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Pollack LR, Downey L, Nomitch JT, Lee RY, Engelberg RA, Weiss NS, Kross EK, Khandelwal N. Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure. Ann Am Thorac Soc 2024; 21:907-915. [PMID: 38323911 PMCID: PMC11160134 DOI: 10.1513/annalsats.202308-694oc] [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: 08/10/2023] [Accepted: 02/05/2024] [Indexed: 02/08/2024] Open
Abstract
Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.
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Affiliation(s)
- Lauren R. Pollack
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Jamie T. Nomitch
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Robert Y. Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Ruth A. Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | | | - Erin K. Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
| | - Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; and
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington
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Zha A, Zhang C, Zhu G, Huang X, Anjum S, Talebi Y, Savitz S, Wu H. African American patients have a higher probability of cognitive impairment after incident stroke: An analysis of national electronic health record data. J Stroke Cerebrovasc Dis 2024:107787. [PMID: 38806108 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107787] [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: 11/13/2023] [Revised: 04/26/2024] [Accepted: 05/20/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Cognitive impairment (CI) and stroke are diseases with significant disparities in race and geography. Post stroke cognitive impairment (PSCI) can be as high as 15-70% but few studies have utilized large administrative or electronic health records (EHR) to evaluate trends in PSCI. We utilized an EHR database to evaluate for disparities in PSCI in a large sample of patients after first recorded stroke to evaluate for disparities in race. METHODS This is a retrospective cohort analysis of Cerner Health Facts® EHR database, which is comprised of EHR data from hundreds of hospitals/clinics in the US from 2009-2018. We evaluated patients ≥40 years of age with a first time ischemic stroke (IS) diagnosis for PSCI using ICD9/10 codes for both conditions. Patients with first stroke in the Cerner database and no pre-existing cognitive impairment were included, we compared hazard ratios for developing PSCI for patient characteristics RESULTS: A total of 150,142 IS patients with follow-up data and no pre-existing evidence of CI were evaluated. Traditional risk factors of age, female sex, kidney injury, hypertension, and hyperlipidemia were associated with PSCI. Only African American stroke survivors had a higher probability of developing PSCI compared to White survivors (HR 1.347, 95% CI (1.270, 1.428)) and this difference was most prominent in the South. Among those to develop PSCI, median time to documentation was 1.8 years in African American survivors. CONCLUSION In a large national database, African American stroke survivors had a higher probability of PSCI five years after stroke than White survivors.
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Affiliation(s)
- Alicia Zha
- Institute of Stroke and Cerebrovascular Disease, Department of Neurology, University of Texas McGovern Medical School, Houston TX, 77030; Department of Neurology, The Ohio State University Wexner Medical Center, Columbus OH, 43210.
| | - Chenguang Zhang
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston TX 77030.
| | - Gen Zhu
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston TX 77030.
| | - Xinran Huang
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston TX 77030.
| | - Sahar Anjum
- Department of Neurology, University of Texas McGovern Medical School, Houston TX, 77030.
| | - Yashar Talebi
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston TX 77030.
| | - Sean Savitz
- Institute of Stroke and Cerebrovascular Disease, Department of Neurology, University of Texas McGovern Medical School, Houston TX, 77030; Department of Neurology, University of Texas McGovern Medical School, Houston TX, 77030.
| | - Hulin Wu
- Institute of Stroke and Cerebrovascular Disease, Department of Neurology, University of Texas McGovern Medical School, Houston TX, 77030; Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, Houston TX 77030.
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Khalil M, Woldesenbet S, Munir MM, Katayama E, Mehdi Khan MM, Altaf A, Rashid Z, Endo Y, Dillhoff M, Tsai S, Pawlik TM. Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery. World J Surg 2024; 48:1075-1083. [PMID: 38436547 DOI: 10.1002/wjs.12106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/09/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. METHODS A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. RESULTS Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p < 0.001). CONCLUSION Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.
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Affiliation(s)
- Mujtaba Khalil
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Selamawit Woldesenbet
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad Musaab Munir
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Erryk Katayama
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Muhammad Muntazir Mehdi Khan
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Abdullah Altaf
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Zayed Rashid
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Yutaka Endo
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Susan Tsai
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
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Burke LG, Burke RC, Duggan CE, Figueroa JF, Boltz M, Fick D, Orav EJ, Marcantonio ER. Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias. J Am Geriatr Soc 2024; 72:1442-1452. [PMID: 38546202 PMCID: PMC11090746 DOI: 10.1111/jgs.18890] [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: 12/22/2023] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Marie Boltz
- The Pennsylvania State University College of Nursing, University Park, PA, USA
| | - Donna Fick
- The Pennsylvania State University College of Nursing, University Park, PA, USA
| | - E. John Orav
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
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Pollack LR, Nomitch JT, Downey L, Paul SR, Reed MJ, Uyeda AM, Kiker WA, Dotolo DG, Dzeng E, Lee RY, Engelberg RA, Kross EK. Mechanical Ventilation in Older Adults With Dementia: Opportunities to Promote Goal-Concordant Care. J Pain Symptom Manage 2024:S0885-3924(24)00741-3. [PMID: 38685288 DOI: 10.1016/j.jpainsymman.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 02/07/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
CONTEXT Recent studies show increasing use of mechanical ventilation among people living with dementia. There are concerns that this trend may not be driven by patient preferences. OBJECTIVES To better understand decision-making regarding mechanical ventilation in people living with dementia. METHODS This was an electronic health record-based retrospective cohort study of older adults with dementia (n = 295) hospitalized at one of two teaching hospitals between 2015 and 2019 who were supported with mechanical ventilation (n = 191) or died without mechanical ventilation (n = 104). Multivariable logistic regression was used to examine associations between patient characteristics and mechanical ventilation use. RESULTS The median age was 78 years (IQR 71-86), 41% were female, 28% resided in a nursing home, and 58% had clinical markers of advanced dementia (dehydration, weight loss, mobility limitations, or pressure ulcers). Among patients supported with mechanical ventilation, 70% were intubated within 24 hours of presentation, including 31% intubated before hospital arrival. Younger age, higher illness acuity, and absence of a treatment-limiting Physician Orders for Life-Sustaining Treatment document were associated with mechanical ventilation use; nursing home residence and clinical markers of advanced dementia were not. Most patients (89%) had a documented goals of care discussion (GOCD) during hospitalization. CONCLUSION Future efforts to promote goal-concordant care surrounding mechanical ventilation use for people living with dementia should involve identifying barriers to goal-concordant care in pre-hospital settings, assessing the timeliness of in-hospital GOCD, and developing strategies for in-the-moment crisis communication across settings.
