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Endo S, Honda T, Sato K, Kubota N, Kamoshida T, Mochizuki A, Fujii M, Ochi J, Miyazaki Y, Tsukada Y. Evaluating the potential of immunotherapy and chemoimmunotherapy in the treatment of elderly non-small cell lung cancer patients: A real-world study. Cancer Treat Res Commun 2023; 37:100755. [PMID: 37660444 DOI: 10.1016/j.ctarc.2023.100755] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/23/2023] [Accepted: 08/25/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Immune checkpoint inhibitor (ICI) has become the standard therapy for metastatic non-small cell lung cancer (NSCLC) patients. However, no robust evidence on the efficacy and safety of ICI in elderly NSCLC patients has been established. MATERIALS AND METHODS This retrospective study aimed to assess the efficacy and safety of ICI in elderly NSCLC patients. NSCLC patients treated with ICI monotherapy or chemoimmunotherapy (CIT) between 2016 and 2022 were divided into two cohorts according to the age: the Elderly cohort (patients aged ≥ 75 years) and the Nonelderly cohort (patients aged < 75 years). The progression-free survival (PFS), tumor response, and frequency of immune-related adverse events (irAEs) were compared between the two cohorts. RESULTS A total of 111 NSCLC patients were included in this study (41 patients in the Elderly cohort and 70 patients in the Nonelderly cohort). The PFS (5.6 months vs. 6.3 months, P = 0.98), response rate (36.6% vs. 44.9%, P = 0.51), and disease control rate (80.5% vs. 76.8%, P = 0.83) were not significantly different between the two cohorts. In a subgroup analysis, stratified according to PD-L1 expression (low vs. high) and ICI treatment mode (ICI monotherapy vs. CIT), the PFSs of both cohorts were also not significantly different, regardless of PD-L1 expression. Moreover, the frequency of irAEs did not significantly differ between elderly and nonelderly NSCLC patients (21/41 [51.2%] vs. 38/70 [54.3%], P = 0.91). CONCLUSION The efficacy and safety of ICI in elderly NSCLC patients were not inferior to those in younger patients.
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Affiliation(s)
- Satoshi Endo
- Department of Respiratory Medicine, Soka Municipal Hospital, 2-21-1 Soka, Soka-shi, Saitama 340-8560, Japan
| | - Takayuki Honda
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Kazuaki Sato
- Department of Respiratory Medicine, Soka Municipal Hospital, 2-21-1 Soka, Soka-shi, Saitama 340-8560, Japan
| | - Natsushi Kubota
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Tatsuhiko Kamoshida
- Department of Respiratory Medicine, Yokosuka Kyosai Hospital, 1-16 Yonegahama-dori, Yokosuka-shi, Kanagawa 238-8558, Japan
| | - Akifumi Mochizuki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Mayumi Fujii
- Department of Respiratory Medicine, Soka Municipal Hospital, 2-21-1 Soka, Soka-shi, Saitama 340-8560, Japan
| | - Junichi Ochi
- Department of Respiratory Medicine, Soka Municipal Hospital, 2-21-1 Soka, Soka-shi, Saitama 340-8560, Japan
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Yoshikazu Tsukada
- Department of Respiratory Medicine, Soka Municipal Hospital, 2-21-1 Soka, Soka-shi, Saitama 340-8560, Japan.
