Background Food insecurity is a complex public health problem affecting many individuals in the United States. Digital health interventions that promote behavior change and provide access to affordable and healthy food may help to alleviate food insecurity. Objective The aim of this study was to characterize food-insecure users of Foodsmart, a telehealth and nutrition platform with meal planning, food ordering, nutrition education, budgeting, and grocery discount features, and to evaluate changes in diet and food insecurity. Methods We retrospectively analyzed data collected from 4595 adults who used the Foodsmart platform between February and October 2021. Participants self-reported their diet, demographics, biometrics, and food insecurity status in a 56-item questionnaire. Participants were reported to be food insecure if they answered “sometimes” or “often” to the question “How often does the food you buy not last and you don't have money to get more?” from the United States Department of Agriculture’s Household Food Security survey. We examined baseline characteristics of participants by food insecurity status, associations between characteristics and baseline food insecurity, and changes in diet quality and food insecurity status. To evaluate potential causes of reversing food insecurity, the use of 6 Foodsmart features was compared between food-insecure participants who achieved food security versus food-insecure participants who remained food insecure, based on their last response to the food insecurity question. Results We found that 16% (742/4595) of participants were food insecure at baseline. Participants who were food insecure at baseline were more likely to be obese, to have at least one chronic condition, to have a lower diet quality, to cook less frequently at home, to think healthy food is too expensive, and less likely to order takeout or eat at a restaurant. Among participants who were food insecure at baseline, 61% (451/742) improved their nutrition and 29% (217/742) responded that they were food secure at follow-up, with an increasing percentage achieving food security with longer enrollment time. Using a multivariable logistic regression model, we found that age, diabetes, prediabetes, BMI categories, and diet quality at baseline were statistically significantly associated with the likelihood of being food insecure at baseline. Among those who were food insecure at baseline, there was a higher relative proportion of participants who achieved food security and used the “deals” (28.6% higher), “CookItNow” (36.4% higher), and “telenutrition” (27.5% higher) features compared to those who remained food insecure. Conclusions This study assesses the characteristics of individuals enrolled on the Foodsmart platform who answered the food insecurity question. We found that a significant number of participants who were food insecure at enrollment achieved food security. This finding shows that telehealth and nutrition platforms may potentially help users improve household food security.
Background and objectivesDespite representing 1% of the population, beneficiaries on long-term dialysis account for over 7% of Medicare’s fee-for-service spending. Because of their focus on care coordination, Accountable Care Organizations may be an effective model to reduce spending inefficiencies for this population. We analyzed Medicare data to examine time trends in long-term dialysis beneficiary alignment to Accountable Care Organizations and differences in spending for those who were Accountable Care Organization aligned versus nonaligned.Design, setting, participants, & measurementsIn this retrospective cohort study, beneficiaries on long-term dialysis between 2009 and 2016 were identified using a 20% random sample of Medicare beneficiaries. Trends in alignment to an Accountable Care Organization were compared with alignment of the general Medicare population from 2012 to 2016. Using an interrupted time series approach, we examined the association between Accountable Care Organization alignment and the primary outcome of total spending for long-term dialysis beneficiaries from prior to Accountable Care Organization implementation (2009–2011) through implementation of the Comprehensive ESRD Care model in October 2015. We fit linear regression models with generalized estimating equations to adjust for patient characteristics.ResultsDuring the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization increased from 6% to 23% from 2012 to 2016. In the time series analysis, spending on Accountable Care Organization–aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified by whether beneficiaries received care from a primary care physician, savings by Accountable Care Organization–aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397).ConclusionsThere was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization from 2012 to 2016. Moreover, in adjusted models, Accountable Care Organization alignment was associated with modest cost savings among long-term dialysis beneficiaries with care by a primary care physician.