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Affiliation(s)
- Lauren R Pollack
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA.
| | - Jamie T Nomitch
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Sudiptho R Paul
- University of Washington School of Medicine (S.R.P.), Seattle, Washington, USA
| | - May J Reed
- Division of Geriatric Medicine (M.J.R.), University of Washington, Seattle, Washington, USA
| | - Alison M Uyeda
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Whitney A Kiker
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Danae G Dotolo
- Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Elizabeth Dzeng
- Department of Medicine (E.D.), University of California San Francisco, San Francisco, California, USA
| | - Robert Y Lee
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Division of Pulmonary (L.R.P., J.T.M., A.M.U., W.A.K., R.Y.L., R.A.E., E.K.K.), Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (L.R.P., J.T.M., A.M.U., W.A.K., D.G.D. R.Y.L., R.A.E., E.K.K.), University of Washington, Seattle, Washington, USA
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Elzeneini M, Nassereddin AT, Li Y, Shah SK, Winchester D, Li A, Guo Y, Shah KB. Dementia is associated with worse procedural outcomes after mitral valve transcatheter edge-to-edge repair. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00119-2. [PMID: 38604834 DOI: 10.1016/j.carrev.2024.03.031] [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: 02/21/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Patients with dementia are at increased risk for adverse events following valvular surgery. Outcomes after mitral transcatheter edge-to-edge repair (TEER) for mitral regurgitation in this vulnerable population are not well understood. METHODS We queried the National Inpatient Sample database for all hospitalizations for mitral TEER between 2016 and 2019. Patients with a validated diagnosis code for dementia were identified by ICD-10 codes and compared to a matched cohort of non-dementia patients using multivariable regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes were hospital length of stay, discharge to nursing facility, total hospital charges, and in-hospital adverse events. RESULTS 24,550 hospitalizations for mitral TEER were identified, including 880 patients (3.6 %) with dementia. Dementia was associated with higher in-hospital mortality (OR 4.31, 95 % CI 2.65 to 6.99, p < 0.001), prolonged length of hospital stay (OR 1.33, 95 % CI 1.12 to 1.57, p 0.001), higher discharge rate to nursing facility (OR 2.71, 95 % CI 2.13-3.44, p < 0.001), and higher rate of in-hospital adverse events including delirium (OR 5.88, 95 % CI 4.06 to 8.52, p < 0.001) and acute stroke (OR 8.87, 95 % CI 5.01 to 15.70, p < 0.001). CONCLUSIONS Dementia is associated with worse post-procedural outcomes after mitral TEER. Further investigation is needed to elucidate mechanisms of poor clinical outcomes and guide shared decision-making in this vulnerable population.
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Affiliation(s)
- Mohammed Elzeneini
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ali T Nassereddin
- Department of Internal Medicine, University of Florida, Gainesville, FL, United States of America
| | - Yujia Li
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, United States of America
| | - Samir K Shah
- Division of Vascular Surgery, University of Florida, Gainesville, FL, United States of America
| | - David Winchester
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America
| | - Ang Li
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, United States of America
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, University of Florida, Gainesville, FL, United States of America
| | - Khanjan B Shah
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, United States of America.
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Chen AC, Epstein AM, Joynt Maddox KE, Grabowski DC, Orav EJ, Barnett ML. Impact of dementia special care units for short-stay nursing home patients. J Am Geriatr Soc 2024; 72:767-777. [PMID: 38041834 PMCID: PMC10947952 DOI: 10.1111/jgs.18708] [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: 06/21/2023] [Revised: 09/19/2023] [Accepted: 11/14/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Improving quality of care provided to short-stay patients with dementia in nursing homes is a policy priority. However, it is unknown whether dementia-focused care strategies are associated with improved clinical outcomes or lower utilization and costs for short-stay dementia patients. METHODS We performed a national survey of nursing home administrators in 2020-2021, asking about the presence of three dementia-focused care services used for their short-stay patients: (1) a dementia care unit, (2) cognitive deficiency training for staff, and (3) dementia-specific occupational therapy. Using Medicare claims, we identified short-stay episodes for beneficiaries residing in surveyed skilled nursing facilities (SNFs) with and without dementia. We compared clinical, cost, and utilization outcomes for dementia patients in SNFs, which did and did not offer dementia-focused care services. As a counterfactual control, we compared these differences to those for non-dementia patients in the same facilities. Our primary quantity of interest was an interaction term between a patients' dementia status and the presence of a dementia-focused care tool. RESULTS The study population included 102,860 Medicare episodes of care from 377 SNF survey respondents in 2018-2019. In adjusted comparisons of the interaction between dementia status and the presence of each dementia-focused care tool, dementia care units were associated with a 1.5-day increase in healthy days at home in the 90 days following discharge (p = 0.01) and a 3.1% decrease in the likelihood of a subsequent SNF admission (p = 0.001). Cognitive deficiency training was also associated with a 2.0% increase in antipsychotics (p = 0.03), whereas dementia-specific occupational therapy was associated with a 1.2% increase in falls (p = 0.01) per patient episode. CONCLUSIONS Self-reported use of dementia care units for short-stay patients was associated with modestly better performance in some, but not all, outcome measures. This provides hypothesis-generating evidence that dementia care units could be a promising mechanism to improve care delivery in nursing homes.
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Affiliation(s)
- Amanda C Chen
- Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts, USA
| | - Arnold M Epstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine and Center for Advancing Health Services, Policy and Economics Research, Institute of Public Health at Washington University, St. Louis, Missouri, USA
| | - David C Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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8
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Wasfy JH, Price M, Normand SLT, Januzzi JL, McCarthy CP, Hsu J. Classification Algorithm to Distinguish Between Type 1 and Type 2 Myocardial Infarction in Administrative Claims Data. Circ Cardiovasc Qual Outcomes 2024; 17:e009986. [PMID: 38240159 PMCID: PMC11087697 DOI: 10.1161/circoutcomes.123.009986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 10/25/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND Type 2 myocardial infarction (T2MI) and type 1 myocardial infarction (T1MI) differ with respect to demographics, comorbidities, treatments, and clinical outcomes. Reliable quality and outcomes assessment depends on the ability to distinguish between T1MI and T2MI in administrative claims data. As such, we aimed to develop a classification algorithm to distinguish between T1MI and T2MI that could be applied to claims data. METHODS Using data for beneficiaries in a Medicare accountable care organization contract in a large health care system in New England, we examined the distribution of MI diagnosis codes between 2018 to 2021 and the patterns of care and coding for beneficiaries with a hospital discharge diagnosis International Classification of Diseases, Tenth Revision code for T2MI, compared with those for T1MI. We then assessed the probability that each hospitalization was for a T2MI versus T1MI and examined care occurring in 2017 before the introduction of the T2MI code. RESULTS After application of inclusion and exclusion criteria, 7759 hospitalizations for myocardial infarction remained (46.5% T1MI and 53.5% T2MI; mean age, 79±10.3 years; 47% female). In the classification algorithm, female gender (odds ratio, 1.26 [95% CI, 1.11-1.44]), Black race relative to White race (odds ratio, 2.48 [95% CI, 1.76-3.48]), and diagnoses of COVID-19 (odds ratio, 1.74 [95% CI, 1.11-2.71]) or hypertensive emergency (odds ratio, 1.46 [95% CI, 1.00-2.14]) were associated with higher odds of the hospitalization being for T2MI versus T1MI. When applied to the testing sample, the C-statistic of the full model was 0.83. Comparison of classified T2MI and observed T2MI suggest the possibility of substantial misclassification both before and after the T2MI code. CONCLUSIONS A simple classification algorithm appears to be able to differentiate between hospitalizations for T1MI and T2MI before and after the T2MI code was introduced. This could facilitate more accurate longitudinal assessments of acute myocardial infarction quality and outcomes.