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Lee W, Basu A, Carlson JJ, Veenstra D. How does cumulative evidence from older adult-specific trials influence clinical practice? A difference-in-differences analysis in early-stage breast cancer. Contemp Clin Trials 2023; 128:107135. [PMID: 36868347 DOI: 10.1016/j.cct.2023.107135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Despite increasing focus on conducting cancer clinical trials in older adults, it is unclear whether such evidence influences practice patterns. We aimed to estimate the impact of cumulative evidence from older adult-specific trial results from the CALGB 9343 and PRIME II trials that found post-lumpectomy irradiation has little benefit among older adults with early-stage breast cancer (ESBC). METHODS Patients diagnosed with ESBC between 2000 and 2018 were identified from the SEER registry data. We examined the incremental immediate effect, incremental average yearly effect, and cumulative effect of a series of CALGB 9343 and PRIME II results on the utilization level of post-lumpectomy irradiation. We conducted difference-in-differences analyses, comparing those aged 70 or older vs. <65 years old. RESULTS The initial 5-year CALGB 9343 results in 2004 led to a significant immediate (-0.038, 95% CI: -0.064, -0.012) and average yearly decrease (-0.008, 95% CI: -0.013, -0.003) in the probability of irradiation use among those aged 70 or older compared to those below 65 years of age. 11-year CALGB 9343 results in 2010 significantly accelerated the average yearly effect by 1.7 percentage points (95% CI: -0.030, -0.004). The other later results did not significantly change the time trend. The cumulative effect of all results between 2004 and 2018 was -26.3 percentage points (95% CI: -0.29, -0.24). CONCLUSION Cumulative evidence from older adult-specific trials in ESBC led to decreasing use of irradiation over time among elderly patients. The rate of decrease after the initial results was accelerated by long-term follow-up results.
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Affiliation(s)
- Woojung Lee
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
| | - Anirban Basu
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
| | - David Veenstra
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Health Sciences Building, 1956 NE Pacific St H362, Seattle, WA, 98195, United States.
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Steiner JF, Ross C, Stiefel M, Mosen D, Banegas MP, Wall AE, Martin C, Kelly TS, Paolino AR, Zeng C. Association between changes in loneliness identified through screening and changes in depression or anxiety in older adults. J Am Geriatr Soc 2022; 70:3458-3468. [PMID: 36053977 DOI: 10.1111/jgs.18012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/09/2022] [Accepted: 07/21/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Changes in loneliness are associated with corresponding changes in depression, anxiety, and general health in population surveys, but few studies have assessed these associations through repeated screening in clinical settings. METHODS Retrospective cohort study among individuals ≥age 65 in an integrated health care system who completed loneliness screening before two annual wellness visits, separated by a mean of 12.9 (SD 2.0) months, between 2013 and 2018. Their responses identified four subgroups: individuals who were persistently lonely; not lonely; experienced an increase (recently lonely); or decrease (previously lonely) in loneliness. Loneliness was assessed with a single item. Depression was assessed with the Patient Health Questionnaire-2. Anxiety was assessed with the Generalized Anxiety Disorder-2. Fair/poor general health was assessed by a single item. Linear mixed effects models assessed changes in outcomes after covariate adjustment. RESULTS The cohort comprised 24,666 individuals (19.2% of older adults in the system). Mean age was 73.7 years (SD 6.4); 54.6% were female, and 11.6% were members of racial and ethnic minority groups. Of these individuals, 1936 (7.8%) were persistently lonely, 1687 (6.8%) were recently lonely, 1551 (6.3%) were previously lonely, and 19,492 (79.0%) were not lonely at either time point. After adjustment for sociodemographic, clinical and social variables, recent loneliness was associated with increases in depression (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.41-2.19) and anxiety (aOR 1.67, 95% CI 1.32-2.10). Previous loneliness was associated with decreases in depression (aOR, 0.46, 95% CI 0.36-0.58) and anxiety (aOR 0.69, 95% CI 0.54-0.90). Changes in loneliness were not associated with changes in general health. CONCLUSIONS Changes in loneliness identified through screening were associated with corresponding changes in depression and anxiety. These findings support the potential value of identifying social risk factors in clinical settings among older adults.
