for type 2 diabetes, yet persistence in NAA use is suboptimal in many diabetes patients. Most of the research on NAA discontinuance has focused on sociodemographic characteristics and general health status, but such factors are inherently limited in explaining dynamic events such as discontinuance.To assess the relative importance of static and proximal dynamic factors in explaining long-term NAA discontinuance among Medicare beneficiaries with diabetes.Two sets of probability models were estimated to predict NAA discontinuance as a function of static variables (age, sex, race, original reason for Medicare entitlement, low-income subsidy and dual Medicare/Medicaid eligibility status, and disease burden) and 21 dynamic factors capturing month-by-month changes in drug use, health status, and use of medical services leading up to discontinuance (defined as month 0) and the previous 4 months (designated months -1 to -4) among 71,619 patients with diabetes enrolled in Medicare Part D plans in 2006-2008.Static variables explained just 1.2% of the variance in probability of NAA discontinuance compared with 14% for all variables combined. Key time-related predictors of NAA discontinuance included discontinuation with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) and statins, hypoglycemia, NAA usage gaps, insulin use, and discharge from hospitals and skilled nursing facilities (SNFs). The strongest significant predictors (P0.05) of NAA discontinuance were discontinuation with statins and ACEIs/ARBs in month 0 (predicted probabilities of 37% and 34%, respectively). Other variables that significantly increased the probability of NAA discontinuance by 10% or more were hypoglycemia in month 0 (14%) and month -1 (17%), discontinuance with ACEIs/ARBs in months -1 (15%) and -2 (10%), discontinuance with statins in month -1 (13%), and insulin use in month 0 (12%). Experiencing a previous gap in NAA therapy was associated with higher likelihood of discontinuance if the gap occurred in month -2 (10%) or month -4 (6%), but a gap in therapy in month -1 actually reduced the likelihood of discontinuance by 13%. Discharge from a hospital or SNF was consistently associated with higher probabilities of NAA discontinuance ranging between 4% and 10%, with higher probabilities occurring closer to month 0.A cascade of dynamic changes preceding discontinuance with NAA therapy among Medicare Part D enrollees with diabetes was observed between 2006 and 2008. Understanding that lack of persistence in drug use is a dynamic rather than a static phenomenon opens up new avenues for investigating and ultimately improving adherence behavior in the elderly.This study was funded by MerckCo. Huang and Raipathak are employees of MerckCo. Brandt reports consultancy and speaker fees from Catapult, Omnicare, RAND, HRSA, CMS, and AGS Beers Criteria. Loh is currently employed at Touro College of Pharmacy. All other authors have no relevant potential conflicts of interest to disclose. Study concept and design were primarily contributed by Stuart, Quinn, and Brandt, along with Shen, Roberto, Hendrick, Huang, and Rajpathak. Shen, Loh, Hendrick, and Kim collected the data, and data interpretation was performed primarily by Stuart, Shen, and Roberto, assisted by Quinn, Brandt, Hendrick, Huang, and Rajpathak. The manuscript was written primarily by Stuart, with assistance from the other authors, and revised by Huang, Rajpathak, and Stuart, with assistance from the other authors.

Objective: African Americans experience high rates of type 2 diabetes mellitus (T2D). Self-management strategies, such as medication adherence, are key to mitigating negative T2D outcomes. This article addresses a gap in the literature by examining the intersections of drug abuse histories and medication adherence among urban, older African Americans with T2D. Method: In-depth interview data were collected as part of a larger ethnographic study examining the subjective experience of T2D among urban older adults. Two representative focal cases were selected and thematic analysis performed to illustrate how former illicit drug addicts perceive prescription medication usage. Results: Narratives reveal that participants are displeased about having to take prescription drugs and are making lifestyle changes to reduce medication usage and maintain sobriety. Discussion: Previous drug abuse not only complicates medication adherence but is also a significant part of how older African Americans who are former drug users frame their understanding of T2D more broadly.

OBJECTIVE To test whether adding mobile application coaching and patient/provider web portals to community primary care compared with standard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A cluster-randomized clinical trial, the Mobile Diabetes Intervention Study, randomly assigned 26 primary care practices to one of three stepped treatment groups or a control group (usual care). A total of 163 patients were enrolled and included in analysis. The primary outcome was change in glycated hemoglobin levels over a 1-year treatment period. Secondary outcomes were changes in patient-reported diabetes symptoms, diabetes distress, depression, and other clinical (blood pressure) and laboratory (lipid) values. Maximal treatment was a mobile- and web-based self-management patient coaching system and provider decision support. Patients received automated, real-time educational and behavioral messaging in response to individually analyzed blood glucose values, diabetes medications, and lifestyle behaviors communicated by mobile phone. Providers received quarterly reports summarizing patient’s glycemic control, diabetes medication management, lifestyle behaviors, and evidence-based treatment options. RESULTS The mean declines in glycated hemoglobin were 1.9% in the maximal treatment group and 0.7% in the usual care group, a difference of 1.2% (P = 0.001) over 12 months. Appreciable differences were not observed between groups for patient-reported diabetes distress, depression, diabetes symptoms, or blood pressure and lipid levels (all P > 0.05). CONCLUSIONS The combination of behavioral mobile coaching with blood glucose data, lifestyle behaviors, and patient self-management data individually analyzed and presented with evidence-based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year.