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Affiliation(s)
- Jason H. Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mary Price
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sharon-Lise T. Normand
- Department of Health Care Policy, Harvard Medical School, and the Department of Biostatistics, Harvard Chan School of Public Health, Boston, MA
| | - James L. Januzzi
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Cian P. McCarthy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John Hsu
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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John London A, Karlawish J, Largent EA, Phillips Hey S, McCarthy EP. Algorithmic identification of persons with dementia for research recruitment: ethical considerations. Inform Health Soc Care 2024; 49:28-41. [PMID: 38196387 PMCID: PMC11001531 DOI: 10.1080/17538157.2023.2299881] [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: 01/11/2024]
Abstract
Underdiagnosis, misdiagnosis, and patterns of social inequality that translate into unequal access to health systems all pose barriers to identifying and recruiting diverse and representative populations into research on Alzheimer's disease and Alzheimer's disease related dementias. In response, some have turned to algorithms to identify patients living with dementia using information that is associated with this condition but that is not as specific as a diagnosis. This paper explains six ethical issues associated with the use of such algorithms including the generation of new, sensitive, identifiable medical information for research purposes without participant consent, issues of justice and equity, risk, and ethical communication. It concludes with a discussion of strategies for addressing these issues and prompting valuable research.
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Affiliation(s)
- Alex John London
- Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Emily A. Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Ellen P. McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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10
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Koyama AK, Nee R, Yu W, Choudhury D, Heng F, Cheung AK, Norris KC, Cho ME, Yan G. Role of Anemia in Dementia Risk Among Veterans With Incident CKD. Am J Kidney Dis 2023; 82:706-714. [PMID: 37516301 PMCID: PMC10822015 DOI: 10.1053/j.ajkd.2023.04.013] [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: 12/22/2022] [Revised: 03/30/2023] [Accepted: 04/30/2023] [Indexed: 07/31/2023]
Abstract
RATIONALE & OBJECTIVE Although some evidence exists of increased dementia risk from anemia, it is unclear whether this association persists among adults with CKD. Anemia may be a key marker for dementia among adults with CKD, so we evaluated whether anemia is associated with an increased risk of dementia among adults with CKD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS The study included 620,095 veterans aged≥45 years with incident stage 3 CKD (estimated glomerular filtration rate [eGFR]<60mL/min/1.73m2) between January 2005 and December 2016 in the US Veterans Health Administration system and followed through December 31, 2018, for incident dementia, kidney failure, or death. EXPOSURE Anemia was assessed based on the average of hemoglobin levels (g/L) during the 2 years before the date of incident CKD and categorized as normal, mild, or moderate/severe anemia (≥12.0, 11.0-11.9,<11.0g/dL, respectively, for women, and≥13.0, 11.0-12.9,<11.0g/dL for men). OUTCOME Dementia and the composite outcome of kidney failure or death. ANALYTICAL APPROACH Adjusted cause-specific hazard ratios were estimated for each outcome. RESULTS At the time of incident CKD, the mean age of the participants was 72 years, 97% were male, and their mean eGFR was 51mL/min per 1.73m2. Over a median 4.1 years of follow-up, 92,306 veterans (15%) developed dementia before kidney failure or death. Compared with the veterans with CKD without anemia, the multivariable-adjusted models showed a 16% (95% CI, 14%-17%) significantly higher risk of dementia for those with mild anemia and a 27% (95% CI, 23%-31%) higher risk with moderate/severe anemia. Combined risk of kidney failure or death was higher at 39% (95% CI, 37%-40%) and 115% (95% CI, 112%-119%) for mild and moderate/severe anemia, respectively, compared with no anemia. LIMITATIONS Residual confounding from the observational study design. Findings may not be generalizable to the broader US population. CONCLUSIONS Anemia was significantly associated with an increased risk of dementia among veterans with incident CKD, underscoring the role of anemia as a predictor of dementia risk. PLAIN-LANGUAGE SUMMARY Adults with chronic kidney disease (CKD) often have anemia. Prior studies among adults in the general population suggest anemia is a risk factor for dementia, though it is unclear whether this association persists among adults with CKD. In this large study of veterans in the United States, we studied the association between anemia and the risk of 2 important outcomes in this population: (1) dementia and (2) kidney failure or death. We found that anemia was associated with a greater risk of dementia as well as risk of kidney failure or death. The study findings therefore emphasize the role of anemia as a key predictor of dementia risk among adults with CKD.
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Affiliation(s)
- Alain K Koyama
- Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Robert Nee
- Walter Reed National Military Medical Center; Uniformed Services University, Bethesda, Maryland
| | - Wei Yu
- University of Virginia, Charlottesville, Virginia
| | - Devasmita Choudhury
- University of Virginia, Charlottesville, Virginia; Virginia-Tech Carilion School of Medicine Medical Center, Roanoke, Virginia; Salem Veterans Affairs Healthcare System, Salem, Virginia
| | - Fei Heng
- University of North Florida, Jacksonville, Florida
| | - Alfred K Cheung
- VA Salt Lake City Healthcare System, Salt Lake City, Utah; University of Utah, Salt Lake City, Utah
| | - Keith C Norris
- University of California-Los Angeles, Los Angeles, California
| | | | - Guofen Yan
- University of Virginia, Charlottesville, Virginia.