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Affiliation(s)
- John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Colleen Ross
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Matthew Stiefel
- Social Health Practice, Kaiser Permanente, Oakland, California, USA
| | - David Mosen
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA.,Department of Radiation Medicine and Applied Sciences, University of California, San Diego, California, USA
| | - Alena E Wall
- Social Health Practice, Kaiser Permanente, Oakland, California, USA
| | - Cally Martin
- Social Health Practice, Kaiser Permanente, Oakland, California, USA
| | - Tammy S Kelly
- Quality, Risk & Patient Safety Department, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Andrea R Paolino
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
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Sturmberg JP, Kissling B, Kühlein T. Shared decision-making in the realm of uncertainty: The example of coronary artery disease through an EBM and complexity science lens. J Eval Clin Pract 2022. [PMID: 36419338 DOI: 10.1111/jep.13794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
Abstract
Patients look to their clinicians for explanations and treatments that achieve predictable cures with certainty. Clinicians usually respond accordingly. Acknowledging uncertainty, while necessary, is difficult, anxiety-provoking and at times overwhelming for patients and clinicians alike. We here present three case studies to illustrate the uncertainties of managing patients with potentially life-threatening illnesses. Research aims to provide answers to clinical problems. But, conducting research almost inevitably entails a reduction of real-world complexities. Research ultimately can only provide 'partial or in general answers' mostly revealing new questions. Due to the complexity of clinical care, research cannot really achieve certainty and predictability for an individual within his specific living context and values. In an unavoidably uncertain environment, instead of oversimplifying, clinicians like patients-as far as possible-ought to better embrace a complexity thinking frame. This provides a deeper understanding how living bodies function as-a-whole within their living contexts. Uncertainty and unpredictability, being inherent elements of complexity thinking, cannot be overcome. However, it may be made easier to cope with uncertainty by at least adopting the thinking in probabilities for benefits and harms of patient related outcomes as introduced in Sackett's Evidence-Based Medicine framework. Through the lenses of evidence-based medicine and complexity sciences this paper critically explores the clinical management of three patients diagnosed as having coronary artery disease. They all received the same treatment even though they presented with very different clinical complaints arising from different disease manifestations. Looking at these case studies the authors reflect on the reasons behind this astonishing, but widely seen medical behaviour of 'one size fits all'. They critically reflect the importance of research and evidence in view of a person-centred solution.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | | | - Thomas Kühlein
- Allgemeinmedizinisches Institut, Universitätsklinikum Erlangen, Erlangen, Germany
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Goyal P, Safford M, Hilmer SN, Steinman MA, Matlock D, Maurer MS, Lachs M, Kronish IM. N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study. Br J Clin Pharmacol 2022; 88:4460-4473. [PMID: 35705532 PMCID: PMC9464693 DOI: 10.1111/bcp.15442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022] Open
Abstract
Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology, Weill Cornell Medicine (New York, NY)
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Monika Safford
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Sarah N. Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital (Sydney, Australia)
| | - Michael A. Steinman
- Division of Geriatrics, University of California San Francisco (San Francisco, CA)
| | - Daniel Matlock
- Division of Geriatrics, University of Colorado (Denver, CO)
| | - Mathew S. Maurer
- Department of Medicine, Columbia University Irving Medical Center (New York, NY)
| | - Mark Lachs
- Division of Geriatrics, Weill Cornell Medicine (New York, NY)
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular Health, Columbia University, (New York, NY)
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6
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Bischof JJ, Elsaid MI, Bridges JFP, Rosko AE, Presley CJ, Abar B, Adler D, Bastani A, Baugh CW, Bernstein SL, Coyne CJ, Durham DD, Grudzen CR, Henning DJ, Hudson MF, Klotz A, Lyman GH, Madsen TE, Reyes-Gibby CC, Rico JF, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Yeung SCJ, Yilmaz S, Caterino JM. Characterization of older adults with cancer seeking acute emergency department care: A prospective observational study. J Geriatr Oncol 2022; 13:943-951. [PMID: 35718667 PMCID: PMC11137847 DOI: 10.1016/j.jgo.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 04/05/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Disparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer. MATERIALS AND METHODS Planned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017. RESULTS Compared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics. DISCUSSION We identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.
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Affiliation(s)
- Jason J Bischof
- Departments of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Mohamed I Elsaid
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA.
| | - John F P Bridges
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, OH, USA.
| | - Ashley E Rosko
- Department of Internal Medicine, Division of Hematology, Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Carolyn J Presley
- Department of Internal Medicine, Division of Medical Oncology, Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Beau Abar
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
| | - David Adler
- Department of Emergency Medicine, University of Rochester, Rochester, NY, USA.
| | - Aveh Bastani
- Department of Emergency Medicine, William Beaumont Hospital - Troy Campus, Troy, MI, USA.