Our aim was to determine whether patient participation in decision-making about diabetes care is associated with understanding of diabetes self-management and subsequent self-care practices. We also identified issues that would impact messaging for use in mobile diabetes communication.A cross-sectional observational study was conducted with type 2 diabetes patients (n = 81) receiving their care at the University of Maryland Joslin Diabetes Center. A convenience sample of patients were eligible to participate if they were aged 25-85 years, had type 2 diabetes, spoke English, and visited their physician diabetes manager within the past 6 months. In-person patient interviews were conducted at the time of clinic visits to assess patient understanding of diabetes management, self-care practices, and perceptions of participation in decision-making about diabetes care.African Americans reported fewer opportunities to participate in decision-making than Caucasians, after controlling for education [mean difference (MD) = -2.4, p = .02]. This association became insignificant after controlling for patient-physician race concordance (MD = -1.5, p = .21). Patient understanding of self-care was predicted by having greater than high school education (MD = 3.6, p = .001) and having physicians who involved them in decision-making about their care. For each unit increase in understanding of diabetes self-care, the mean patient self-care practice score increased by 0.16 (p = .003), after adjustment for patient race and education.Patient participation in decision-making is associated with better understanding of care. Participation in decision-making plays a key role in patient understanding of diabetes self-management and subsequent self-care practices. Patients with limited education need specific instruction in foot care, food choices, and monitoring hemoglobin A1c.

More than 24 million people in the United States have diabetes mellitus, and this number will grow by 1 million per year due to population aging and other factors.1,2 The risk of diabetes mellitus increases dramatically with age, and the devastating effect of diabetes mellitus is particularly evident in elderly and institutionalized people. Whereas 5.6% of noninstitutionalized Americans have diabetes mellitus, up to one-quarter of America's 1.5 million nursing home (NH) residents have diabetes mellitus.2–4 NH residents with diabetes mellitus have higher rates of cardiovascular disease, visual problems, foot conditions, kidney failure, urinary incontinence, depression, cognitive impairment, injurious falls, nutritional deficiencies, and pain than residents without diabetes mellitus.2,3 As the population ages, the burden of the costs of and care for diabetes mellitus will fall heavily on the U.S. long-term care system. Following intensive regimens for the management of diabetes mellitus is essential to delaying or avoiding its many negative health consequences. Standard diagnostic and preventive procedures include periodic dilated eye examinations, lipid profiling and testing of glycosylated hemoglobin (HbA1c), fasting plasma glucose, and serum creatinine. The American Geriatrics Society (AGS) provides guidelines for older persons with diabetes mellitus,5 and guidelines for institutionalized elderly adults have also been offered.6 Unfortunately, many elderly persons with diabetes mellitus, whether in the community or residing in an NH, do not receive the level of diagnostic and preventive care prescribed by these guidelines.7–12 An important question for researchers and clinicians alike pertains to the relationship between NH admission and quality of care for diabetes mellitus. Although the structured care environment of the NH might lead to better care, priority may be given to more-urgent health concerns in people newly admitted to the NH, or the goals of care for diabetes mellitus may change as the costs and expected benefits of procedures are considered.3,5,11,13,14 Care may also change as NH physicians, rather than endocrinologists, direct care.15 Drawing inferences about this question from existing studies of community- and NH-dwelling elderly persons with diabetes mellitus is not possible because of widely varying sample demographics, data collection time frames, geographic locations, and inclusion and exclusion of short-stay NH patients. Additionally, it is likely that community-dwelling persons with diabetes mellitus admitted to an NH differ from those remaining in the community in the severity of their diabetes mellitus and other comorbidities.14 To examine the relationship between NH admission and quality of care for diabetes mellitus, care provided to a single sample of NH residents before and after NH admission must be examined. Because of its prevalence and relationship to care practices, evaluations of care of diabetes mellitus in the NH should also take dementia into account. Approximately half of all NH residents have dementia.16 A wide range of studies have documented a connection between cognitive impairment and the provision of less-aggressive care related to diabetes mellitus,12–15,17 although these studies did not consider the role of NH admission or did not examine diabetes mellitus care practices across a wide spectrum of quality indicators. Thus, a resident's status with regard to dementia is an important factor to consider when examining how admission to an NH relates to care for diabetes mellitus. Because diabetes mellitus is a disease for which the parameters of good care are relatively well defined, comparing the provision of procedures related to the care of diabetes mellitus to those with and without dementia also yields insights into the quality of care for patients with dementia. For five basic diagnostic and preventive procedures related to diabetes mellitus, the current study asks whether care is provided at higher rates in the 12-month period before or after NH admission and for those with or without dementia. Interactions between dementia status and place of residence were also looked for, and rates of receiving these procedures in each setting were examined. For each procedure, basic rates and rates adjusted for variables that may affect the amount or type of care received by people newly admitted to the NH, including resident demographics, health status, and the previous year's healthcare utilization, were examined.