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Park CM, Sison SDM, McCarthy EP, Shi S, Gouskova N, Lin KJ, Kim DH. Claims-Based Frailty Index as a Measure of Dementia Severity in Medicare Claims Data. J Gerontol A Biol Sci Med Sci 2023; 78:2145-2151. [PMID: 37428879 PMCID: PMC10613007 DOI: 10.1093/gerona/glad166] [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: 02/13/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Dementia severity is unavailable in administrative claims data. We examined whether a claims-based frailty index (CFI) can measure dementia severity in Medicare claims. METHODS This cross-sectional study included the National Health and Aging Trends Study Round 5 participants with possible or probable dementia whose Medicare claims were available. We estimated the Functional Assessment Staging Test (FAST) scale (range: 3 [mild cognitive impairment] to 7 [severe dementia]) using information from the survey. We calculated CFI (range: 0-1, higher scores indicating greater frailty) using Medicare claims 12 months prior to the participants' interview date. We examined C-statistics to evaluate the ability of the CFI in identifying moderate-to-severe dementia (FAST stage 5-7) and determined the optimal CFI cut-point that maximized both sensitivity and specificity. RESULTS Of the 814 participants with possible or probable dementia and measurable CFI, 686 (72.2%) patients were ≥75 years old, 448 (50.8%) were female, and 244 (25.9%) had FAST stage 5-7. The C-statistic of CFI to identify FAST stage 5-7 was 0.78 (95% confidence interval: 0.72-0.83), with a CFI cut-point of 0.280, achieving the maximum sensitivity of 76.9% and specificity of 62.8%. Participants with CFI ≥0.280 had a higher prevalence of disability (19.4% vs 58.3%) and dementia medication use (6.0% vs 22.8%) and higher risk of mortality (10.7% vs 26.3%) and nursing home admission (4.5% vs 10.6%) over 2 years than those with CFI <0.280. CONCLUSIONS Our study suggests that CFI can be useful in identifying moderate-to-severe dementia from administrative claims among older adults with dementia.
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Affiliation(s)
- Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephanie Denise M Sison
- Division of General Internal Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandra Shi
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalia Gouskova
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Bélanger E, Rosendaal N, Gutman R, Lake D, Santostefano CM, Meyers DJ, Gozalo PL. Identifying Medicare beneficiaries with Alzheimer's disease and related dementia using home health OASIS assessments. J Am Geriatr Soc 2023; 71:3229-3236. [PMID: 37358283 PMCID: PMC10592468 DOI: 10.1111/jgs.18487] [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: 12/19/2022] [Revised: 04/24/2023] [Accepted: 05/21/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Home health services are an important site of care following hospitalization among Medicare beneficiaries, providing health assessments that can be leveraged to detect diagnoses that are not available in other data sources. In this work, we aimed to develop a parsimonious and accurate algorithm using home health outcome and assessment information set (OASIS) measures to identify Medicare beneficiaries with a diagnosis of Alzheimer's disease and related dementia (ADRD). METHODS We conducted a retrospective cohort study of Medicare beneficiaries with a complete OASIS start of care assessment in 2014, 2016, 2018, or 2019 to determine how well the items from various versions could identify those with an ADRD diagnosis by the assessment date. The prediction model was developed iteratively, comparing the performance of different models in terms of sensitivity, specificity, and accuracy of prediction, from a multivariable logistic regression model using clinically relevant variables, to regression models with all available variables and predictive modeling techniques, to estimate the best performing parsimonious model. RESULTS The most important predictors of having a diagnosis of ADRD by the start of care OASIS assessment were a prior discharge diagnosis of ADRD among those admitted from an inpatient setting, and frequently exhibiting symptoms of confusion. Results from the parsimonious model were consistent across the four annual cohorts and OASIS versions with high specificity (above 96%), but poor sensitivity (below 58%). The positive predictive value was high, over 87% across study years. CONCLUSIONS The proposed algorithm has high accuracy, requires a single OASIS assessment, is easy to implement without sophisticated statistical models, and can be used across four OASIS versions and in situations where claims are not available to identify individuals with a diagnosis of ADRD, including the growing population of Medicare Advantage beneficiaries.
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Affiliation(s)
- Emmanuelle Bélanger
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Nicole Rosendaal
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Derek Lake
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Christopher M Santostefano
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - David J Meyers
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Pedro L Gozalo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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13
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Lusk JB, Choi S, Clark AG, Johnson K, Ford CB, Greiner MA, Goetz M, Kaufman BG, O'Brien R, O'Brien EC. Dementia and Parkinson's disease diagnoses in electronic health records vs. Medicare claims data: a study of 101,980 linked patients. BMC Neurol 2023; 23:325. [PMID: 37700254 PMCID: PMC10496225 DOI: 10.1186/s12883-023-03361-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/07/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Medicare claims and electronic health record data are both commonly used for research and clinical practice improvement; however, it is not known how concordant diagnoses of neurodegenerative diseases (NDD, comprising dementia and Parkinson's disease) are in these data types. Therefore, our objective was to determine the sensitivity and specificity of neurodegenerative disease (NDD) diagnoses contained in structured electronic health record (EHR) data compared to Medicare claims data. METHODS This was a retrospective cohort study of 101,980 unique patients seen at a large North Carolina health system between 2013-2017, which were linked to 100% North and South Carolina Medicare claims data, to evaluate the accuracy of diagnoses of neurodegenerative diseases in EHRs compared to Medicare claims data. Patients age > 50 who were enrolled in fee-for-service Medicare were included in the study. Patients were classified as having or not having NDD based on the presence of validated ICD-CM-9 or ICD-CM-10 codes associated with NDD or claims for prescription drugs used to treat NDD. EHR diagnoses were compared to Medicare claims diagnoses. RESULTS The specificity of any EHR diagnosis of NDD was 99.0%; sensitivity was 61.3%. Positive predictive value and negative predictive value were 90.8% and 94.1% respectively. Specificity of an EHR diagnosis of dementia was 99.0%, and sensitivity was 56.1%. Specificity of an EHR diagnosis of PD was 99.7%, while sensitivity was 76.1%. CONCLUSIONS More research is needed to investigate under-documentation of NDD in electronic health records relative to Medicare claims data, which has major implications for clinical practice (particularly patient safety) and research using real-world data.
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Affiliation(s)
- Jay B Lusk
- Duke University School of Medicine, DUMC 3710, Durham, NC, 27710, USA.
- Duke University Fuqua School of Business, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
- Department of Neurology, Duke University, Durham, NC, USA.
| | - Sujung Choi
- Janssen Scientific Affairs, Inc, Titusville, NJ, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Kim Johnson
- Department of Neurology, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Brystana G Kaufman
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | | | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
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14
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Johnston KJ, Loux T, Joynt Maddox KE. Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia. Med Care 2023; 61:570-578. [PMID: 37411003 PMCID: PMC10328553 DOI: 10.1097/mlr.0000000000001876] [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: 07/08/2023]
Abstract
BACKGROUND Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown. OBJECTIVE The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status. RESEARCH DESIGN Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns. SUBJECTS A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey. MEASURES We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status. RESULTS Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05). CONCLUSION Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.