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Steven L Bernstein
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California San Diego, San Diego, CA, USA.
| | - Danielle D Durham
- Department of Radiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Daniel J Henning
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.
| | | | - Adam Klotz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center and the Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Troy E Madsen
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Cielito C Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Juan Felipe Rico
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Richard J Ryan
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA.
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Robert Swor
- Department of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI, USA.
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine @ Dartmouth, Lebanon, NH, USA.
| | - Arvind Venkat
- Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, USA.
| | - Jason Wilson
- Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Sai-Ching Jim Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Sule Yilmaz
- Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jeffrey M Caterino
- Departments of Emergency Medicine and Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Gurwitz JH, Quinn CC, Abi-Elias IH, Adams AS, Bartel R, Bonner A, Boxer R, Delude C, Gifford D, Hanson B, Ito K, Jain P, Magaziner JS, Mazor KM, Mitchell SL, Mody L, Nace D, Ouslander J, Reifsnyder J, Resnick B, Zimmerman S. Advancing clinical trials in nursing homes: A proposed roadmap to success. Geriatr Nurs 2022; 45:230-234. [PMID: 35361514 PMCID: PMC8960155 DOI: 10.1016/j.gerinurse.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.
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Affiliation(s)
- Jerry H Gurwitz
- Meyers Health Care Institute, Worcester, MA, USA; UMass Chan Medical School, Worcester, MA, USA.
| | | | | | - Alyce S Adams
- Stanford University School of Medicine, Stanford, CA, USA
| | - Rosie Bartel
- AGING Patient/Caregiver Advisory Council, Worcester, MA, USA
| | - Alice Bonner
- Institute for Healthcare Improvement, Boston, MA, USA; Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | | | - David Gifford
- American Health Care Association, Washington, DC, USA
| | - Bruce Hanson
- AGING Patient/Caregiver Advisory Council, Worcester, MA, USA
| | - Kouta Ito
- Meyers Health Care Institute, Worcester, MA, USA; UMass Chan Medical School, Worcester, MA, USA
| | - Paavani Jain
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay S Magaziner
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kathleen M Mazor
- Meyers Health Care Institute, Worcester, MA, USA; UMass Chan Medical School, Worcester, MA, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Lona Mody
- University of Michigan, Ann Arbor, MI, USA
| | - David Nace
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA
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8
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Bayliss EA, Shetterly SM, Drace ML, Norton JD, Maiyani M, Gleason KS, Sawyer JK, Weffald LA, Green AR, Reeve E, Maciejewski ML, Sheehan OC, Wolff JL, Kraus C, Boyd CM. Deprescribing Education vs Usual Care for Patients With Cognitive Impairment and Primary Care Clinicians: The OPTIMIZE Pragmatic Cluster Randomized Trial. JAMA Intern Med 2022; 182:534-542. [PMID: 35343999 PMCID: PMC8961395 DOI: 10.1001/jamainternmed.2022.0502] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/06/2022] [Indexed: 12/13/2022]
Abstract
Background Individuals with dementia or mild cognitive impairment frequently have multiple chronic conditions (defined as ≥2 chronic medical conditions) and take multiple medications, increasing their risk for adverse outcomes. Deprescribing (reducing or stopping medications for which potential harms outweigh potential benefits) may decrease their risk of adverse outcomes. Objective To examine the effectiveness of increasing patient and clinician awareness about the potential to deprescribe unnecessary or risky medications among patients with dementia or mild cognitive impairment. Design, Setting, and Participants This pragmatic, patient-centered, 12-month cluster randomized clinical trial was conducted from April 1, 2019, to March 31, 2020, at 18 primary care clinics in a not-for-profit integrated health care delivery system. The study included 3012 adults aged 65 years or older with dementia or mild cognitive impairment who had 1 or more additional chronic medical conditions and were taking 5 or more long-term medications. Interventions An educational brochure and a questionnaire on attitudes toward deprescribing were mailed to patients prior to a primary care visit, clinicians were notified about the mailing, and deprescribing tip sheets were distributed to clinicians at monthly clinic meetings. Main Outcomes and Measures The number of prescribed long-term medications and the percentage of individuals prescribed 1 or more potentially inappropriate medications (PIMs). Analysis was performed on an intention-to-treat basis. Results This study comprised 1433 individuals (806 women [56.2%]; mean [SD] age, 80.1 [7.2] years) in 9 intervention clinics and 1579 individuals (874 women [55.4%]; mean [SD] age, 79.9 [7.5] years) in 9 control clinics who met the eligibility criteria. At baseline, both groups were prescribed a similar mean (SD) number of long-term medications (7.0 [2.1] in the intervention group and 7.0 [2.2] in the control group), and a similar proportion of individuals in both groups were taking 1 or more PIMs (437 of 1433 individuals [30.5%] in the intervention group and 467 of 1579 individuals [29.6%] in the control group). At 6 months, the adjusted mean number of long-term medications was similar in the intervention and control groups (6.4 [95% CI, 6.3-6.5] vs 6.5 [95% CI, 6.4-6.6]; P = .14). The estimated percentages of patients in the intervention and control groups taking 1 or more PIMs were similar (17.8% [95% CI, 15.4%-20.5%] vs 20.9% [95% CI, 18.4%-23.6%]; P = .08). In preplanned subgroup analyses, adjusted differences between the intervention and control groups were -0.16 (95% CI, -0.34 to 0.01) for individuals prescribed 7 or more long-term medications at baseline (n = 1434) and -0.03 (95% CI, -0.20 to 0.13) for those prescribed 5 to 6 medications (n = 1578) (P = .28 for interaction; P = .19 for subgroup interaction for PIMs). Conclusions and Relevance This large-scale educational deprescribing intervention for older adults with cognitive impairment taking 5 or more long-term medications and their primary care clinicians demonstrated small effect sizes and did not significantly reduce the number of long-term medications and PIMs. Such interventions should target older adults taking relatively more medications. Trial Registration ClinicalTrials.gov Identifier: NCT03984396.
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Affiliation(s)
- Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | | | - Melanie L. Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Jonathan D. Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Kathy S. Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Linda A. Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora
| | - Ariel R. Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, South Australia, Australia
| | - Matthew L. Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, North Carolina
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina
| | - Orla C. Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer L Wolff
- School of Public Health, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Cynthia M. Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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9
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Affiliation(s)
- Adrian C Traeger
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Rowena Ivers
- Graduate Medicine, University of Wollongong, Wollongong, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
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10
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Gurwitz JH, Quinn CC, Abi-Elias IH, Adams AS, Bartel R, Bonner A, Boxer R, Delude C, Gifford D, Hanson B, Ito K, Jain P, Magaziner JS, Mazor KM, Mitchell SL, Mody L, Nace D, Ouslander J, Reifsnyder J, Resnick B, Zimmerman S. Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success. J Am Geriatr Soc 2022; 70:701-708. [PMID: 35195276 PMCID: PMC8910690 DOI: 10.1111/jgs.17696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 02/02/2023]
Abstract
An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.
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Affiliation(s)
- Jerry H. Gurwitz
- Meyers Health Care Institute, Worcester, MA, USA
- UMass Chan Medical School, Worcester, MA, USA
| | | | | | - Alyce S. Adams
- Stanford University School of Medicine, Stanford, CA, USA
| | - Rosie Bartel
- AGING Patient/Caregiver Advisory Council, Worcester, MA, USA
| | - Alice Bonner
- Institute for Healthcare Improvement, Boston, MA, USA
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | | | - David Gifford
- American Health Care Association, Washington, DC, USA
| | - Bruce Hanson
- AGING Patient/Caregiver Advisory Council, Worcester, MA, USA
| | - Kouta Ito
- Meyers Health Care Institute, Worcester, MA, USA
- UMass Chan Medical School, Worcester, MA, USA
| | - Paavani Jain
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Kathleen M. Mazor
- Meyers Health Care Institute, Worcester, MA, USA
- UMass Chan Medical School, Worcester, MA, USA
| | - Susan L. Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Lona Mody
- University of Michigan, Ann Arbor, MI, USA
| | - David Nace
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA
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11
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Gurwitz JH, Quinn CC, Abi-Elias IH, Adams AS, Bartel R, Bonner A, Boxer R, Delude C, Gifford D, Hanson B, Ito K, Jain P, Magaziner JS, Mazor KM, Mitchell SL, Mody L, Nace D, Ouslander J, Reifsnyder J, Resnick B, Zimmerman S. Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success. J Am Med Dir Assoc 2022; 23:345-349. [PMID: 34953784 PMCID: PMC8692165 DOI: 10.1016/j.jamda.2021.11.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/26/2021] [Indexed: 12/26/2022]
Abstract
An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.