National data find glycemic control is within target (A1c7.0%) for 37% of patients with diabetes, and only 7% meet recommended glycemic, lipid, and blood pressure goals.To compare active interventions and usual care for glucose control in a randomized clinical trial (RCT) among persons with diabetes cared for by primary care physicians (PCPs) over the course of 1 year.Physician practices (n=36) in 4 geographic areas are randomly assigned to 1 of 4 study groups. The intervention is a diabetes communication system, using mobile phones and patient/physician portals to allow patient-specific treatment and communication. All physicians receive American Diabetes Association (ADA) Guidelines for diabetes care. Patients with poor diabetes control (A1cor =7.5%) at baseline (n=260) are enrolled in study groups based on PCP randomization. All study patients receive blood glucose (BG) meters and a year's supply of testing materials. Patients in three treatment groups select one of two mobile phone models, receive one-year unlimited mobile phone data and service plan, register on the web-based individual patient portal and receive study treatment phone software based on study assignment. Control group patients receive usual care from their PCP. The primary outcome is mean change in A1c over a 12-month intervention period.Traditional methods of disease management have not achieved adequate control for BG and other conditions important to persons with diabetes. Tools to improve communication between patients and PCPs may improve patient outcomes and be satisfactory to patients and physicians. This RCT is ongoing.

Studies have consistently shown racial disparities in advance directive completion for nursing home residents but have not examined whether this disparity is due to differences in interactions with healthcare providers. This study had two aims: to determine whether the racial disparity in advance directive completion by nursing home residents is related to differences in discussion of treatment restrictions with healthcare providers and to examine whether there is a racial disparity in perceptions of residents' significant others that additional discussions would be helpful. Participants were 2,171 white or black (16% of sample) residents newly admitted to 59 nursing homes. Data were collected from structured interviews with residents' significant others and review of nursing home charts. Questions included whether advance directives were completed, whether treatment restrictions were discussed with the resident or family, and whether more discussion would have been helpful. Frequencies according to race were determined for each question; P-values and logistic regression models were obtained. Black residents were less likely to have completed any advance directives (P

A clinical intervention pilot study to improve depression care for short-stay nursing home Medicare-reimbursed rehabilitation patients funded by the National Institute on Aging was conducted. Despite solid theoretical and clinical grounding and the support of a large nursing home company, several roadblocks to implementation were encountered, including involving patients and families, communication between providers, involving community primary care physicians, staff time constraints, and conducting research with short-stay patients. Although frustrating from a research standpoint, these roadblocks closely reflect problems identified by the American Geriatrics Society as impeding the delivery of high-quality transitional care in geriatrics. These research roadblocks are described as they were encountered in the clinical setting, and each is placed within the larger context of challenges associated with care transitions, especially for older persons with complex health needs receiving nursing home rehabilitation. Finally, recommendations are offered for researchers conducting much-needed research within geriatric transitional care settings, including starting early in the care transition chain and assisting patients and families with providing continuity across care settings.

Less than 63% of individuals with diabetes meet professional guidelines target of hemoglobin A1c7.0%, and only 7% meet combined glycemic, lipid, and blood pressure goals. The primary study aim was to assess the impact on A1c of a cell phone-based diabetes management software system used with web-based data analytics and therapy optimization tools. Secondary aims examined health care provider (HCP) adherence to prescribing guidelines and assessed HCPs' adoption of the technology.Thirty patients with type 2 diabetes were recruited from three community physician practices for a 3-month study and evenly randomized. The intervention group received cell phone-based software designed by endocrinologists and CDEs (WellDoc Communications, Inc., Baltimore, MD). The software provided real-time feedback on patients' blood glucose levels, displayed patients' medication regimens, incorporated hypo- and hyperglycemia treatment algorithms, and requested additional data needed to evaluate diabetes management. Patient data captured and transferred to secure servers were analyzed by proprietary statistical algorithms. The system sent computer-generated logbooks (with suggested treatment plans) to intervention patients' HCPs.The average decrease in A1c for intervention patients was 2.03%, compared to 0.68% (P0.02, one-tailed) for control patients. Of the intervention patients, 84% had medications titrated or changed by their HCP compared to controls (23%, P = 0.002). Intervention patients' HCPs reported the system facilitated treatment decisions, provided organized data, and reduced logbook review time.Adults with type 2 diabetes using WellDoc's software achieved statistically significant improvements in A1c. HCP and patient satisfaction with the system was clinically and statistically significant.