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Affiliation(s)
- Kenton J Johnston
- General Medical Sciences Division, Washington University School of Medicine
| | - Travis Loux
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, Saint Louis University
| | - Karen E Joynt Maddox
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
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15
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Yu X, Kuo YF, Raji MA, Berenson AB, Baillargeon J, Giordano TP. Dementias Among Older Males and Females in the U.S. Medicare System With and Without HIV. J Acquir Immune Defic Syndr 2023; 93:107-115. [PMID: 36881792 PMCID: PMC10293071 DOI: 10.1097/qai.0000000000003184] [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: 09/16/2022] [Accepted: 02/22/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Despite the growing concern that people with HIV (PWH) will experience a disproportionate burden of dementia as they age, very few studies have examined the sex-specific prevalence of dementia, including Alzheimer disease and related dementias (AD/ADRD) among older PWH versus people without HIV (PWOH) using large national samples. METHODS We constructed successive cross-sectional cohorts including all PWH aged 65+ years from U.S. Medicare enrollees and PWOH in a 5% national sample of Medicare data from 2007 to 2019. All AD/ADRD cases were identified by ICD-9-CM/ICD-10-CM diagnosis codes. Prevalence of AD/ADRD was calculated for each calendar year by sex-age strata. Generalized estimating equations were used to assess factors associated with dementia and calculate the adjusted prevalence. RESULTS PWH had a higher prevalence of AD/ADRD, which increased over time compared with PWOH, especially among female beneficiaries and with increasing age. For example, among those aged 80+ years, the prevalence increased from 2007 to 2019 (females with HIV: 31.4%-44.1%; females without HIV: 27.4%-29.9%; males with HIV: 26.2%-33.3%; males without HIV: 21.0%-23.5%). After adjustment for demographics and comorbidities, the differences in dementia burden by HIV status remained, especially among older age groups. CONCLUSIONS Older Medicare enrollees with HIV had an increased dementia burden over time compared with those without HIV, especially women and older subjects. This underscores the need to develop tailored clinical practice guidelines that facilitate the integration of dementia and comorbidity screening, evaluation, and management into the routine primary care of aging PWH.
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Affiliation(s)
- Xiaoying Yu
- Department of Biostatistics & Data Science, University of Texas Medical Branch at Galveston (UTMB), Galveston, TX, USA
- Center for Interdisciplinary Research in Women’s Health, UTMB
| | - Yong-Fang Kuo
- Department of Biostatistics & Data Science, University of Texas Medical Branch at Galveston (UTMB), Galveston, TX, USA
- Center for Interdisciplinary Research in Women’s Health, UTMB
| | | | - Abbey B. Berenson
- Center for Interdisciplinary Research in Women’s Health, UTMB
- Department of Obstetrics & Gynecology, UTMB
| | | | - Thomas P. Giordano
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
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Hale EW, Macchi ZA, Pressman PS. Delirium Following Anticholinergic Use in Hospitalized Patients With Dementia. Neurohospitalist 2023; 13:153-155. [PMID: 37064926 PMCID: PMC10091436 DOI: 10.1177/19418744221135914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We sought to explore rates of delirium amongst hospitalized patients with dementia following orders for anticholinergic medications. We hypothesized that patients receiving anticholinergic medications would have higher rates of delirium than similar, unexposed patients. We performed a retrospective chart review of 23 031 hospitalized individuals with Alzheimer's disease, vascular dementia, or unspecified dementia from 2011-2018. Rates of delirium diagnosis and haloperidol orders following anticholinergic administration were compared to patients with dementia without anticholinergic orders. Significant differences in rates of delirium and orders for haloperidol were observed between exposed and unexposed groups, with delirium having a relative risk of 2.3 and orders for haloperidol having a relative risk of 10.4. The number needed to harm for anticholinergic exposure was 5.45 for delirium and 7.09 for haloperidol. The identified difference suggests that inpatient use of anticholinergic medications may increase the risk of delirium in hospitalized patients with dementia. Despite this risk, our review suggests that anticholinergic administration is common during hospital stays among patients with dementia. Anticholinergic use may be a modifiable risk factor for delirium prevention, which could improve inpatient management of patients with dementia.
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Affiliation(s)
- Elijah W. Hale
- University of Colorado School of
Medicine, Aurora, CO, USA
| | - Zachary A. Macchi
- University of Colorado School of
Medicine, Aurora, CO, USA
- Behavioral Neurology Section, University of Colorado School of
Medicine, Aurora, CO, USA
| | - Peter S. Pressman
- University of Colorado School of
Medicine, Aurora, CO, USA
- Behavioral Neurology Section, University of Colorado School of
Medicine, Aurora, CO, USA
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17
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Growdon ME, Gan S, Yaffe K, Lee AK, Anderson TS, Muench U, Boscardin WJ, Steinman MA. New psychotropic medication use among Medicare beneficiaries with dementia after hospital discharge. J Am Geriatr Soc 2023; 71:1134-1144. [PMID: 36514208 PMCID: PMC10089969 DOI: 10.1111/jgs.18161] [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: 07/06/2022] [Revised: 10/21/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hospitalizations among people with dementia (PWD) may precipitate behavioral changes, leading to the psychotropic medication use despite adverse outcomes and limited efficacy. We sought to determine the incidence of new psychotropic medication use among community-dwelling PWD after hospital discharge and, among new users, the proportion with prolonged use. METHODS This was a retrospective cohort study using a 20% random sample of Medicare claims in 2017, including hospitalized PWD with traditional and Part D Medicare who were 68 years or older. The primary outcome was incident prescribing at discharge of psychotropics including antipsychotics, sedative-hypnotics, antiepileptics, and antidepressants. This was defined as new prescription fills (i.e., from classes not used in 180 days preadmission) within 7 days of hospital or skilled nursing facility discharge. Prolonged use was defined as the proportion of new users who continued to fill newly prescribed medications beyond 90 days of discharge. RESULTS The cohort included 117,022 hospitalized PWD with a mean age of 81 years; 63% were female. Preadmission, 63% were using at least 1 psychotropic medication; 10% were using medications from ≥3 psychotropic classes. These included antidepressants (44% preadmission), antiepileptics (29%), sedative-hypnotics (21%), and antipsychotics (11%). The proportion of PWD discharged from the hospital with new psychotropics ranged from 1.9% (antipsychotics) to 2.9% (antiepileptics); 6.6% had at least one new class started. Among new users, prolonged use ranged from 36% (sedative-hypnotics) to 63% (antidepressants); across drug classes, prolonged use occurred in 51%. Predictors of newly initiated psychotropics included length of stay (≥median vs. CONCLUSIONS Hospitalized PWD have a high prevalence of preadmission psychotropic medication use; against this baseline, discharge from the hospital with new psychotropics is relatively uncommon. Nevertheless, prolonged use of newly initiated psychotropics occurs in a substantial proportion of this population.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Siqi Gan
- Division of Geriatrics, University of California, San Francisco, California, USA
- Northern California Institute for Research and Education, San Francisco, California, USA
| | - Kristine Yaffe
- Mental Health, San Francisco VA Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Departments of Neurology and Psychiatry, University of California, San Francisco, California, USA
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
| | - Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ulrike Muench
- Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, California, USA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California, USA
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18
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Clark CJ, Adler R, Xiang L, Shah SK, Cooper Z, Kim DH, Lin KJ, Hsu J, Lipsitz S, Weissman JS. Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study. Am J Surg 2023:S0002-9610(23)00108-3. [PMID: 37031040 DOI: 10.1016/j.amjsurg.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/22/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery. METHODS Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes. RESULTS 5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001). CONCLUSIONS The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.
