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Objective To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years). Methods We used Health and Retirement Study data (2012–2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals. Results Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents. Discussion Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.

Caring for a partner with dementia poses significant emotional burden and high care demands, but changes in impacts before and after dementia onset is unclear.Examine changes in depressive symptoms and hours of care provided by caregivers through the course of their partners' cognitive decline.Retrospective, observational study using household survey data from 2000-2016 Health and Retirement Study and count models to evaluate older individuals' (ages ≥51 y) depressive symptoms (measured using the shortened Center for Epidemiologic Studies Depression Scale) and weekly caregiving in the 10 years before and after their partners' dementia onset (identified using Telephone Interview Cognitive Status screening). Relationships were examined overall and by sex and race.We identified 8298 observations for 1836 older caregivers whose partners developed dementia. From before to after partners' dementia onset, caregivers' mean (SD) depressive symptoms increased from 1.4 (1.9) to 1.9 (2.1) ( Plt;0.001) and weekly caregiving increased from 4.4 (19.7) to 20.8 (44.1) ( Plt;0.001) hours. Depressive symptoms and caregiving hours were higher for women compared with men. Depressive symptoms were higher for Blacks compared with Whites, while caregiving hours were higher for Whites. The expected count of caregivers' depressive symptoms and caregiving hours increased by 3% ( Plt;0.001) and 9% ( P =0.001) before partners' dementia onset and decreased by 2% ( Plt;0.001) and 1% ( P =0.63) following partners' dementia onset. No differences observed by sex or race.Depressive symptoms and instrumental burdens for caregivers increase substantially before the onset of dementia in partners. Early referral to specialty services is critical.

Background Physical function worsens with older age, particularly for sedentary and socially isolated individuals, and this often leads to injuries. Through reductions in physical activity, the COVID-19 pandemic may have worsened physical function and led to higher fall-related risks. Methods A nationally representative online survey of 2006 U.S. adults aged 50-80 was conducted in January 2021 to assess changes in health behaviors (worsened physical activity and less daily time spent on feet), social isolation (lack of companionship and perceived isolation), physical function (mobility and physical conditioning), and falls (falls and fear of falling) since March 2020. Multivariable logistic regression was used to assess relationships among physical activity, social isolation, physical function, falls, and fear of falling. Results Among respondents, 740 (36.9%) reported reduced physical activity levels, 704 (35.1%) reported reduced daily time spent on their feet since March 2020, 712 (37.1%) reported lack of companionship, and 914 (45.9%) social isolation. In multivariable models, decreased physical activity (adjusted risk ratio, ARR: 2.92, 95% CI: 2.38, 3.61), less time spent on one's feet (ARR: 1.95, 95% CI: 1.62, 2.34), and social isolation (ARR: 1.51, 95% CI: 1.30, 1.74) were associated with greater risks of worsened physical conditioning. Decreased physical activity, time spent daily on one's feet, and social isolation were similarly associated with worsened mobility. Worsened mobility was associated with both greater risk of falling (ARR: 1.70, 95% CI: 1.35, 2.15) and worsened fear of falling (ARR: 2.02, 95% CI: 1.30, 3.13). Worsened physical conditioning and social isolation were also associated with greater risk of worsened fear of falling. Conclusion The COVID-19 pandemic was associated with worsened physical functioning and fall outcomes, with the greatest effect on individuals with reduced physical activity and social isolation. Public health actions to address reduced physical activity and social isolation among older adults are needed.

Non-Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non-Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset.We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee-for-service claims. Using the Hurd algorithm (a regression-based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use.We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p-value0.001. 23.8% of non-Hispanic Black versus 31.4% of non-Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education.Lower diagnosis rates of dementia among non-Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia-related outcomes among non-Hispanic Black Americans.

To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65.Health and Retirement Study survey data (1998-2018).We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensity-weighted pre- and post-Medicare eligibility cohorts. A regression discontinuity design compared the self-reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility.Not applicable.A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage-point decrease in the probability of informal care received for stroke patients (p = 0.003) but not in the other acute care cohorts. Men had a 16.8 percentage-point decrease (p = 0.002) in the probability of any care receipt.Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode-based reimbursement models that alter professional rehabilitative care intensity.

Family members—mainly spouses and partners—are the primary caregivers for individuals with Alzheimer’s disease and related dementias (ADRDs), chronic progressive illnesses requiring increasing levels of care. We performed a retrospective observational analysis comparing depressive symptoms of 16,650 older individuals with partners without ADRDs, and those recently (within 2 years) or less recently diagnosed (≥2 years prior), controlling for lagged sociodemographic and health characteristics. The mean number of reported depressive symptoms was 1.2 ( SD = 1.8). Compared with respondents with partners with no ADRD, having a partner with any ADRD was associated with a 0.35 increase (95% confidence interval [CI] = [0.30, 0.41]), or 30% increase, in depressive symptoms. A less recent partner diagnosis was associated with a 33% increase, while a recent diagnosis was associated with a 27% increase. Clinically meaningful and longitudinally worsening depressive symptoms amplify the need to prioritize partner health and family-centered care following an ADRD diagnosis.

Over 6 million Americans have Alzheimer's Disease or Related Dementia (ADRD) but whether spikes in spending surrounding a new diagnosis reflect pre-diagnosis morbidity, diagnostic testing, or treatments for comorbidities is unknown.We used the 1998-2018 Health and Retirement Study and linked Medicare claims from older (≥65) adults to assess incremental quarterly spending changes just before versus just after a clinical diagnosis (diagnosis cohort, n = 2779) and, for comparative purposes, for a cohort screened as impaired based on the validated Telephone Interview for Cognitive Status (TICS) (impairment cohort, n = 2318). Models were adjusted for sociodemographic and health characteristics. Spending patterns were examined separately by sex, race, education, dual eligibility, and geography.Among the diagnosis cohort, mean (SD) overall spending was $4773 ($9774) per quarter - 43% of which was spending on hospital care ($2048). In adjusted analyses, spending increased by $8400 (p 0.001), or 156%, from $5394 in the quarter prior to $13,794 in the quarter including the diagnosis. Among the cohort in which impairment was incidentally detected using the TICS, adjusted spending did not change from just before to after detection of impairment, from $2986 before and $2962 after detection (p = 0.90). Incremental spending changes did not differ by sex, race, education, dual eligibility, or geography.Large, transient spending increases accompany an ADRD diagnosis that may not be attributed to impairment or changes in functional status due to dementia. Further study may help reveal how treatment for comorbidities is associated with the clinical diagnosis of dementia, with potential implications for Medicare spending.