Rowe and Kahn's concept of successful aging remains an important model of well-being; additional research is needed, however, to identify how economically and socially disadvantaged older adults experience well-being, including the role of life events. The findings presented here help address this gap by examining the subjective construction of well-being among urban African American adults (age ≥ 50) with Type 2 diabetes.As part of the National Institute on Aging-funded Subjective Experience of Diabetes among Urban Older Adults study, ethnographers interviewed African American older adults with diabetes (n = 41) using an adaptation of the McGill Illness Narrative Interview. Data were coded using an inductively derived codebook. Codes related to aging, disease prognosis, and "worldview" were thematically analyzed to identify constructions of well-being.Participants evaluate their well-being through comparisons to the past and to the illnesses of friends and family. Diabetes self-care motivates social engagement and care of others. At times, distrust of medical institutions means well-being also is established through nonadherence to suggested biomedical treatment.Hardship and illness in participants' lives frame their diabetes experience and notions of well-being. Providers need to be aware of the social, economic, and political lenses shaping diabetes self-management and subjective well-being.

Although mortality for cardiovascular disease (CVD) has declined for several decades, heart disease and stroke continue to be the leading causes of death, disability, and high healthcare costs. Unhealthy behaviors related to CVD risk (eg, smoking, sedentary lifestyle, and unhealthful eating habits) remain highly prevalent. The high rates of overweight, obesity, and type 2 diabetes mellitus (T2DM); the persistent presence of uncontrolled hypertension; lipid levels not at target; and the ≈18% of adults who continue to smoke cigarettes pose formidable challenges for achieving improved cardiovascular health.1,2 It is apparent that the performance of healthful behaviors related to the management of CVD risk factors has become an increasingly important facet of the prevention and management of CVD.3 In 2010, the American Heart Association (AHA) made a transformative shift in its strategic plan and added the concept of cardiovascular health.2 To operationalize this concept, the AHA targeted 4 health behaviors in the 2020 Strategic Impact Goals: reduction in smoking and weight, healthful eating, and promotion of regular physical activity. Three health indicators also were included: glucose, blood pressure (BP), and cholesterol. On the basis of the AHA Life’s Simple 7 metrics for improved cardiovascular health, 30% have not reached the target levels for lipids or BP. National Health and Nutrition Examination Survey (NHANES) data revealed that people who met ≥6 of the cardiovascular health metrics had a significantly better risk profile (hazard ratio for all-cause mortality, 0.49) compared with individuals who had achieved only 1 metric or none.2 The studies reviewed in this statement targeted these behaviors (ie, smoking, physical activity, healthful eating, and maintaining a healthful weight) and cardiovascular health indicators (ie, blood …

Objectives: To evaluate the association between dementia and mortality, adverse health events, and discharge disposition of newly admitted nursing home residents. It was hypothesized that residents with dementia would die at a higher rate and develop more adverse health events (e.g., infections, fevers, pressure ulcers, falls) than residents without dementia because of communication and self-care difficulties. Design: An expert clinician panel diagnosed an admission cohort from a stratified random sample of 59 Maryland nursing homes, between 1992 and 1995. The cohort was followed for up to 2 years or until discharge. Setting: Fifty-nine Maryland nursing homes. Participants: Two thousand one hundred fifty-three newly admitted residents aged 65 and older not having resided in a nursing home for 8 or more days in the previous year. Measurements: Mortality, infection, fever, pressure ulcers, fractures, and discharge home. Results: Residents with dementia had significantly lower overall rates of infection (relative risk (RR)=0.77, 95% confidence interval (CI)=0.70–0.85) and mortality (RR=0.61, 95% CI=0.53–0.71) than those without dementia, whereas rates of fever, pressure ulcers, and fractures were similar for the two groups. These results persisted when rates were adjusted for demographic characteristics, comorbid conditions, and functional status. During the first 90 days of the nursing home stay, residents with dementia had significantly lower rates of mortality if not admitted for rehabilitative care under a Medicare qualifying stay (RR=0.25, 95% CI=0.14–0.45), were less often discharged home (RR=0.33, 95% CI=0.28–0.38), and tended to have lower fever rates (RR=0.78, 95% CI=0.63–0.96) than residents without dementia. Conclusion: Newly admitted nursing home residents with dementia have a profile of health events that is distinct from that of residents without dementia, indicating that the two groups have different long-term care needs. Results suggest that further investigation of whether residents with dementia can be well managed in alternative residential settings would be valuable.