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Mork D, Braun D, Zanobetti A. Time-lagged relationships between a decade of air pollution exposure and first hospitalization with Alzheimer's disease and related dementias. ENVIRONMENT INTERNATIONAL 2023; 171:107694. [PMID: 36521347 PMCID: PMC9885762 DOI: 10.1016/j.envint.2022.107694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/11/2022] [Accepted: 12/11/2022] [Indexed: 05/09/2023]
Abstract
Alzheimer's disease and related dementias (ADRD) poses substantial health challenges among an aging population. One of the primary challenges in studying ADRD is that biological processes underlying these ailments begin decades prior to diagnosis. Previous studies indicate a relationship between ADRD and air pollution exposure to both fine particulate matter (PM2.5) and nitrogen dioxide (NO2) but are limited in their interpretation because they consider exposure measurements at a single time point. Our retrospective cohort study considered 27 + million Medicare enrollees in the United States followed up to 17 years and matched with highly accurate annual air pollution exposure measurements for PM2.5, NO2, and summer ozone. We applied distributed lag models and estimated the lagged associations between air pollution and odds of first hospitalization with ADRD. We found significantly increased odds due to overall PM2.5 and NO2 exposure and time-lagged exposure 10 and 8 years prior to admission, respectively. Furthermore, we found the connection between air pollution exposure and increased odds of first hospitalization with ADRD exists at air pollution levels below current National Ambient Air Quality Standards set by the US Environmental Protection Agency, with the steepest increase in odds occurring at low concentrations of PM2.5. Our findings are the first to show that air pollution exposures from as many as 10 years prior to the admission are related to increased odds of hospitalizations with ADRD. As there are no clear treatments available for ADRD, identifying modifiable risk factors such as air pollution exposure may make significant contributions towards prevention or delayed disease progression.
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Affiliation(s)
- Daniel Mork
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Danielle Braun
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Antonella Zanobetti
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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20
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Moura LM, Zafar S, Benson NM, Festa N, Price M, Donahue MA, Normand SL, Newhouse JP, Blacker D, Hsu J. Identifying Medicare Beneficiaries With Delirium. Med Care 2022; 60:852-859. [PMID: 36043702 PMCID: PMC9588515 DOI: 10.1097/mlr.0000000000001767] [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: 01/28/2023]
Abstract
BACKGROUND Each year, thousands of older adults develop delirium, a serious, preventable condition. At present, there is no well-validated method to identify patients with delirium when using Medicare claims data or other large datasets. We developed and assessed the performance of classification algorithms based on longitudinal Medicare administrative data that included International Classification of Diseases, 10th Edition diagnostic codes. METHODS Using a linked electronic health record (EHR)-Medicare claims dataset, 2 neurologists and 2 psychiatrists performed a standardized review of EHR records between 2016 and 2018 for a stratified random sample of 1002 patients among 40,690 eligible subjects. Reviewers adjudicated delirium status (reference standard) during this 3-year window using a structured protocol. We calculated the probability that each patient had delirium as a function of classification algorithms based on longitudinal Medicare claims data. We compared the performance of various algorithms against the reference standard, computing calibration-in-the-large, calibration slope, and the area-under-receiver-operating-curve using 10-fold cross-validation (CV). RESULTS Beneficiaries had a mean age of 75 years, were predominately female (59%), and non-Hispanic Whites (93%); a review of the EHR indicated that 6% of patients had delirium during the 3 years. Although several classification algorithms performed well, a relatively simple model containing counts of delirium-related diagnoses combined with patient age, dementia status, and receipt of antipsychotic medications had the best overall performance [CV- calibration-in-the-large <0.001, CV-slope 0.94, and CV-area under the receiver operating characteristic curve (0.88 95% confidence interval: 0.84-0.91)]. CONCLUSIONS A delirium classification model using Medicare administrative data and International Classification of Diseases, 10th Edition diagnosis codes can identify beneficiaries with delirium in large datasets.
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Affiliation(s)
- Lidia M.V.R. Moura
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicole M. Benson
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - Natalia Festa
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary Price
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maria A. Donahue
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sharon-Lise Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Deborah Blacker
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - John Hsu
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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21
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Shah SK, Adler RR, Xiang L, Clark CJ, Cooper Z, Finlayson E, Kim DH, Lin KJ, Lipsitz SR, Weissman JS. Patients living with dementia have worse outcomes when undergoing high-risk procedures. J Am Geriatr Soc 2022; 70:2838-2846. [PMID: 35637607 PMCID: PMC9588582 DOI: 10.1111/jgs.17893] [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: 11/01/2021] [Revised: 04/18/2022] [Accepted: 05/03/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with Alzheimer's Disease and Related Dementias (ADRD) undergoing inpatient procedures represent a population at elevated risk for adverse outcomes including postoperative complications, mortality, and discharge to a higher level of care. Outcomes may be particularly poor in patients with ADRD undergoing high-risk procedures. We sought to determine traditional (e.g., 30-day mortality) and patient-centered (e.g., discharge disposition) outcomes in patients with ADRD undergoing high-risk inpatient procedures. METHODS This retrospective cohort study analyzed electronic health records linked to fee-for-service Medicare claims data at a tertiary care academic health system. All patients from a large multi-hospital health system undergoing high-risk inpatient procedures from October 1, 2015 to September 30, 2017 with continuous Medicare Parts A and B enrollment in the 12 months prior to and 90 days following the procedure were included. RESULTS This study included 6779 patients. 536 (7.9%) had ADRD. A multivariable analysis of outcomes demonstrated higher risks for postoperative complications (OR 1.49, 95% CI 1.23-1.81) and 90-day mortality (OR 1.44 [95% CI 1.09-1.91]) in patients with ADRD compared to those without. Patients with ADRD were more likely to be discharged to a higher level of care (OR 1.70, 95% CI 1.32-2.18) and only 37.3% of patients admitted from home were discharged to home. CONCLUSIONS Compared to those without ADRD, patients living with ADRD undergoing high-risk procedures have poor traditional and patient-centered outcomes including increased risks for 90-day mortality, postoperative complications, longer hospital lengths of stay, and discharge to a higher level of care. These data may be used by patients, their surrogates, and their physicians to help align surgical decision-making with health care goals.
