Meal Delivery Programs Reduce The Use Of Costly Health Care In Dually Eligible Medicare And Medicaid Beneficiaries.
ABSTRACT: Delivering food to nutritionally vulnerable patients is important for addressing these patients' social determinants of health. However, it is not known whether food delivery programs can reduce the use of costly health services and decrease medical spending among these patients. We sought to determine whether home delivery of either medically tailored meals or nontailored food reduces the use of selected health care services and medical spending in a sample of adults dually eligible for Medicare and Medicaid. Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program. Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending. These findings suggest the potential for meal delivery programs to reduce the use of costly health care and decrease spending for vulnerable patients.
Project description:Importance:Whether interventions to improve food access can reduce health care use is unknown. Objective:To determine whether participation in a medically tailored meal intervention is associated with fewer subsequent hospitalizations. Design, Setting, and Participants:A retrospective cohort study was conducted using near/far matching instrumental variable analysis. Data from the 2011-2015 Massachusetts All-Payer Claims database and Community Servings, a not-for-profit organization delivering medically tailored meals (MTMs), were linked. The study was conducted from December 15, 2016, to January 16, 2019. Recipients of MTMs who had at least 360 days of preintervention claims data were matched to nonrecipients on the basis of demographic, clinical, and neighborhood characteristics. Interventions:Weekly delivery of 10 ready-to-consume meals tailored to the specific medical needs of the individual under the supervision of a registered dietitian nutritionist. Main Outcomes and Measures:Inpatient admissions were the primary outcome. Secondary outcomes were admission to a skilled nursing facility and health care costs (from medical and pharmaceutical claims). Results:There were 807 eligible MTM recipients. After matching, there were 499 MTM recipients, matched to 521 nonrecipients for a total of 1020 study participants (mean [SD] age, 52.7 [14.5] years; 568 [55.7%] female). Prior to matching and compared with nonrecipients in the same area, health care use, health care cost, and comorbidity were all significantly higher in recipients. For example, preintervention mean (SD) inpatient admissions were 1.6 (6.5) in MTM recipients vs 0.2 (0.8) in nonrecipients (P < .001), and mean health care costs were $80 617 ($312 337) vs $16 138 ($68 738) (P < .001). Recipients compared with nonrecipients were also significantly more likely to have HIV (21.9% vs 0.7%, P < .001), cancer (37.9% vs 11.3%, P < .001), and diabetes (33.7% vs 7.0%, P < .001). In instrumental variable analyses, MTM receipt was associated with significantly fewer inpatient admissions (incidence rate ratio [IRR], 0.51; 95% CI, 0.22-0.80; risk difference, -519; 95% CI, -360 to -678 per 1000 person-years). Similarly, MTM receipt was associated with fewer skilled nursing facility admissions (IRR, 0.28; 95% CI, 0.01-0.60; risk difference, -913; 95% CI, -689 to -1457 per 1000 person-years). The models estimated that, had everyone in the matched cohort received treatment owing to the instrument (and including the cost of program participation), mean monthly costs would have been $3838 vs $4591 if no one had received treatment owing to the instrument (difference, -$753; 95% CI, -$1225 to -$280). Conclusions and Relevance:Participation in a medically tailored meals program appears to be associated with fewer hospital and skilled nursing admissions and less overall medical spending.