RESEARCH OBJECTIVE: Over 40 million older Americans rely on informal care (unpaid assistance for personal care such and instrumental support, including toileting, bathing, and shopping). Prior work illustrates 68–230% greater spending on post‐acute care after surgery for Medicare beneficiaries compared to older commercial insurance enrollees. Such enhanced access to post‐acute care may reduce the need for family and friend caregiving support for rehabilitation following acute medical events. While use of informal care is substantial among older Americans, little is known about informal support for patients after acute medical events, and how formal post‐acute care influences its use. STUDY DESIGN: We used 1998 to 2018 Health and Retirement Study (HRS) data to assess changes in weekly hours of informal care received by individuals experiencing acute events before and after Medicare eligibility. We created two similar cohorts of individuals near the Medicare eligibility age: pre‐Medicare, or individuals ages 59–66 and not covered by Medicare; and Medicare, or individuals ages 67–74. We used a threshold of 67, rather than 65, for the Medicare cohort to account for the two‐year lookback period used in HRS survey questions. The cohorts were matched using inverse probability treatment weights. A regression discontinuity design assessed three types of caregiving – the proportion of respondents receiving care, intensity of care among care recipients, and care intensity among all respondents – before and after Medicare eligibility. We estimated generalized linear models with a log link and gamma distribution that regressed informal care on Medicare status, a centered age variable, and an interaction between Medicare status and centered age. Sensitivity analyses included stratification by surgery type and by sex. POPULATION STUDIED: 4264 Health and Retirement Study participants near the age of Medicare eligibility in one of three self‐reported acute medical cohorts: stroke, heart surgery, or joint surgery. PRINCIPAL FINDINGS: Among near‐retirement individuals, 2031 (47.6%) had a stroke, 1038 (24.3%) underwent heart surgery, and 1038 (28.0%) underwent joint surgery. Of the 937 (22.3%) of patients who reported receiving care from an informal caregiver, average care measured 34.0 (SD: 49.2) weekly hours. Mean (SD) weekly informal caregiving hours were 7.5 (27.0) overall, and 12.1 (34.7), 3.8 (18.5), and 2.9 (14.1) for stroke, heart surgery, and joint surgery patients, respectively. In adjusted analyses, the proportion of stroke patients receiving informal care decreased from 39.5% to 28.6% (or by 28%) and the average weekly amount of care decreased from 21.0 to 10.3 hours (or 51%) after Medicare enrollment. Non‐significant decreases were observed for the other medical cohorts. There was a non‐significant average decrease of 22.8 hours (or 40%) in the intensity of care received by men after one of three events. CONCLUSIONS: Access to Medicare coverage was associated with a 51% reduction in informal care received by older Medicare stroke patients, potentially by increasing access to post‐acute services. IMPLICATIONS FOR POLICY OR PRACTICE: Post‐acute care is increasingly targeted for cost savings under Medicare policies, which may restrict access to post‐acute care and rehabilitation, impacting demand for informal care for older adults with stroke.

Falls are common adverse events following hospital discharge. However, prevention programs are not tailored for older patients transitioning home. To inform development of transitional fall prevention programs, nine older adults designated as being at risk of falls during hospitalization who were recently discharged home were asked about their perceptions of fall risk and prevention, as well as their knowledge and opinion of materials from the Centers for Disease Control and Prevention Stopping Elderly Accidents, Deaths & Injuries Initiative. Using the constant comparative method, five themes were identified: Sedentary Behaviors and Limited Functioning ; Prioritization of Social Involvement ; Low Perceived Fall Risk and Attribution of Risk to External Factors ; Avoidance and Caution as Fall Prevention ; and Limited Falls Prevention Information During Transition from Hospital to Home . Limited awareness of and engagement in effective fall prevention may heighten recently discharged older adults' risks for falls. Prevention programs tailored to the post-discharge period may engage patients in fall prevention, promote well-being and independence, and link hospital and community efforts. [ Journal of Gerontological Nursing, 45 (1), 23–30.]

Objectives: Despite detrimental effects of depressive symptoms on self-care and health, hospital discharge practices and the benefits of different discharge settings are poorly understood in the context of depression. Methods: This retrospective cohort study comprised 23,485 hospitalizations from Medicare claims linked to the Health and Retirement Study (2000–2014). Results: Respondents with depressive symptoms were no more likely to be referred to home health, whereas the probability of discharge to skilled nursing facilities (SNFs) went up a half percentage point with each increasing symptom, even after adjusting for family support and health. Rehabilitation in SNFs, compared to routine discharges home, reduced the positive association between depressive symptoms and 30-day hospital readmissions (OR = 0.95, p = 0.029) but did not prevent 30-day falls, 1-year falls, or 1-year mortality associated with depressive symptoms. Discussion: Depressive symptoms were associated with discharges to SNFs, but SNFs do not appear to address depressive symptoms to enhance functioning and survival.

Importance The Centers for Medicare & Medicaid Services is beginning to consider adjusting for social risk factors, such as dual eligibility for Medicare and Medicaid, when evaluating hospital performance under value-based purchasing programs. It is unknown whether dual eligibility represents a unique domain of social risk or instead represents clinical risk unmeasured by variables available in traditional Medicare claims. Objective To assess how dual eligibility for Medicare and Medicaid is associated with risk-adjusted readmission rates after surgery. Design, Setting, and Participants A retrospective cohort study was conducted of 55 651 Medicare beneficiaries undergoing general, vascular, and gynecologic surgery at 62 hospitals in Michigan between January 1, 2014, and December 1, 2016. Representative cohorts were derived from traditional Medicare claims (n = 29 710) and the Michigan Surgical Quality Collaborative (MSQC) clinical registry (n = 25 941), which includes additional measures of clinical risk. Statistical analysis was conducted between April 10 and July 15, 2019. The association between dual eligibility and risk-adjusted 30-day readmission rates after surgery was compared between models inclusive and exclusive of additional measurements of clinical risk. The study also examined how dual eligibility is associated with hospital profiling using risk-adjusted readmission rates. Exposures Dual eligibility for Medicare and Medicaid. Main Outcomes and Measures Risk-adjusted all-cause 30-day readmission after surgery. Results There were a total of 3986 dual-eligible beneficiaries in the Medicare claims cohort (2554 women; mean [SD] age, 72.9 [6.9] years) and 1608 dual-eligible beneficiaries in the MSQC cohort (990 women; mean [SD] age, 72.9 [6.8] years). In both data sets, higher proportions of dual-eligible beneficiaries were younger, female, and nonwhite than Medicare-only beneficiaries (Medicare claims cohort: female, 2554 of 3986 [64.1%] vs 12 879 of 25 724 [50.1%]; nonwhite, 1225 of 3986 [30.7%] vs 2783 of 25 724 [10.8%]; MSQC cohort: female, 990 of 1608 [61.6%] vs 12 578 of 24 333 [51.7%]; nonwhite, 416 of 1608 [25.9%] vs 2176 of 24 333 [8.9%]). In the Medicare claims cohort, dual-eligible beneficiaries were more likely to be readmitted (15.5% [95% CI, 13.7%-17.3%]) than Medicare-only beneficiaries (13.3% [95% CI, 12.7%-13.9%]; difference, 2.2 percentage points [95% CI, 0.4-3.9 percentage points]). In the MSQC cohort, after adjustment for more granular measures of clinical risk, dual eligibility was not significantly associated with readmission (difference, 0.6 percentage points [95% CI, –1.0 to 2.2 percentage points]). In both the Medicare claims and MSQC cohorts, adding dual eligibility to risk-adjustment models had little association with hospital ranking using risk-adjusted readmission rates. Conclusions and Relevance This study suggests that dual eligibility for Medicare and Medicaid may reflect unmeasured clinical risk of readmission in claims data. Policy makers should consider incorporating more robust measures of social risk into risk-adjustment models used by value-based purchasing programs.