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Affiliation(s)
- Samir K Shah
- Division of Vascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Rachel R Adler
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lingwei Xiang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Clancy J Clark
- Division of Surgical Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily Finlayson
- Department of Surgery, Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
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22
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Festa N, Price M, Weiss M, Moura LMVR, Benson NM, Zafar S, Blacker D, Normand SLT, Newhouse JP, Hsu J. Evaluating The Accuracy Of Medicare Risk Adjustment For Alzheimer's Disease And Related Dementias. Health Aff (Millwood) 2022; 41:1324-1332. [PMID: 36067434 PMCID: PMC9973227 DOI: 10.1377/hlthaff.2022.00185] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In 2020 Medicare reintroduced Alzheimer's disease and related dementias (ADRD) Hierarchical Condition Categories (HCCs) to risk-adjust Medicare Advantage and accountable care organization (ACO) payments. The potential for Medicare spending increases from this policy change are not well understood because the baseline accuracy of ADRD HCCs is uncertain. Using linked 2016-18 claims and electronic health record data from a large ACO, we evaluated the accuracy of claims-based ADRD HCCs against a reference standard of clinician-adjudicated disease. An estimated 7.5 percent of beneficiaries had clinician-adjudicated ADRD. Among those with ADRD HCCs, 34 percent did not have clinician-adjudicated disease. The false-negative and false-positive rates were 22.7 percent and 3.2 percent, respectively. Medicare spending for those with false-negative ADRD HCCs exceeded that of true positives by $14,619 per beneficiary. If, after the reintroduction of risk adjustment for ADRD, all false negatives were coded as having ADRD, expenditure benchmarks for beneficiaries with ADRD would increase by 9 percent. Monitoring ADRD coding could become challenging in the setting of concurrent incentives to decrease false-negative rates and increase false-positive rates.
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Affiliation(s)
- Natalia Festa
- Natalia Festa , Yale University, New Haven, Connecticut
| | - Mary Price
- Mary Price, Massachusetts General Hospital and Harvard University, Boston, Massachusetts
| | - Max Weiss
- Max Weiss, Massachusetts General Hospital and Harvard University
| | - Lidia M V R Moura
- Lidia M. V. R. Moura, Massachusetts General Hospital and Harvard University
| | - Nicole M Benson
- Nicole M. Benson, Massachusetts General Hospital and Harvard University; McLean Hospital, Belmont, Massachusetts
| | - Sahar Zafar
- Sahar Zafar, Massachusetts General Hospital and Harvard University
| | - Deborah Blacker
- Deborah Blacker, Massachusetts General Hospital and Harvard University
| | | | | | - John Hsu
- John Hsu, Massachusetts General Hospital and Harvard University
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23
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Noori A, Magdamo C, Liu X, Tyagi T, Li Z, Kondepudi A, Alabsi H, Rudmann E, Wilcox D, Brenner L, Robbins GK, Moura L, Zafar S, Benson NM, Hsu J, R Dickson J, Serrano-Pozo A, Hyman BT, Blacker D, Westover MB, Mukerji SS, Das S. Development and Evaluation of a Natural Language Processing Annotation Tool to Facilitate Phenotyping of Cognitive Status in Electronic Health Records: Diagnostic Study. J Med Internet Res 2022; 24:e40384. [PMID: 36040790 PMCID: PMC9472045 DOI: 10.2196/40384] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/29/2022] [Accepted: 07/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Electronic health records (EHRs) with large sample sizes and rich information offer great potential for dementia research, but current methods of phenotyping cognitive status are not scalable. OBJECTIVE The aim of this study was to evaluate whether natural language processing (NLP)-powered semiautomated annotation can improve the speed and interrater reliability of chart reviews for phenotyping cognitive status. METHODS In this diagnostic study, we developed and evaluated a semiautomated NLP-powered annotation tool (NAT) to facilitate phenotyping of cognitive status. Clinical experts adjudicated the cognitive status of 627 patients at Mass General Brigham (MGB) health care, using NAT or traditional chart reviews. Patient charts contained EHR data from two data sets: (1) records from January 1, 2017, to December 31, 2018, for 100 Medicare beneficiaries from the MGB Accountable Care Organization and (2) records from 2 years prior to COVID-19 diagnosis to the date of COVID-19 diagnosis for 527 MGB patients. All EHR data from the relevant period were extracted; diagnosis codes, medications, and laboratory test values were processed and summarized; clinical notes were processed through an NLP pipeline; and a web tool was developed to present an integrated view of all data. Cognitive status was rated as cognitively normal, cognitively impaired, or undetermined. Assessment time and interrater agreement of NAT compared to manual chart reviews for cognitive status phenotyping was evaluated. RESULTS NAT adjudication provided higher interrater agreement (Cohen κ=0.89 vs κ=0.80) and significant speed up (time difference mean 1.4, SD 1.3 minutes; P<.001; ratio median 2.2, min-max 0.4-20) over manual chart reviews. There was moderate agreement with manual chart reviews (Cohen κ=0.67). In the cases that exhibited disagreement with manual chart reviews, NAT adjudication was able to produce assessments that had broader clinical consensus due to its integrated view of highlighted relevant information and semiautomated NLP features. CONCLUSIONS NAT adjudication improves the speed and interrater reliability for phenotyping cognitive status compared to manual chart reviews. This study underscores the potential of an NLP-based clinically adjudicated method to build large-scale dementia research cohorts from EHRs.