Project description:BACKGROUND:Food insecurity, defined as inconsistent food access owing to cost, leads to poor health. OBJECTIVE:To test whether a medically tailored meal delivery program improved dietary quality in individuals with type 2 diabetes and food insecurity. DESIGN:Randomized cross-over clinical trial. PARTICIPANTS:Forty-four adults with diabetes, hemoglobin A1c?>?8.0%, and food insecurity (defined as at least one positive item on the two-item "Hunger Vital Sign"). INTERVENTION:In the Community Servings: Food as Medicine for Diabetes cross-over clinical trial (NCT02426138), conducted from June 2015 to July 2017, we randomly assigned the order of "on-meals" (home delivery of 10 meals/week for 12 weeks delivered by Community Servings, a non-profit organization) and "off-meals" (12 weeks usual care and a Choose MyPlate healthy eating brochure) periods. MAIN MEASURES:The primary outcome was Healthy Eating Index 2010 score (HEI), assessed by three 24-h food recalls in both periods. Higher HEI score (range 0-100; clinically significant difference 5) represents better dietary quality. Secondary outcomes included food insecurity and self-reported hypoglycemia. KEY RESULTS:Mean "on-meal" HEI score was 71.3 (SD 7.5) while mean "off-meal" HEI score was 39.9 (SD 7.8) (difference 31.4 points, p?<?0.0001). Participants experienced improvements in almost all sub-categories of HEI score, with increased consumption of vegetables, fruits, and whole grains and decreased solid fats, alcohol, and added sugar consumption. Participants also reported lower food insecurity (42% "on-meal" vs. 62% "off-meal," p?=?0.047), less hypoglycemia (47% "on-meal" vs. 64% "off-meal," p?=?0.03), and fewer days where mental health interfered with quality of life (5.65 vs. 9.59 days out of 30, p?=?0.03). CONCLUSIONS:For food-insecure individuals with diabetes, medically tailored meals improved dietary quality and food insecurity and reduced hypoglycemia. Longer-term studies should evaluate effects on diabetes control (e.g., hemoglobin A1c) and patient-reported outcomes (e.g., well-being).
Project description:BACKGROUND:Medically-tailored meal programs that provide home-delivered medically-appropriate food are an emerging intervention when type 2 diabetes co-occurs with food insecurity (limited or uncertain access to nutritious food owing to cost). We sought to understand the experiences of medically-tailored meal program participants. METHODS:We conducted semi-structured interviews with participants in a randomized trial of medically-tailored meals (NCT02426138) until reaching content saturation. Participants were adults (age?>?20?years) with type 2 diabetes in eastern Massachusetts, and the interviews were conducted from April to July 2017. Interviews were transcribed verbatim and coded by two independent reviewers. We determined emergent themes using content analysis. RESULTS:Twenty individuals were interviewed. Their mean age was 58 (SD: 13) years, 60.0% were women, 20.0% were non-Hispanic black, and 15.0% were Hispanic. Key themes were 1) satisfaction and experience with medically-tailored meals 2) food preferences and cultural appropriateness, 3) diabetes management and awareness, and 4) suggestions for improvement and co-interventions. Within these themes, participants were generally satisfied with medically-tailored meals and emphasized the importance of receiving culturally appropriate food. Participants reported several positive effects of medically-tailored meals, including improved quality of life and ability to manage diabetes, and stress reduction. Participants suggested combining medically-tailored meals with diabetes self-management education or lifestyle interventions. CONCLUSIONS:Individuals with diabetes and food insecurity expressed satisfaction with the medically-tailored meal program, and reported that participation reduced stress and the burden of diabetes management. Suggestions to help ensure the success of medically-tailored meal programs included a strong emphasis on culturally acceptability and accommodating taste preferences for provided foods, and combining medically-tailored meals with diabetes education or lifestyle intervention. TRIAL REGISTRATION:ClinicalTrials.gov NCT02426138.
Project description:To test the relationship between older Americans Act (OAA) program expenditures and the prevalence of low-care residents in nursing homes (NHs). DATA SOURCES AND COLLECTION: Two secondary data sources: State Program Reports (state expenditure data) and NH facility-level data downloaded from LTCfocUS.org for 16,030 US NHs (2000-2009).Using a two-way fixed effects model, we examined the relationship between state spending on OAA services and the percentage of low-care residents in NHs, controlling for facility characteristics, market characteristics, and secular trends.Results indicate that increased spending on home-delivered meals was associated with fewer residents in NHs with low-care needs.States that have invested in their community-based service networks, particularly home-delivered meal programs, have proportionally fewer low-care NH residents.