COVID-19 has revealed gaps in services and supports for older adults, even as needs for health and social services have dramatically increased and may produce a cascade of disability after the pandemic subsides. In this essay, we discuss the perfect storm of individual and environmental risk factors, including deconditioning, reductions in formal and informal care support, and social isolation. We then evaluate opportunities that have arisen for strengthening person-centered services and supports for older adults, through in-home acute and primary medical care, aggressive use of video telehealth and social interaction, and implementation of volunteer or paid intergenerational service.

Key Points Question Are financial incentives from Medicare’s Hospital Readmissions Reduction Program associated with hospital readmission performance? Findings This cohort study using Medicare performance data from 2823 hospitals from 2016 to 2019 found that hospitals with greater incentives for readmission avoidance had larger decreases in excess readmission, whereas hospitals with no incentives had increases in excess readmissions across Hospital Readmissions Reduction Program–targeted conditions. Meaning The findings suggest that the penalty incentives in the readmissions program were associated with improvements in readmission avoidance., Importance The strongest evidence for the effectiveness of Medicare's Hospital Readmissions Reduction Program (HRRP) involves greater reductions in readmissions for hospitals receiving penalties compared with those not receiving penalties. However, the HRRP penalty is an imperfect measure of hospitals' marginal incentive to avoid a readmission for HRRP-targeted diagnoses. Objectives To assess the association between hospitals’ condition-specific incentives and readmission performance and to examine the responsiveness of hospitals to condition-specific incentives compared with aggregate penalty amounts. Design, Setting, and Participants This retrospective cohort analysis used Medicare readmissions data from 2823 US short-term acute care hospitals participating in HRRP to compare 3-year (fiscal years 2016-2019) follow-up readmission performance according to tertiles of hospitals' baseline (2016) marginal incentives for each of 5 HRRP-targeted conditions (acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, pneumonia, and hip and/or knee surgery). Main Outcomes and Measures Linear regression models were used to estimate mean change in follow-up readmission performance, measured using the excess readmissions ratio, with baseline condition-specific incentives and aggregate penalty amounts. Results Of 2823 hospitals that participated in the HRRP from baseline to follow-up, 2280 (81%) had more than 1 excess readmission for 1 or more applicable condition and 543 (19%) did not have any excess readmissions. The mean (SD) financial incentive to reduce readmissions for incentivized hospitals ranged from $8762 ($3699) to $58 158 ($26 198) per 1 avoided readmission. Hospitals with greater incentives for readmission avoidance had greater decreases in readmissions compared with hospitals with smaller incentives (45% greater for pneumonia, 172% greater for acute myocardial infarction, 40% greater for hip and/or knee surgery, 32% greater for chronic obstructive pulmonary disease, and 13% greater for heart failure), whereas hospitals with no incentives had increases in excess readmissions of 4% to 7% (median, 4% [percentage change for nonincentivized hospitals was 3.7% for pneumonia, 4.2% for acute myocardial infarction, 7.1% for hip and/or knee surgery, 3.7% for chronic obstructive pulmonary disease, and 3.7% for heart failure]; P, This cohort study assesses the association of incentives from Medicare’s Hospital Readmissions Reduction Program with hospital readmission performance from 2016 to 2019.

INTRODUCTION: This study develops a measure of Alzheimer’s disease and Related Dementias (ADRD) using Medicare claims. METHODS: Validation resembles the approach of the American Psychological Association, including (i) content validity, (ii) construct validity, and (iii) predictive validity. RESULTS: We found that four items -- a Medicare claim recording ADRD 1-year ago, 2-years ago, 3-years ago, and a total stay of 6-months in a nursing home -- exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD. DISCUSSION: Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.

Background To evaluate the association between social capital and 30-day readmission to the hospital among Medicare beneficiaries overall, beneficiaries with dementia and related memory disorders, and beneficiaries with dual eligibility for Medicaid. Methods Using Health and Retirement Study (HRS) data linked with 2008–2015 Medicare claims from traditional Medicare beneficiaries hospitalized during the study period (1246 unique respondents, 2212 total responses), we examined whether dementia and related memory disorders and dual eligibility were associated with social capital. We then estimated a multiple regression model to test whether social capital was associated with a reduced likelihood of readmission. Results Dementia was associated with an − 0.241 standard deviation (sd) change in social capital (95% CI: − 0.378, − 0.103), dual eligibility with a − 0.461 sd change (95% CI: − 0.611, − 0.310), and the occurrence of both was associated with an additional − 0.236 sd change (95% CI: − 0.525, − 0.053). 30-day readmission rates were 14.47% over the study period. In both adjusted and unadjusted models, social capital was associated with small and nonsignificant differences in 30-day readmissions. These effects did not vary across dementia status and socioeconomic status. Conclusions Dementia and dual eligibility were associated with lower social capital, but social capital was not associated with the risk of readmission for any population.

