For older adults to decide whether inguinal hernia repair will meaningfully improve their lives, it is critical to (1) understand how the operation affects them and whether it enhances outcomes that matter to them, and (2) identify ways to improve how surgeons discuss the benefits of surgery and how they prepare older adults for postoperative recovery.
We conducted semi-structured interviews with 40 Veterans ≥ 65 years old who had inguinal hernia repair at two high-volume Veterans Affairs hospitals.
Participants were all men; their mean age was 73 years, 65% were White, and 33% were Black. Older adults felt that the surgical team provided excellent reassurance regarding the safety and efficacy of surgery but expressed a desire for improved listening during preoperative counseling and for clearer communication regarding the reality of postoperative recovery. Veterans reported a return to baseline physical and cognitive function between 2 days and 6 weeks after surgery, though two Veterans experienced significant short-term cognitive dysfunction. Those who reported dissatisfaction with preoperative communication were more likely to be surprised or concerned about postoperative symptoms.
Our study provides critical information on how hernia repair affects the lives of older adults, and this can be used to better prepare the patients for surgery and to help them decide whether surgery will meaningfully enhance their quality of life.
Patients aged 65+ are underrepresented in surgical clinical trials, and few studies have explored the unique barriers that limit participation of older adults in surgical trials. We aimed to identify barriers and facilitators to participation in surgical randomized trials among adults aged 65+.
Patients aged 65+ years having hernia surgery at two high-volume Veterans' Affairs hospitals.
We conducted semi-structured interviews to identify barriers and facilitators to participation in clinical trials. Interviews were analyzed with directed content analysis.
We interviewed 40 Veterans aged 65+ years. The most frequently cited barriers to participation were logistical (e.g., needing to visit the hospital more frequently) and emotional (e.g., medical mistrust, fear of hospitals, and fear of bodily harm). COVID-19 pandemic-related misinformation was commonly cited by these participants as a justification for medical mistrust. The most frequently cited motivators to participate in trials were altruism, access to novel treatments, increased time with clinicians, and advancing scientific knowledge. Patients uncertain about participation were potentially persuadable by referencing the impact of the trial on their friends and family, or by increasing transparency around trial purpose and design. Notably, using virtual visits to minimize travel to the hospital was not regarded as a viable way to address logistical barriers.
Increasing the participation of older adults in surgical clinical trials will require a multi-factorial strategy that emphasizes communication of benefits to more than just the patient and includes deliberate planning to combat misperceptions and misinformation.
Cover caption: Outcomes of high-risk surgery in patients living with ADRD compared to those without. See the related article by Shah et al., pages 3434–3443.
Recent payment reforms in the United States have been credited with reducing the use of institutional post-acute care (PAC) after total knee arthroplasty (TKA) and total hip arthroplasty (THA). This dual-country study of Canada and the United States compares longitudinal trends in discharge to institutional PAC after primary TKA or THA.
We conducted serial cross-sectional analyses to compare discharge to institutional PAC trends among adults aged ≥ 66 years undergoing primary TKA or THA in the United States and Canada from 2013 to 2019. Patient-level data were obtained from population-based Medicare claims in the United States and analogous datasets in Ontario. Discharge trends were assessed using standardized differences and linear regression models to evaluate relative changes over time.
Patients receiving TKA (2,308,001) and THA (1,234,149) in the United States and Ontario (106,721 and 53,371, respectively) were similar in age (73–74 years) and sex (~60% female). The absolute reduction in institutional PAC discharge over time for TKA was greater in the United States (slope = −3.59) than in Canada (slope = −0.53) (p < 0.0001), but relative reductions (slope = −8.78 in the United States, slope = −6.99 in Canada) were statistically similar (p = 0.08). THA showed a similar trend of absolute reductions; however, the relative reduction trend in the United States (slope = −9.98) was steeper than in Canada (slope = −6.46) (p = 0.0009).
The US payment reforms from 2013 to 2019 were associated with a greater impact on reducing institutional PAC utilization for THA than for TKA.
Population-level interventions are needed to address the overrepresentation of older pedestrians in deaths from traffic crashes. Data are absent on whether specific publicly licensed or public establishments are associated with increased risk to older pedestrians, despite their attractiveness as partners for government efforts. We conducted a nationwide location-based case–control study to examine the associations between publicly licensed or public establishments of daily living for older adults and the location of pedestrian fatalities in motor vehicle crashes. We also assessed etiological heterogeneity by pedestrian age and time of day.