Project description:OBJECTIVE:To evaluate the effects of a supermarket meal bundling and electronic reminder intervention on food choices of families with children. DESIGN:Quasi-experimental (meal bundling) and randomized, controlled trial (electronic reminders). SETTING:Large supermarket in Maine during 40-week baseline and 16-week intervention periods in 2015-2016. PARTICIPANTS:English-speaking adults living with at least 1 child aged ?18 years (n?=?300) with 25% of households participating in the Supplemental Nutrition Assistance Program. INTERVENTION(S):(1) Four bundles of ingredients needed to make 8 low-cost healthful meals were promoted in the store through displays and point-of-purchase messaging for 4 weeks each; (2) weekly electronic messages based on principles from behavioral psychology were sent to study participants reminding them to look for meal bundles in the store. MAIN OUTCOME MEASURES:(1) Difference in storewide sales and individual purchases of bundled items (measured using supermarket loyalty card data) from baseline to intervention in intervention vs control groups. ANALYSIS:Regressions controlling for total food spending and accounting for repeated measures. RESULTS:There were no differences in spending on bundled items resulting from the meal bundling intervention or the electronic reminders. CONCLUSIONS AND IMPLICATIONS:Overall, there was little impact of healthful meal bundles and electronic reminders on storewide sales or purchases of promoted items in a large supermarket.
Project description:First-degree relatives (FDRs) of people diagnosed with colorectal cancer (CRC) have a two- to threefold increased risk of developing the same disease. Tailored print interventions based on behavior change theories have demonstrated considerable promise in facilitating health-promoting behaviors. This study compared the impact of two mailed print interventions on CRC screening outcomes among FDRs.This randomized trial compared effects of two mailed print interventions--one tailored and one nontailored--on participation in CRC screening among FDRs of CRC survivors. Data collected via phone interviews from 140 FDRs at baseline, 1 week post-intervention, and 3 months post-intervention.At 3 months, both the tailored and nontailored interventions yielded modest but statistically insignificant increases in adherence to any CRC screening test (14% vs. 21%, respectively; p=0.30). While there were no main effects for tailored versus nontailored interventions, there were significant interactions that showed that the tailored print intervention had significantly greater effects on forward stage movement for CRC screening depending on stage of adoption at baseline, race, and objective CRC risk. Receipt of the tailored intervention was 2.5 times more likely to move baseline precontemplators and contemplators forward in stage of adoption for colonoscopy (95% CI: 1.10-5.68) and was three times more likely to move Caucasians forward in stage of adoption for FOBT (95% CI: 1.00-9.07). In addition, the tailored intervention was 7.7 times more likely to move people at average risk forward in stage of adoption for colonoscopy (95% CI: 1.25-47.75).The tailored print intervention was more effective at moving Caucasians, those in precontemplation and contemplation at baseline, and those at average risk forward in their stage of adoption for CRC screening.Both tailored and nontailored print interventions showed moderate effects for increasing CRC screening participation. Tailored print interventions may be more effective for certain subgroups.
Project description:Interventions tailored to sociopsychological factors associated with health behaviors have promise for reducing colorectal cancer screening disparities, but limited research has assessed their impact in multiethnic populations. We examined whether an interactive multimedia computer program (IMCP) tailored to expanded health belief model sociopsychological factors could promote colorectal cancer screening in a multiethnic sample.We undertook a randomized controlled trial, comparing an IMCP tailored to colorectal cancer screening self-efficacy, knowledge, barriers, readiness, test preference, and experiences with a nontailored informational program, both delivered before office visits. The primary outcome was record-documented colorectal cancer screening during a 12-month follow-up period. Secondary outcomes included postvisit sociopsychological factor status and discussion, as well as clinician recommendation of screening during office visits. We enrolled 1,164 patients stratified by ethnicity and language (49.3% non-Hispanic, 27.2% Hispanic/English, 23.4% Hispanic/Spanish) from 26 offices around 5 centers (Sacramento, California; Rochester and the Bronx, New York; Denver, Colorado; and San Antonio, Texas).Adjusting for ethnicity/language, study center, and the previsit value of the dependent variable, compared with control patients, the IMCP led to significantly greater colorectal cancer screening knowledge, self-efficacy, readiness, test preference specificity, discussion, and recommendation. During the followup period, 132 (23%) IMCP and 123 (22%) control patients received screening (adjusted difference = 0.5 percentage points, 95% CI -4.3 to 5.3). IMCP effects did not differ significantly by ethnicity/language.Sociopsychological factor tailoring was no more effective than nontailored information in encouraging colorectal cancer screening in a multiethnic sample, despite enhancing sociopsychological factors and visit behaviors associated with screening. The utility of sociopsychological tailoring in addressing screening disparities remains uncertain.