BACKGROUND: To address concerns that the Hospital Readmissions Reduction Program (HRRP) unfairly penalized safety net hospitals treating patients with high social and functional risks, Medicare recently modified HRRP to compare hospitals with similar proportions of high-risk, dual-eligible patients (“peer group hospitals”). Whether the change fully accounts for patients’ social and functional risks is unknown. OBJECTIVE: Examine risk-standardized readmission rates (RSRRs) and hospital penalties after adding patient-level social and functional and community-level risk factors. DESIGN: Using 2000-2014 Medicare hospital discharge, Health and Retirement Study, and community-level data, latent factors for patient social and functional factors and community factors were identified. We estimated RSRRs for peer groups and by safety net status using four hierarchical logistic regression models: “base” (HRRP model); “patient” (base plus patient factors); “community” (base plus community factors); and “full” (all factors). The proportion of hospitals penalized was calculated by safety net status. PATIENTS: 20,255 fee-for-service Medicare beneficiaries (65+) with eligible index hospitalizations MAIN MEASURES: RSRRs KEY RESULTS: Half of safety net hospitals are in peer group 5. Compared with other hospitals, peer group 5 hospitals (most dual-eligibles) treated sicker, more functionally limited patients from socially disadvantaged groups. RSRRs decreased by 0.7% for peer groups 2 and 4 and 1.3% for peer group 5 under the patient and full (versus base) models. Measured performance improved after adjusting for patient risk factors for hospitals in peer group 4 and 5 hospitals, but worsened for those in peer groups 1, 2, and 3. Under the patient (versus base) model, fewer safety net hospitals (48.7% versus 51.3%) but more non-safety net hospitals (50.0% versus 49.1%) were penalized. CONCLUSIONS: Patient-level risk adjustment decreased RSRRs for hospitals serving more at-risk patients and proportion of safety net hospitals penalized, while modestly increasing RSRRs and proportion of non-safety net hospitals penalized. Results suggest HRRP modifications may not fully account for hospital variation in patient-level risk. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06222-1) contains supplementary material, which is available to authorized users.

We examined the financial incentives to avoid readmissions under Medicare’s Hospital Readmission Reduction Program for safety-net hospitals (SNHs) and teaching hospitals (THs) compared with other hospitals. Using Medicare’s FY2016 Hospital Compare and readmissions data for 2,465 hospitals, we tested for differential revenue gains for SNHs ( n = 658) relative to non-SNHs ( n = 1,807), and for major ( n = 231) and minor ( n = 591) THs relative to non-THs ( n = 1,643). We examined hospital-level factors predicting differences in revenue gains by hospital type. The revenue gains of an avoided readmission were 10% to 15% greater for major THs compared with non-THs ($18,047 vs. $15,478 for acute myocardial infarction) but no different for SNHs compared with non-SNHs. The greater revenue gains for THs were strongly positively predicted by hospitals’ poor initial readmission performance. We found little evidence that the Hospital Readmission Reduction Program creates disincentives for SNHs and THs to invest in readmission reduction efforts, and THs have greater returns from readmissions avoidance than non-THs.

Objectives To compare the accuracy of and factors affecting the accuracy of self‐reported fall‐related injuries (SFRIs) with those of administratively obtained FRIs (AFRIs). Design Retrospective observational study Setting United States Participants Fee‐for‐service Medicare beneficiaries aged 65 and older (N=47,215). Measurements We used 24‐month self‐report recall data from 2000–2012 Health and Retirement Study data to identify SFRIs and linked inpatient, outpatient, and ambulatory Medicare data to identify AFRIs. Sensitivity and specificity were assessed, with AFRIs defined using the University of California at Los Angeles/RAND algorithm as the criterion standard. Logistic regression models were used to identify sociodemographic and health predictors of sensitivity. Results Overall sensitivity and specificity were 28% and 92%. Sensitivity was greater for the oldest adults (38%), women (34%), those with more functional limitations (47%), and those with a prior fall (38%). In adjusted results, several participant factors (being female, being white, poor functional status, depression, prior falls) were modestly associated with better sensitivity and specificity. Injury severity (requiring hospital care) most substantively improved SFRI sensitivity (73%). Conclusion An overwhelming 72% of individuals who received Medicare‐reimbursed health care for FRIs failed to report a fall injury when asked. Future efforts to address underreporting in primary care of nonwhite and healthier older adults are critical to improve preventive efforts. Redesigned questions—for example, that address stigma of attributing injury to falling—may improve sensitivity.

OBJECTIVE: To estimate expenditures for fall-related injuries (FRIs) among older Medicare beneficiaries. DATA SOURCES: The 2007-2009 Medicare claims and 2008 Health and Retirement Study (HRS) data for 5,497 (228 FRI and 5,269 non-FRI) beneficiaries. STUDY DESIGN: FRIs were indicated by inpatient/outpatient ICD-9 diagnostic codes for fractures, trauma, dislocations, and by e-codes. A pre-post comparison group design was used to estimate the differential change in pre-post expenditures for the FRI relative to the non-FRI cohort (FRI expenditures). Out-of-pocket (OOP) costs, service category total annual FRI-related Medicare expenditures, expenditures related to the type of initial FRI treatment (inpatient, ED, outpatient), and the risk of persistently high expenditures (4th quartile for each post-FRI quarter) were estimated. PRINCIPAL FINDINGS: Estimated FRI expenditures were $9,389 (95 percent CI: $5,969-$12,808). Inpatient, physician/outpatient, skilled nursing facility, and home health comprised 31, 18, 39, and 12 percent of the total. OOP costs were $1,363.0 (95 percent CI: $889-$1,837). Expenditures for FRIs initially treated in inpatient/ED/outpatient settings were $21,424/$6,142/$8,622. The FRI cohort had a 64 percent increased risk of persistently high expenditures. Total Medicare expenditures were $13 billion (95 percent CI: $9-$18 billion). CONCLUSIONS: FRIs are associated with substantial, persistent Medicare expenditures. Cost-effectiveness of multifactorial falls prevention programs should be assessed using these expenditure estimates.© Health Research and Educational Trust. Language: en

Key Points Question What are older adults’ risks of fall injuries in the periods surrounding hospitalization? Findings This retrospective cohort study using national survey and linked Medicare data observed spikes in older adult fall injury risk in the periods just before and after hospitalization. Risk increases were particularly pronounced for those who experienced an inpatient fall injury. Meaning These findings suggest that efforts to improve coordination of fall injury risk during care transitions into and out of the hospital are needed., This cohort study estimates the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization., Importance To date, measurement and treatment of older adult fall injury has been siloed within specific care settings, such as a hospital or within a nursing home or community. Little is known about changes in fall risk across care settings. Understanding the occurrence of falls across settings has implications for measuring and incentivizing high-value care across care settings. Objective To estimate the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization. Design, Setting, and Participants This cohort study is a longitudinal analysis of 12-month periods that include an anchor hospital stay using national data from 2006 to 2014. Participants included older (aged ≥65 years) Medicare fee-for-service beneficiaries from the Health and Retirement Study. Weekly fall injury rates were computed for 4 periods compared with the anchor hospitalization: at baseline (1-6 months before hospitalization), just before (