Background Diabetes-related costs are the highest across all chronic conditions in the United States, with type 2 diabetes accounting for up to 95% of all cases of diabetes. A healthy diet is strongly associated with lowering glycated hemoglobin A1c (HbA1c) levels among individuals with diabetes, which can help curtail other health complications. Digital health platforms can offer critical support for improving diet and glycemic control among individuals with diabetes. Less is known about the characteristics of people with diabetes who use digital health platforms (specifically, a platform that integrates personalized healthy meal plans and food ordering) and changes in their HbA1c levels. Objective The aim of this study is to characterize Foodsmart users with diabetes and evaluate the longitudinal impact of Foodsmart—a personalized digital nutrition platform with meal planning, food ordering, and nutrition education features—on changes in HbA1c levels. Methods We retrospectively analyzed data collected from 643 adults with at least two self-reported HbA1c entries in the Foodsmart platform between January 2016 and June 2021. Participants self-reported their HbA1c levels, height, weight, health conditions, and diet in a 53-item food frequency questionnaire. Diabetes was defined as HbA1c ≥6.5%. We analyzed distributions of characteristics by baseline diabetes status and examined the association of characteristics with the likelihood of having diabetes at baseline. To evaluate the change in HbA1c levels among Foodsmart users, we calculated mean changes (absolute and percent) in HbA1c among participants with diabetes and by length of follow-up. We also compared changes in HbA1c and weight between participants with diabetes at baseline who achieved a normal HbA1c level and those who did not. Results We found that 43.5% (280/643) of the participants with at least two HbA1c level entries had diabetes at baseline. Participants with diabetes at baseline were more likely to be male, have a higher weight and BMI, report high blood pressure, and have a poorer diet in comparison to participants without diabetes. Using a multivariable logistic regression model, we found that being male and obese were statistically significantly associated with baseline diabetes. Among participants with diabetes at baseline, HbA1c was reduced, on average, by 0.46%. In addition, 21.4% (60/280) of participants with diabetes achieved a normal HbA1c level (<6.5%) in their last HbA1c level entry; this percentage increased with longer follow-up time (39% [7/18] at >24 months). In a sensitivity analysis, users with an HbA1c ≥7.0% at baseline had an average absolute change of –0.62% and 31.2% (62/199) of these participants achieved HbA1c levels of less than 7.0%. Conclusions This study assessed characteristics of individuals enrolled on the Foodsmart platform with HbA1c levels and found that users with diabetes had lower HbA1c levels over time and a sizable percentage of participants were successful in achieving normal levels.
ObjectivesWe sought to estimate reliable change thresholds for the Montreal Cognitive Assessment (MoCA) for older adults with suspected Idiopathic Normal Pressure Hydrocephalus (iNPH). Furthermore, we aimed to determine the likelihood that shunted patients will demonstrate significant improvement on the MoCA, and to identify possible predictors of this improvement.MethodsPatients (N = 224) presenting with symptoms of iNPH were given a MoCA assessment at their first clinic visit, and also before and after tap test (TT) or extended lumbar drainage (ELD). Patients who were determined to be good candidates for shunts (N = 71, 31.7%) took another MoCA assessment following shunt insertion. Reliable change thresholds for MoCA were derived using baseline visit to pre-TT/ELD assessment using nine different methodologies. Baseline characteristics of patients whose post-shunt MoCA did and did not exceed the reliable change threshold were compared.ResultsAll nine of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 16 to 22 (38.4% of patients). Furthermore, a majority of reliable change methods indicated that a 5-point increase in MoCA would be reliable for patients with a baseline MoCA from 14 to 25. Reliable change thresholds varied across methods from 4 to 7 points for patients outside of this range. 10.1% had at least a 5-point increase from baseline to post-TT/ELD. Compared to patients who did not receive a shunt, patients who received a shunt did not have lower average MoCA at baseline (p = 0.88) or have better improvement in MoCA scores after the tap test (p = 0.17). Among shunted patients, 23.4% improved by at least 5 points on the MoCA from baseline to post-shunt. Time since onset of memory problems and post-TT/ELD gait function were the only clinical factors significantly associated with having a reliable change in MoCA after shunt insertion (p = 0.019; p = 0.03, respectively).ConclusionsIn patients with iNPH, clinicians could consider using a threshold of 5 points for determining whether iNPH-symptomatic patients have experienced cognitive benefits from cerebrospinal fluid drainage at an individual level. However, a reliable change cannot be detected for patients with a baseline MoCA of 26 or greater, necessitating a different cognitive assessment tool for these patients.
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