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Affiliation(s)
- Jerry H Gurwitz
- Meyers Health Care Institute, Worcester, MA, USA; UMass Chan Medical School, Worcester, MA, USA.
| | | | | | - Alyce S Adams
- Stanford University School of Medicine, Stanford, CA, USA
| | - Rosie Bartel
- AGING Patient/Caregiver Advisory Council, Worcester, MA, USA
| | - Alice Bonner
- Institute for Healthcare Improvement, Boston, MA, USA; Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | | | | | - David Gifford
- American Health Care Association, Washington, DC, USA
| | - Bruce Hanson
- AGING Patient/Caregiver Advisory Council, Worcester, MA, USA
| | - Kouta Ito
- Meyers Health Care Institute, Worcester, MA, USA; UMass Chan Medical School, Worcester, MA, USA
| | - Paavani Jain
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay S Magaziner
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kathleen M Mazor
- Meyers Health Care Institute, Worcester, MA, USA; UMass Chan Medical School, Worcester, MA, USA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Lona Mody
- University of Michigan, Ann Arbor, MI, USA
| | - David Nace
- University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA
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12
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Turnbull A, Kaplan R, Adeli E, Lin FV. A Novel Explainability Approach for Technology-Driven Translational Research on Brain Aging. J Alzheimers Dis 2022; 88:1229-1239. [PMID: 35754280 PMCID: PMC9399001 DOI: 10.3233/jad-220441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Brain aging leads to difficulties in functional independence. Mitigating these difficulties can benefit from technology that predicts, monitors, and modifies brain aging. Translational research prioritizes solutions that can be causally linked to specific pathophysiologies at the same time as demonstrating improvements in impactful real-world outcome measures. This poses a challenge for brain aging technology that needs to address the tension between mechanism-driven precision and clinical relevance. In the current opinion, by synthesizing emerging mechanistic, translational, and clinical research-related frameworks, and our own development of technology-driven brain aging research, we suggest incorporating the appreciation of four desiderata (causality, informativeness, transferability, and fairness) of explainability into early-stage research that designs and tests brain aging technology. We apply a series of work on electrocardiography-based "peripheral" neuroplasticity markers from our work as an illustration of our proposed approach. We believe this novel approach will promote the development and adoption of brain aging technology that links and addresses brain pathophysiology and functional independence in the field of translational research.
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Affiliation(s)
- Adam Turnbull
- Department of Psychiatry and Behavioral Sciences, Stanford University, CA, USA
- School of Nursing, University of Rochester Medical Center, NY, USA
| | - Robert Kaplan
- Clinical Excellence Research Center (CERC), Stanford University, CA, USA
| | - Ehsan Adeli
- Department of Psychiatry and Behavioral Sciences, Stanford University, CA, USA
- Wu Tsai Neurosciences Institute, Stanford University, CA, USA
| | - Feng V. Lin
- Department of Psychiatry and Behavioral Sciences, Stanford University, CA, USA
- Wu Tsai Neurosciences Institute, Stanford University, CA, USA
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13
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Callahan KE. Challenges and Facilitators in Implementing a Focus on Function in Structured Clinical Settings. THE PUBLIC POLICY AND AGING REPORT 2021; 32:13-18. [PMID: 35127104 PMCID: PMC8803265 DOI: 10.1093/ppar/prab028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Indexed: 12/25/2022]
Affiliation(s)
- Kathryn E Callahan
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA,Address correspondence to: Kathryn E. Callahan, MD, MS, Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA. E-mail:
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