Key Points Question Is Medicare’s Hospital Readmissions Reduction Program associated with changes in the probability of readmission for discharged patients revisiting the emergency department (ED)? Findings In this cohort study including data for 9 914 068 patients, the Hospital Readmissions Reduction Program was associated with a 1.4% decrease in readmissions at the ED revisit. The program was associated with 1.2% fewer readmissions from the ED involving clinical presentations for which admission is usually indicated. Meaning These findings suggest that the Hospital Readmissions Reduction Program was associated with changes in the probability of readmission for certain conditions, highlighting the critical and evolving role of the ED in hospital readmission patterns., This cohort study examines the association of the implementation of Medicare’s Hospital Readmissions Reduction Program (HRRP) with changes in the probability of readmission among recently discharged patients revisiting the emergency department., Importance The Medicare Hospital Readmissions Reduction Program (HRRP) is associated with reduced readmission rates, but it is unknown how this decrease occurred. Objective To examine whether the HRRP was associated with changes in the probability of readmission at emergency department (ED) visits after hospital discharge (ED revisits) overall and depending on whether admission is typically indicated for the patient’s condition at the ED revisit. Design, Setting, and Participants This retrospective cohort study used hospital and ED discharge data from California, Florida, and New York from January 1, 2010, to December 31, 2014. A difference-in-differences analysis examined change in readmission probability at ED revisits for recently discharged patients; ED revisits with clinical presentations for which admission is typically indicated vs those for which admission is more variable (ie, discretionary) were examined separately. Inclusion criteria were Medicare patients 65 years and older who revisited an ED within 30 days of inpatient discharge. Data were analyzed from December 18, 2018, to September 11, 2019. Exposures Before and after HRRP implementation among patients initially hospitalized for targeted vs nontargeted conditions. Main Outcomes and Measures Thirty-day unplanned hospital readmissions at the ED revisit. Results A total of 9 914 068 index hospitalizations were identified in California, Florida, and New York from 2010 to 2014. Of 2 052 096 discharges in 2010, 1 168 126 (56.9%) discharges were women and 566 957 discharges (27.6%) were among patients older than 85 years. Among 1 421 407 patients with an unplanned readmission within 30 days of discharge, 1 266 107 patients (89.1%) were admitted through the ED. A total of 1 906 498 ED revisits were identified. After adjusting for patient demographic and clinical characteristics from the index hospitalization, HRRP implementation was associated with fewer readmissions from the ED, with a difference-in-difference estimate of −0.9 (95% CI, −1.4 to −0.4) percentage points (P

This study aimed (1) to estimate the impact of an incremental reduction in excess readmissions on a hospital’s Medicare reimbursement revenue, for hospitals subject to penalties under the Medicare’s Hospital Readmissions Reduction Program and (2) to evaluate the economic case for an investment in a readmission reduction program. For 2,465 hospitals with excess readmissions in the Fiscal Year 2016 Hospital Compare data set, we (1) used the Hospital Readmissions Reduction Program statute to estimate hospital-specific Medicare reimbursement gains per an avoided readmission and (2) carried out a pro forma analysis of investment in a broad-scale readmission reduction program under conservative assumptions regarding program effectiveness and using program costs from earlier studies. For an average hospital, avoiding one excess readmission would result in reimbursement gains of $10,000 to $58,000 for Medicare discharges. The economic case for investments in a readmission reduction effort was strong overall, with the possible exception of hospitals with low excess readmissions.

Older spousal caregiving relationships involve support that may be affected by the health of either the caregiver or care recipient. We conducted a longitudinal analysis using pooled data from 4,632 community-dwelling spousal care recipients and caregivers aged ⩾50 from the 2002 to 2014 waves of the Health and Retirement Study. We specified logistic and negative binomial regression models using lagged predictor variables to assess the role of partner health status on spousal caregiver and care recipient health care utilization and physical functioning outcomes. Care recipients’ odds of hospitalization, odds ratio (OR): 0.83, p

Background Although common and preventable, healthcare-acquired infections (HAI) are associated with high risk for hospital readmission. This risk may increase when follow-up care is not provided. However, whether infection-related readmissions are more common in older adults discharged from the hospital to a skilled nursing facility (SNF) vs. home or home healthcare is unknown. Methods We used 2013–14 national discharge data and logistic regression models to retrospectively examine the relationship of discharge disposition (home, SNF, home healthcare) with unplanned readmission for the same HAI observed at the index admission, among Medicare beneficiaries 65, controlling for patient sociodemographics, comorbidity score, and length of stay during index hospitalization. Results Of 318,134 index admissions involving HAI treatment, 158,682 (50%) were discharged to a SNF, 76,523 (24%) to home, and 82,929 (26%) to home health. Overall, 7,867 (2.5%) of index admissions involving treatment for an HAI resulted in a linked HAI readmission. HAI readmissions were more common for Clostridium difficile infections (4.0%) and urinary tract infections (UTI, 2.3%) than for ventilator-acquired pneumonia (1.4%) or surgical site infections (1.1%) (P < 0.001). Being discharged home or to home healthcare, compared with a SNF, was associated with increased odds (OR: 1.63, P < 0.001 for each) of HAI readmission. This was equivalent to a 1.2% lower risk of a linked HAI readmission for those discharged to a SNF compared with home or home healthcare. This risk difference was observed to increase with greater patient comorbidity scores. Conclusion We conclude that Clostridium difficile and UTIs result in higher risk for readmission than other HAIs. Patients discharged to nursing facilities are protected from readmission. Further research into identifying modifiable mechanisms for HAI readmission, in order to improve post-hospital care of infection at home, is needed. Disclosures All authors: No reported disclosures.

This study examined differences between paid and unpaid family/friend caregivers to better understand the consumer-driven caregiving workforce. We compared economic vulnerability, unhealthy behavior, and serious emotional distress for 475 paid and 10,500 unpaid family/friend informal caregivers from the 2009 California Health Interview Survey. We then estimated whether caregiver status moderated the relationship between economic vulnerability and health outcomes. Compared to unpaid family/friend caregivers, paid family/friend caregivers had a 27% greater risk ( p = .002) of economic vulnerability. Among all family/friend caregivers, the probabilities of serious emotional distress and unhealthy behaviors increased by >100% and 28% for those with the greatest compared to the least economic vulnerability, and caregiver type did not moderate these relationships. To address economic and health vulnerabilities of paid informal caregivers, policy makers might increase wages in consumer-driven programs. These changes could prove beneficial to both paid informal caregivers and their care recipients, while reducing long-term inefficiencies in consumer-driven programs.

