IMPORTANCE Hospital-at-home (HaH) care provides acute hospital-level care in a patient's home as a substitute for traditional inpatient care. In September 2017, the Physician-Focused Payment Model Technical Advisory Committee recommended implementation of an alternative payment model for a new model of HaH that bundles the acute episode with 30 days of postacute transitional care. OBJECTIVE To report outcomes of this new payment model for HaH care. DESIGN, SETTING, AND PARTICIPANTS Case-control study of HaH care patients with a concurrent control group of hospital inpatients recruited from emergency departments (EDs) and residences in New York City from November 18, 2014, to August 31, 2017. HaH patients were 18 years or older with fee-for-service Medicare and acute medical illness requiring inpatient-level care. Control patients met HaH eligibility but refused participation or were seen in the ED when a HaH admission could not be initiated. EXPOSURES HaH care or inpatient care. MAIN OUTCOMES AND MEASURES Primary outcomes were acute period length of stay (LOS), all-cause 30-day hospital readmissions and ED visits, admissions to skilled nursing facilities (SNFs), referral to a certified home health care agency, and patient experiences with care. Analyses accounted for nonrandom selection using inverse probability weighting. RESULTS Among the 507 patients enrolled (mean [SD] age, 74.6 [15.7] years; 68.6% women), data were available on all patients 30 days postdischarge. HaH patients (n = 295) were older than controls (n = 212) and more likely to have a preacute functional impairment. HaH patients had shorter LOS (3.2 days vs 5.5 days; difference, −2.3 days; 95% CI, −1.8 to −2.7 days; weighted P < .001); lower rates of readmissions (8.6% [25] vs 15.6% [32]; difference, −7.0%; 95% CI, −12.9% to −1.1%; weighted P < .001), ED revisits (5.8% [17] vs 11.7% [24]; difference, −5.9%; 95% CI, −11.0% to −0.7%; weighted P < .001), and SNF admissions (1.7% [5] vs 10.4% [22]; difference, −8.7%; 95% CI, −13.0% to −4.3%; weighted P < .001); and were also more likely to rate their hospital care highly (68.8% [119] vs 45.3% [67]; difference, 23.5%; 95% CI, 12.9% to 34.1%; weighted P < .001). There were no differences in referrals to certified home health agencies. CONCLUSIONS AND RELEVANCE HaH care bundled with a 30-day postacute transitional care episode was associated with better patient outcomes and ratings of care compared with inpatient hospitalization. This model warrants consideration for addition to Medicare's current portfolio of shared savings programs.

IMPORTANCE-There is substantial uncertainty about optimal glycemic control in older adults with type 2 diabetes mellitus.OBSERVATIONS-Four large randomized clinical trials (RCTs), ranging in size from 1791 to 11440 patients, provide the majority of the evidence used to guide diabetes therapy. Most RCTs of intensive vs standard glycemic control excluded adults older than 80 years, used surrogate end points to evaluate microvascular outcomes and provided limited data on which subgroups are most likely to benefit or be harmed by specific therapies. Available data from randomized clinical trials

Background Homebound older adults have significant multi-morbidity, disability, and difficulty accessing care- traits that would suggest a high mortality rate. Yet, the association between homebound status and mortality is uncertain. Design, Settings and Participants The study sample consisted of 6,400 older adults from the National Health and Aging Trends Study (NHATS) interviewed between 2011 and 2013. NHATS is a nationally representative sample of Medicare beneficiaries ages 65 and older who complete annual, in-person interviews on late-life function and disability. Measurements We described two-year mortality rates and the prevalence of homebound status in the year prior to death using three categories of homebound status- homebound (never or rarely left home in the last month), semihomebound (only left home with assistance, needed help or had difficulty) and nonhomebound (left home without help or difficulty). Results In unadjusted analyses, two-year mortality was 40.3% in the homebound, 21.3% in the semihomebound and 5.8% in the nonhomebound. Homebound status was associated with increased two-year mortality, adjusted for sociodemographics, comorbidities and functional status (hazard ratio (HR), 2.08; 95% confidence interval (CI), 1.63-2.65, p<.001). Half (50.9%) of older community-dwelling Medicare beneficiaries were homebound in the year prior to death. Conclusion Homebound status is associated with an increased risk of death independent of functional impairment and comorbidities. In order to improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable patients.

Abnormalities in brain γ-aminobutyric acid (GABA) have been implicated in various neuropsychiatric and neurological disorders. However, in vivo GABA detection by proton magnetic resonance spectroscopy (1H MRS) presents significant challenges arising from low brain concentration, overlap by much stronger resonances, and contamination by mobile macromolecule (MM) signals. This study addresses these impediments to reliable brain GABA detection with the J-editing difference technique on a 3T MR system in healthy human subjects by (a) assessing the sensitivity gains attainable with an 8-channel phased-array head coil, (b) determining the magnitude and anatomic variation of the contamination of GABA by MM, and (c) estimating the test-retest reliability of measuring GABA with this method. Sensitivity gains and test-retest reliability were examined in the dorsolateral prefrontal cortex (DLPFC), while MM levels were compared across three cortical regions: the DLPFC, the medial prefrontal cortex (MPFC) and the occipital cortex (OCC). A 3-fold higher GABA detection sensitivity was attained with the 8-channel head coil compared to the standard single-channel head coil in DLPFC. Despite significant anatomic variation in GABA+MM and MM across the three brain regions (p < 0.05), the contribution of MM to GABA+MM was relatively stable across the three voxels, ranging from 41% to 49%, a non-significant regional variation (p = 0.58). The test-retest reliability of GABA measurement, expressed either as ratios to voxel tissue water (W) or total creatine, was found to be very high for both the single-channel coil and the 8-channel phased-array coil. For the 8-channel coil, for example, Pearson’s correlation coefficient of test vs. retest for GABA/W was 0.98 (R2 = 0.96, p = 0.0007), the percent coefficient of variation (CV) was 1.25%, and the intraclass correlation coefficient (ICC) was 0.98. Similar reliability was also found for the co-edited resonance of combined glutamate and glutamine (Glx) for both coils.

Background Limited health literacy is associated with low adherence to asthma controller medications among older adults. Objective We sought to describe the causal pathway linking health literacy to medication adherence by modeling asthma illness and medication beliefs as mediators. Methods We recruited adults aged 60 years and older with asthma from hospital and community practices in New York, New York, and Chicago, Illinois. We measured health literacy and medication adherence using the Short Test of Functional Health Literacy in Adults and the Medication Adherence Rating Scale, respectively. We used validated instruments to assess asthma illness and medication beliefs. We assessed cognition using a cognitive battery. Using structural equation modeling, we modeled illness and medication beliefs as mediators of the relationship between health literacy and adherence while controlling for cognition. Results Our study included 433 patients with a mean age of 67 ± 6.8 years. The sample had 84% women, 31% non-Hispanic blacks, and 39% Hispanics. The 36% of patients with limited health literacy were more likely to have misconceptions about asthma (P < .001) and asthma medications (P < .001). Health literacy had a direct effect (β = 0.089; P < .001) as well as an indirect effect on adherence mediated by medications concerns (β = 0.033; P = .002). Neither medication necessity (β = 0.044; P = .138) nor illness beliefs (β = 0.007; P = .143) demonstrated a mediational role between health literacy and adherence. Conclusions Interventions designed to improve asthma controller medication adherence in older adults may be enhanced by addressing concerns about medications in addition to using communication strategies appropriate for populations with limited health literacy and cognitive impairments.