Between 2017 and 2018, there were 10,529 locations where a pedestrian was killed (case location) across the 380 Metropolitan Statistical Areas of the conterminous United States. For each case location two matched control locations were selected. The density of residential living facilities and walkable destinations for older adults was measured within a 1-km radial buffer of each location. Data were analyzed using conditional logistic regression models, adjusting for matching factors, neighborhood composition and walkability metrics.
There was a dose–response relationship between the density of older adult walkable destinations (hospitals, health care delivery venues, health services, pharmacies, senior centers, libraries, community centers) and location case–control status by age group of the fatally struck pedestrian. The strongest pattern was observed for the 65+ age group: Adjusted Odds Ratio (AOR) = 1.61 (95% CI: 1.26–2.06) for Q2; AOR = 2.58 for Q3 (95% CI: 1.99–3.34); and AOR = 3.44 for Q4 (95% CI = 2.61–4.52). Only among the age 50–64 and 65+ age groups was the highest category of density of residential facilities (assisted living facilities, skilled nursing facilities, continuing care retirement communities) associated with fatality location case–control status.
Future research might explore whether prioritizing traffic safety programs near destinations where older adults commonly frequent, such as medical centers, prevents older adult pedestrian fatalities.
As more older adults become homebound, home-based medical care (HBMC) has increased, but little is known about the HBMC workforce. This study analyzes national data on the size and structural features of HBMC providers from 2016 to 2022.
We analyzed annual primary care data for all traditional Medicare enrollees, classifying visits as HBMC (private residence or assisted living facility [ALF]) or non-HBMC (office or telemedicine). We evaluated trends in HBMC providers and visits by HBMC practice exclusivity (only-HBMC or both HBMC and non-HBMC), care setting (private residence, ALF), provider type (physician, nurse practitioner [NP], physician assistant [PA]), and visit volume. We assessed geographic variation in HBMC's share of primary care and payment differences between HBMC and non-HBMC services.
In 2022, 16,125 of 304,326 (5%) primary care clinicians delivered 5.6 million HBMC visits, with most visits (66%) in ALFs. From 2016 to 2022, HBMC providers increased by 40% and visits by 29%. The proportion of only-HBMC providers rose from 50.2% to 61.7%, whereas providers with volume > 1000 visits/year fell from 46.8% to 38.9%. The increase in providers was higher in private residences (49%) than ALFs (33%), though average provider volume decreased in private residences (−24%) and rose in ALFs (7%). NPs among HBMC providers increased from 42.2% to 63.0%, PAs from 6.6% to 8.2%, and physicians dropped from 51.3% to 28.9%. HBMC's share of all visits increased from 3.9% to 5.4%, driven more by ALF visits. Non-HBMC service payments grew faster than those for HBMC services.
Against the backdrop of an expanding HBMC workforce and rising visit volumes from 2016 to 2022, our findings highlight significant shifts in the structural composition of providers. These shifts emphasize the need for ongoing research to address their implications for access, quality, and outcomes in homebound older adults.
Medicare Advantage (MA) plans now cover 54% of all Medicare beneficiaries. However, MA is understudied in the nursing home population. We analyzed MA enrollment trends and resident and facility characteristics from 2010 through 2023.
We calculated the point prevalence of MA enrollment for long-stay nursing home residents, short-stay residents, and all other Medicare beneficiaries from 2010 to 2023, and compared variation in MA growth at the state level between long-stay residents and the general Medicare population. We analyzed how the composition of Traditional Medicare- and MA-enrolled long-stay residents changed over time, changes in special needs plan (SNP) enrollment, and nursing home quality for MA enrollees. We also tracked monthly MA enrollment rates among nursing home residents before and after they became long-stay.
MA enrollment among long-stay residents increased from 12.9% in 2010 to 36.5% in 2023, a 183% increase, outpacing the growth rate among the overall Medicare population. There was substantial geographic variation in MA growth between long-stay residents and others across states. Enrollment in Institutional SNPs grew substantially, accounting for about 35% of MA enrollment among long-stay residents. Dual-Eligible SNP enrollment also accounted for a substantial proportion among MA long-stay residents, ranging between 12% and 20% across years. Long-stay residents covered by Traditional Medicare and MA showed comparable clinical characteristics and had similar shares residing in high-quality nursing homes. Disenrollment from MA sharply increased as beneficiaries entered nursing homes for long-term care.
The substantial growth in MA enrollment among long-stay nursing home residents, coupled with the notable geographic variation and disenrollment, underscores the importance of recognizing that not all beneficiary groups experience MA in the same way. Targeted monitoring is needed to ensure that MA plans adequately address the care needs of this high-risk population.
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