Rationale Falls are common among older adults and may be related to depressive symptoms (DS). With advancing age, there is an onset of chronic conditions, sensory impairments, and activity limitations that are associated with falls and with depressive disorders. Prior cross-sectional studies have observed significant associations between DS and subsequent falls as well as between fractures and subsequent clinical depression and DS. Objective The directionality of these observed relationship between falls and DS is in need of elaboration given that cross-sectional study designs can yield biased estimates of the DS-falls relationship. Methods Using 2006–2010 Health and Retirement Study data, cross-lagged panel structural equation models were used to evaluate associations between falls and DS among 7233 community-dwelling adults ages ≥65. Structural coefficients between falls and DS (in 2006→2008, 2008→2010) were estimated. Results A good-fitting model was found: Controlling for baseline (2006) physical functioning, vision, chronic conditions, and social support and neighborhood social cohesion, falls were not associated with subsequent DS, but a 0.5 standard deviation increase in 2006 DS was associated with a 30% increase in fall risk two years later. This DS-falls relationship was no longer significant when use of psychiatric medications, which was positively associated with falls, was included in the model. Conclusion Using sophisticated methods and a large U.S. sample, we found larger magnitudes of effect in the DS-falls relationship than in prior studies—highlighting the risk of falls for older adults with DS. Medical providers might assess older individuals for DS as well as use of psychotropic medications as part of a broadened falls prevention approach. National guidelines for fall risk assessments as well as quality indicators for fall prevention should include assessment for clinical depression.

BackgroundFalls and fall-related injuries (FRI) are common and costly occurrences among older adults living in the community, with increased risk for those with physical and cognitive limitations. Caregivers provide support for older adults with physical functioning limitations, which are associated with fall risk.DesignUsing the 2004-2012 waves of the Health and Retirement Study, we examined whether receipt of low (0-13 weekly hours) and high levels (≥14 weekly hours) of informal care or any formal care is associated with lower risk of falls and FRIs among community-dwelling older adults. We additionally tested whether serious physical functioning (≥3 activities of daily living) or cognitive limitations moderated this relationship.ResultsCaregiving receipt categories were jointly significant in predicting noninjurious falls (P=0.03) but not FRIs (P=0.30). High levels of informal care category (P=0.001) and formal care (P

Importance National injury surveillance systems use administrative data to collect information about severe fall-related trauma and mortality. Measuring milder injuries in ambulatory clinics would improve comprehensive outcomes measurement across the care spectrum. Objectives To assess a flexible set of administrative data–only algorithms for health systems to capture a greater breadth of injuries than traditional fall injury surveillance algorithms and to quantify the algorithm inclusiveness and validity associated with expanding to milder injuries. Design, Setting, and Participants In this longitudinal diagnostic study of 13 939 older adults (≥65 years) in the nationally representative Health and Retirement Study, a survey was conducted every 2 years and was linked to hospital, emergency department, postacute skilled nursing home, and outpatient Medicare claims (2000-2012). During each 2-year observation period, participants were considered to have sustained a fall-related injury (FRI) based on a composite reference standard of having either an external cause of injury (E-code) or confirmation by the Health and Retirement Study patient interview. A framework involving 3 algorithms withInternational Classification of Diseases, Ninth Revisioncodes that extend FRI identification with administrative data beyond the use of fall-related E-codes was developed: an acute care algorithm (head and face or limb, neck, and trunk injury reported at the hospital or emergency department), a balanced algorithm (all acute care algorithm injuries plus severe nonemergency outpatient injuries), and an inclusive algorithm (almost all injuries). Data were collected from January 1, 1998, through December 31, 2012, and statistical analysis was performed from August 1, 2016, to March 1, 2019. Main Outcomes and Measures Validity, measured as the proportion of potential FRI diagnoses confirmed by the reference standard, and inclusiveness, measured as the proportion of reference-standard FRIs captured by the potential FRI diagnoses. Results Of 13 939 participants, 1672 (42.4%) were male, with a mean (SD) age of 77.56 (7.63) years. Among 50 310 observation periods, 9270 potential FRI diagnoses (18.4%) were identified; these were tested against 8621 reference-standard FRIs (17.1%). Compared with the commonly used method of E-coded–only FRIs (2-year incidence, 8.8% [95% CI, 8.6%-9.1%]; inclusion of 51.5% [95% CI, 50.4%-52.5%] of the reference-standard FRIs), FRI inclusion was increased with use of the study framework of algorithms. With the acute care algorithm (2-year incidence, 12.6% [95% CI, 12.4%-12.9%]), validity was prioritized (88.6% [95% CI, 87.4%-89.8%]) over inclusiveness (62.1% [95% CI, 61.1%-63.1%]). The balanced algorithm showed a 2-year incidence of 14.6% (95% CI, 14.3%-14.9%), inclusion of 65.3% (95% CI, 64.3%-66.3%), and validity of 83.2% (95% CI, 81.9%-84.6%). With the inclusive algorithm, the number of potential FRIs increased compared with the E-code–only method (2-year incidence, 17.4% [95% CI, 17.1%-17.8%]; inclusion, 68.4% [95% CI, 67.4%-69.3%]; validity, 75.2% [95% CI, 73.7%-76.6%]). Conclusions and Relevance The findings suggest that use of algorithms withInternational Classification of Diseases, Ninth Revisioncodes may increase inclusion of FRIs by health care systems compared with E-codes and that these algorithms may be used by health systems to evaluate interventions and quality improvement efforts.

Key Points Question To what extent do falls play a role in hospital readmissions for older patients, including those with acute geriatric risk factors? Findings This cohort study using Hospital Cost and Utilization Project data from 8.3 million Medicare beneficiaries found that fall-related injuries ranked as high as the third-leading readmission diagnosis, depending on the type of initial hospitalization. Fall injuries ranked still higher for patients with a high preexisting risk of falling and for those discharged home or to home health care rather than to a skilled nursing facility. Meaning Fall-related injuries are leading diagnoses for hospital readmissions, particularly for at-risk older adults discharged home, highlighting the need for greater attention to transitional prevention strategies to avoid postdischarge falls., This cohort study of data from the Hospital Cost and Utilization Project Nationwide Readmissions Database compares 30-day fall-related readmissions with other leading rehospitalization diagnoses in Medicare beneficiaries 65 years and older with a variety of index admissions., Importance Falls are common among older adults, particularly those with previous falls and cognitive impairment and in the postdischarge period. Hospitals have financial incentives to reduce both inpatient falls and hospital readmissions, yet little is known about whether fall-related injuries (FRIs) are common diagnoses for 30-day hospital readmissions. Objective To compare fall-related readmissions with other leading rehospitalization diagnoses, including for patients at greatest risk of readmission. Design, Setting, and Participants Retrospective cohort study of the Hospital Cost and Utilization Project’s Nationwide Readmissions Database of nationally representative US hospital discharges among Medicare beneficiaries aged 65 years and older from January 1, 2013, to November 30, 2014. The prevalence and ranking of FRIs compared with other diagnostic factors for 30-day unplanned hospital-wide readmissions were determined, overall and for 2 acute geriatric cohorts, classified by fall injury or cognitive impairment diagnoses observed at the index admission. Analyses were also stratified by patient discharge disposition (home, home health care, skilled nursing facility). Analyses were conducted from February 1, 2018, to February 26, 2018. Main Outcomes and Measures Unplanned hospital-wide readmission within 30 days of discharge. Results From the database, 8 382 074 eligible index admissions were identified, including 746 397 (8.9%) in the FRI cohort and 1 367 759 (16.3%) in the cognitive impairment cohort. Among the entire 8 382 074-discharge cohort, mean (SD) age was 77.7 (7.8) years and 4 736 281 (56.5%) were female. Overall, 1 205 962 (14.4%) of index admissions resulted in readmission, with readmission rates of 12.9% for those with a previous fall and 16.0% for patients with cognitive impairment. Overall, FRIs ranked as the third-leading readmission diagnosis, accounting for 60 954 (5.1%) of all readmission diagnoses. Within the novel acute geriatric cohorts, FRIs were the second-leading diagnosis for readmission both for patients with an FRI at index admission (10.3% of all readmission diagnoses) and those with cognitive impairment (7.0% of all readmission diagnoses). For those with an FRI at index admission and discharged home or to home health care, FRIs were the leading readmission diagnosis. Conclusions and Relevance This study found that posthospital FRIs were a leading readmission diagnosis, particularly for patients originally admitted with a FRI or cognitive impairment. Targeting at-risk hospitalized older adults, particularly those discharged to home or home health care, is an underexplored, cost-effective mechanism with potential to reduce readmissions and improve patient care.