Project description:An increase in physical activity for secondary prevention of cardiovascular disease and cardiac rehabilitation has multiple therapeutic benefits, including decreased mortality. Internet- and mobile-based interventions for physical activity have shown promising results in helping users increase or maintain their level of physical activity in general and specifically in secondary prevention of cardiovascular diseases and cardiac rehabilitation. One component related to the efficacy of these interventions is tailoring of the content to the individual.Our trial assessed the effect of a longitudinally tailored Internet- and mobile-based intervention for physical activity as an extension of a face-to-face cardiac rehabilitation stay. We hypothesized that users of the tailored intervention would maintain their physical activity level better than users of the nontailored version.The study population included adult participants of a cardiac rehabilitation program in Norway with home Internet access and a mobile phone. The participants were randomized in monthly clusters to a tailored or nontailored (control) intervention group. All participants had access to a website with information regarding cardiac rehabilitation, an online discussion forum, and an online activity calendar. Those using the tailored intervention received tailored content based on models of health behavior via the website and mobile fully automated text messages. The main outcome was self-reported level of physical activity, which was obtained using an online international physical activity questionnaire at baseline, at discharge, and at 1 month and 3 months after discharge from the cardiac rehabilitation program.Included in the study were 69 participants. One month after discharge, the tailored intervention group (n=10) had a higher median level of overall physical activity (median 2737.5, IQR 4200.2) than the control group (n=14, median 1650.0, IQR 2443.5), but the difference was not significant (Kolmogorov-Smirnov Z=0.823, P=.38, r=.17). At 3 months after discharge, the tailored intervention group (n=7) had a significantly higher median level of overall physical activity (median 5613.0, IQR 2828.0) than the control group (n=12, median 1356.0, IQR 2937.0; Kolmogorov-Smirnov Z=1.397, P=.02, r=.33). The median adherence was 45.0 (95% CI 0.0-169.8) days for the tailored group and 111.0 (95% CI 45.1-176.9) days for the control group; however, the difference was not significant (P=.39). There were no statistically significant differences between the 2 groups in stage of change, self-efficacy, social support, perceived tailoring, anxiety, or depression.Because of the small sample size and the high attrition rate at the follow-up visits, we cannot make conclusions regarding the efficacy of our approach, but the results indicate that the tailored version of the intervention may have contributed to the long-term higher physical activity maintained after cardiac rehabilitation by participants receiving the tailored intervention compared with those receiving the nontailored intervention.ClinicalTrials.gov: NCT01223170; http://clinicaltrials.gov/show/NCT01223170 (Archived by WebCite at http://www.webcitation.org/6Nch4ldcL).
Project description:Enhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.To test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.We compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.A total of 1,433,297 adults aged 18-64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.CareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.Outcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.By the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: -$192, -$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.A PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.
Project description:Safety nets are expanding in African countries as a policy instrument to alleviate poverty and food insecurity. Whether safety nets have improved household food security and child diet and nutrition in sub-Saharan Africa has not been well documented. This paper takes the case of Ethiopia's Productive Safety Net Program (PSNP) and provides evidence of the impact of safety nets on household food security and child nutritional outcomes. Prior studies provide inconclusive evidence as to whether PSNP has improved household food security and child nutrition. These studies used analytical approaches that correct for selection bias but have overlooked the effect of time-varying confounders that might have resulted in biased estimation. Given that household food security status is both the criteria for participation and one of the desirable outcomes of the program, estimating the causal impact of PSNP on household food security and child nutrition is prone to endogeneity due to selection bias and time-varying confounders. Therefore, the objectives of this paper are (1) to examine the impacts of PSNP on household food security, child meal frequency, child diet diversity, and child anthropometry using marginal structural modeling approach that takes into account both selection bias and time-varying confounders and (2) to shed some light on policy and programmatic implications. Results show that PSNP has not improved household food insecurity, child dietary diversity, and child anthropometry despite its positive impact on child meal frequency. Household participation in PSNP brought a 0.308 unit gain on child meal frequency. Given the consequence of food insecurity and child undernutrition on physical and mental development, intergenerational cycle of poverty, and human capital formation, the program would benefit if it is tailored to nutrition-specific and nutrition-sensitive interventions.