OBJECTIVES: Compare expenditures of fall-related injuries (FRIs) using several methods to identify FRIs in administrative claims data. RESEARCH DESIGN: Using 2007-2009 Medicare claims and 2008 Health and Retirement Survey data, FRIs were identified using external-cause-of-injury (e-codes 880/881/882/884/885/888) only, e-codes plus a broad set of primary diagnosis codes, and a newer approach using e-codes and diagnostic and procedural codes. Linear regression models adjusted for sociodemographic, health, and geographic characteristics were used to estimate per-FRI, service component, patient cost share, expenditures by type of initial FRI treatment (inpatient, emergency department only, outpatient), and total annual FRI-related Medicare expenditures. SUBJECTS: The analysis included 5497 community-dwelling adults ≥65 (228 FRI, 5269 non-FRI individuals) with continuous Medicare coverage and alive during the 24-month study. RESULTS: The 3 FRI identification methods produced differing distributions of index FRI type and varying estimated expenditures: $12,171 [95% confidence interval (CI), $4662-$19,680], $5648 (95% CI, $3819-$7476), and $9388 (95% CI, $5969-$12,808). In all models, most spending occurred in hospital, outpatient, and skilled nursing facility (SNF) settings, but greater proportions of SNF and outpatient spending were observed with commonly used FRI identification methods. Patient cost-sharing was estimated at $691-$1900 across the 3 methods. Inpatient-treated index FRIs were more expensive than emergency department and outpatient-treated FRIs across all methods, but were substantially higher when identifying FRI using only e-codes. Estimated total FRI-related Medicare expenditures were highly variable across methods. CONCLUSIONS: FRIs are costly, with implications for Medicare and its beneficiaries. However, expenditure estimates vary considerably based on the method used to identify FRIs. Language: en

Objectives Parents of newborns and children with special health care needs (CSHCN) often experience conflict between employment and family responsibilities. Family leave benefits such as the federal Family and Medical Leave Act and California's Paid Family Leave Insurance program help employed parents miss work to bond with a newborn or care for an ill child. The use of these benefits, however, is rare among mothers of CSHCN and fathers in general and limited even among mothers of newborns. We explored barriers to and experiences with leave-taking among parents of newborns and CSHCN. Methods We conducted semistructured qualitative interviews in 2008 with 10 mothers and 10 fathers of newborns and 10 mothers and 10 fathers of CSHCN in Los Angeles to explore their need for and experiences with family leave. Qualitative analytical techniques were used to identify themes in the transcripts. Results All parents reported difficulties in accessing and using benefits, including lack of knowledge by employers, complexity of rules and processes, and inadequacy of the benefits themselves. Parents of CSHCN also described being too overwhelmed to rapidly seek and process information in the setting of urgent and often unexpected health crises. Most parents expressed a clear desire for expert guidance and saw hospitals and clinics as potentially important providers. Conclusions Even when parents are aware of family leave options, substantial barriers prevent many, especially parents of CSHCN, from learning about or applying for benefits. Clinics and hospitals might be opportune settings to reach vulnerable parents at times of need.

Pooled data from the 2007, 2009, and 2011/2012 California Health Interview Surveys were used to compare the number of self-reported annual physician visits among 36,808 Medicare beneficiaries ≥65 in insurance groups with differential cost-sharing. Adjusted for adverse selection and a set of health covariates, Medicare fee-for-service (FFS) only beneficiaries had similar physician utilization compared with HMO enrollees but fewer visits compared with those with supplemental (1.04, p = .001) and Medicaid (1.55, p = .003) coverage. FFS only beneficiaries in very good or excellent health had fewer visits compared with those of similar health status with supplemental (1.30, p = .001) or Medicaid coverage (2.15, p = .002). For subpopulations with several chronic conditions, FFS only beneficiaries also had fewer visits compared with beneficiaries with supplemental or Medicaid coverage. Observed differences in utilization may reflect efficient and necessary physician utilization among those with chronic health needs.

Baby Boomers, persons born between the years of 1946 and 1964, are exhibiting worrying health trends. Although age-specific mortality rates and the proportion of Baby Boomers reporting poor or fair health declined substantially from 1982 to 1997, recent findings indicate significantly worse outcomes in chronic conditions such as obesity, diabetes, and cardiovascular disease (Martin, Freedman, Schoeni, & Andreski, 2009). Baby Boomers exhibit higher obesity rates and have been obese for longer periods of their lives compared with earlier generations (Leveille, Wee, & Iezzoni, 2005). Moreover, Baby Boomers have high rates of metabolic syndrome (Ford, Giles, & Dietz, 2002), which increases the risk for diabetes and for cardiovascular disease and mortality for middle-aged men (Lakka et al., 2002). Behavioral risk factors may have something to do with these increasingly poor health outcomes. For instance, physical inactivity and being overweight, among other behaviors or characteristics, contribute to chronic illness (Manson, Skerrett, Greenland, & VanItallie, 2004). Additionally, a World Bank study found that certain behavioral risk factors contributed significantly to years of lost life among 40- to 59-year-olds in high-income countries—5% of lost years of life was attributable to low fruit and vegetable intake, 5% to physical inactivity, and 31% to smoking among men (Lopez, Mathers, Ezzati, Jamison, & Murray, 2006). Although behavioral factors such as avoiding smoking, managing weight, and engaging in physical activity are essential to avoiding disability, many U.S. Baby Boomers are not engaging in healthy behaviors. Approximately 22% of 45- to 64-year-old adults are smokers (Centers for Disease Control and Prevention, 2009), and adults aged 55–64 years exhibit eating habits associated with poor nutritional quality (Davis, Murphy, Neuhaus, Gee, & Quiroga, 2000). Epidemiological research also indicates rising soda portion sizes, ranging from 12 to 20 fluid ounces (oz), among Americans (Nielsen & Popkin, 2003). The 2008 Physical Activity Guidelines for Americans indicate that “medium activity” (150–300 min of moderate-intensity activity or 75–150 min of vigorous-intensity physical activity per week) conveys substantial health benefits, but many Americans have low levels of physical activity (Department of Health and Human Services, 2008). Informal caregiving might be an additional cause for concern for Baby Boomers. The burden of caregiving is significant and well documented, and over 10 million adults over the age of 50—primarily Baby Boomers—care for an aging parent (MetLife, 2011). An estimated 3.3 million U.S. adults provided unpaid, informal care for a spouse in the past 12 months, and the percentage of 50- to 64-year-olds providing informal care is growing (National Family Caregivers Association, 2011). However, there is limited research to date regarding the combination of smoking, physical activity, and diet among caregivers—including Baby Boomer caregivers. Some studies have shown that caregivers engage in fewer health-promoting self-care behaviors (Acton, 2002), including their amount of exercise (Janevic & Connell, 2004). Compared with non-caregivers, certain adults caring for family members from multiple generations are less likely to exercise regularly but smoke marginally more cigarettes (Chassin, Macy, Seo, Presson, & Sherman, 2009). However, other earlier studies had insignificant findings. One study observed that caregivers did not significantly reduce their use of preventive services and did not report a higher number of missed meals, missed doctor appointments, missed flu shots, or higher levels of smoking (Burton, Newsom, Schulz, Hirsch, & German, 1997). Another study found that caregivers did not significantly differ from non-caregivers on 10 of 13 health practices or on the total number of positive health behaviors (Scharlach, Midanik, Runkle, & Soghikian, 1997). To further explore health behaviors of Baby Boomer caregivers, the present study used a representative statewide survey and adapted a theoretical stress model (Vitaliano et al., 2002) to examine smoking, sedentary behavior, and eating habits among Baby Boomer caregivers. The proposed model posits several pathways that might separately or jointly influence health behaviors, the first of which is exposure to stress. Stress may lead people to seek out pleasurable stimuli (Zillman & Bryant, 1985) and raises hormone levels that over time may alter health behaviors (Vitaliano, Zhang, & Scanlan, 2003). Stress exposure among younger adults, for instance, has been associated with higher consumption of sweets, including soda (Elfhag, Tholin, & Rasmussen, 2008), and high-fat and high-caloric food (Zellner et al., 2006). Stress has also been associated with lower levels of physical activity and increased rates of smoking among working adults (Ng & Jeffery, 2003). Psychological distress resulting from exposure to caregiving is the second potential pathway to poor health behavior. Distress is negative affect or depressed mood, hassles, burden, and absence of positive experiences in response to chronic stress (Vitaliano et al., 2002). Researchers have observed associations between psychological distress and eating, including sugar and soda consumption (Shi, Taylor, Wittert, Goldney, & Gill, 2010), as well as smoking (Pratt, Dey, & Cohen, 2007). One study found that adults with high stress levels have higher depression levels and lower participation in sports activities (Wijndaelea et al., 2007). Personal or social resources may also affect distress and health behaviors. Women are more likely to engage in stress-induced eating (Greeno & Wing, 1994), and income is negatively associated with depression levels (Schulz, Tompkins, & Rau, 1988) as well as health behaviors such as smoking, physical activity, and diet; additionally, education and occupation may influence health behavior (Laaksonen, Prattala, Helasoja, Uutela, & Lahelma, 2003). Married persons have better psychological well-being compared with those who are single (Shapiro & Keyes, 2008). Although employment may function as a type of personal resource, it may also create “negative spillover” from the workplace to the household, causing psychological distress (Riley & Bowen, 2005). Additionally, individuals living in less socially cohesive neighborhoods are more likely to smoke and less likely to exercise (Clark et al., 2008). Caregiving itself involves chronic stress and psychological distress (Schulz & Sherwood, 2008), and different types or amounts of caregiving may involve varying levels of stress exposure. For instance, spousal caregivers provide the most all-inclusive care (Pinquart & Sorensen, 2003b) and are at risk for psychological distress (Pruchno & Potashnik, 1989) and less nutritious eating (Connell, 1994). Moreover, the number of stressors experienced by spousal caregivers explained roughly one quarter of their depression and one half of their stress levels (Vedhara, Shanks, Anderson, & Lightman, 2000). Although there is some evidence that burden and distress levels do not differ among caregivers caring for biologically related family members compared with in-laws (Pinquart & Sorenson, 2011), caregiver strain is associated with the caregiver living situation (Deimling, Bass, Townsend, & Noelker, 1989). At the same time, the amount or level of caregiving provided are negatively associated with exercise (Sisk, 2000) and health-risk behaviors (Burton, Zdaniuk, Schulz, Jackson, & Hirsch, 2003). In this study, we were interested in testing for associations between caregivers’ exposure to stress and negative health behaviors, controlling for psychological distress, and personal and social resources. The negative health behaviors we examined were smoking, sedentary behavior, regular soda and fast-food consumption, as well as global, negative health behavior. For the present study, we developed three separate hypotheses to test, based on Vitaliano’s stress model: Controlling for other factors, caregivers will be more likely than non-caregivers to engage in negative health behavior (H1); Controlling for other factors, spousal caregivers will be more likely than other caregivers to engage in negative health behavior (H2); and Controlling for other factors, more weekly caregiver hours and a greater total duration of caregiving time will each be associated with negative health behavior (H3).

This policy brief profiles California's informal caregivers—adults who provide care to a family member or friend coping with an illness or disability. Although caregivers appear to be as healthy as noncaregivers of the same age, they report higher levels of psychological distress and engagement in poor health-related behaviors, such as smoking. Middle-aged caregivers may be at greatest risk for poor health outcomes such as high blood pressure, diabetes and heart disease. Few caregivers are paid for their work or use state services that might help alleviate both financial and psychological burdens. Caregivers should foresee difficult times ahead, given recent state budget cuts to programs that support caregivers, and older and disabled adults.