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Affiliation(s)
- Ayush Noori
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Colin Magdamo
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Xiao Liu
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Tanish Tyagi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Zhaozhi Li
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Akhil Kondepudi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Haitham Alabsi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Emily Rudmann
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Vaccine and Immunotherapy Center, Division of Infectious Disease, Boston, MA, United States
| | - Douglas Wilcox
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Laura Brenner
- Harvard Medical School, Boston, MA, United States
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Gregory K Robbins
- Harvard Medical School, Boston, MA, United States
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
| | - Lidia Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Sahar Zafar
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Nicole M Benson
- Harvard Medical School, Boston, MA, United States
- Mongan Institute, Massachusetts General Hospital, Boston, MA, United States
- McLean Hospital, Belmont, MA, United States
| | - John Hsu
- Harvard Medical School, Boston, MA, United States
- Mongan Institute, Massachusetts General Hospital, Boston, MA, United States
| | - John R Dickson
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Alberto Serrano-Pozo
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Bradley T Hyman
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Deborah Blacker
- Harvard Medical School, Boston, MA, United States
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Shibani S Mukerji
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
| | - Sudeshna Das
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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24
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Pritchard JE, Wilson LE, Miller SM, Greiner MA, Cohen HJ, Kaye DR, Zhang T, Dinan MA. Association between cognitive impairment and oral anticancer agent use in older patients with metastatic renal cell carcinoma. J Am Geriatr Soc 2022; 70:2330-2343. [PMID: 35499667 PMCID: PMC9378524 DOI: 10.1111/jgs.17826] [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: 12/03/2021] [Revised: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Kidney cancer is the fastest-growing cancer diagnosis in the developed world. About 16% of new cases are stage IV, which has a low five-year survival rate. Many patients with metastatic renal cell carcinoma (mRCC) are older and may have mild cognitive impairment or dementia (MCI/D). Given prior reports of patients with dementia initiating less cancer therapy and the importance of oral anticancer agents (OAAs) in mRCC treatment, we investigated the prevalence of preexisting MCI/D in patients with mRCC and their OAA use. METHODS SEER-Medicare patients were analyzed who were ≥65 years, diagnosed with mRCC between 2007 and 2015, and had Medicare part D coverage. Patterns and predictors of (a) OAA utilization within the 12 months following mRCC diagnosis and (b) adherence (percent of days covered [PDC] ≥ 80%) during the first 90 days following treatment initiation were assessed. RESULTS Of the 2792 eligible patients, 268 had preexisting MCI/D, and 907 initiated OAA treatment within 12 months of mRCC diagnosis. Patients with preexisting MCI/D were less likely to begin an OAA than those without MCI/D (fully-adjusted HR 0.53, 95% CI 0.38-0.76). Among OAA initiators, a preexisting MCI/D diagnosis did not alter the likelihood that a person would be adherent (adjusted RR 0.84, 95% CI 0.55-1.28). CONCLUSIONS Patients with preexisting MCI/D were half as likely to start an OAA during the year following mRCC diagnosis than patients without comorbid MCI/D. The 90-day adherence of OAA initiators was not significantly different between those with and without preexisting MCI/D. In light of this, clinicians should assess mRCC patients for cognitive impairment and take steps to optimize OAA utilization by those with MCI/D.
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Affiliation(s)
| | | | - Samuel M. Miller
- National Clinician Scholars Program, Yale University
- Department of Surgery, Yale University
| | | | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University
| | | | - Tian Zhang
- Division of Medical Oncology, Department of Medicine, Duke University
- Division of Hematology and Oncology, Department of Internal Medicine, UT Southwestern Medical Center
| | - Michaela A. Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center
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25
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Grodstein F, Chang CH, Capuano AW, Power MC, Marquez DX, Barnes LL, Bennett DA, James BD, Bynum JPW. Identification of Dementia in Recent Medicare Claims Data, Compared With Rigorous Clinical Assessments. J Gerontol A Biol Sci Med Sci 2022; 77:1272-1278. [PMID: 34919685 PMCID: PMC9159666 DOI: 10.1093/gerona/glab377] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Medicare fee-for-service (FFS) claims data are increasingly leveraged for dementia research. Few studies address the validity of recent claim data to identify dementia, or carefully evaluate characteristics of those assigned the wrong diagnosis in claims. METHODS We used claims data from 2014 to 2018, linked to participants administered rigorous, annual dementia evaluations in 5 cohorts at the Rush Alzheimer's Disease Center. We compared prevalent dementia diagnosed through the 2016 cohort evaluation versus claims identification of dementia, applying the Bynum-standard algorithm. RESULTS Of 1 054 participants with Medicare Parts A and B FFS in a 3-year window surrounding their 2016 index date, 136 had prevalent dementia diagnosed during cohort evaluations; the claims algorithm yielded 217. Sensitivity of claims diagnosis was 79%, specificity 88%, positive predictive value 50%, negative predictive value 97%, and overall accuracy 87%. White participants were disproportionately represented among detected dementia cases (true positive) versus cases missed (false negative) by claims (90% vs 75%, respectively, p = .04). Dementia appeared more severe in detected than missed cases in claims (mean Mini-Mental State Exam = 15.4 vs 22.0, respectively, p < .001; 28% with no limitations in activities of daily living versus 45%, p = .046). By contrast, those with "over-diagnosis" of dementia in claims (false positive) had several worse health indicators than true negatives (eg, self-reported memory concerns = 51% vs 29%, respectively, p < .001; mild cognitive impairment in cohort evaluation = 72% vs 44%, p < .001; mean comorbidities = 7 vs 4, p < .001). CONCLUSIONS Recent Medicare claims perform reasonably well in identifying dementia; however, there are consistent differences in cases of dementia identified through claims than in rigorous cohort evaluations.
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Affiliation(s)
- Francine Grodstein
- Rush Alzheimer’s Disease Center, Chicago, Illinois, USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Chiang-Hua Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ana W Capuano
- Rush Alzheimer’s Disease Center, Chicago, Illinois, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Melinda C Power
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - David X Marquez
- Rush Alzheimer’s Disease Center, Chicago, Illinois, USA
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Lisa L Barnes
- Rush Alzheimer’s Disease Center, Chicago, Illinois, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - David A Bennett
- Rush Alzheimer’s Disease Center, Chicago, Illinois, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Bryan D James
- Rush Alzheimer’s Disease Center, Chicago, Illinois, USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Gutierrez J. The persistent disparity in brain health among aging people with HIV. AIDS 2022; 36:475-477. [PMID: 35084385 PMCID: PMC8827616 DOI: 10.1097/qad.0000000000003148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jose Gutierrez
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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27
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Wang L, Laurentiev J, Yang J, Lo YC, Amariglio RE, Blacker D, Sperling RA, Marshall GA, Zhou L. Development and Validation of a Deep Learning Model for Earlier Detection of Cognitive Decline From Clinical Notes in Electronic Health Records. JAMA Netw Open 2021; 4:e2135174. [PMID: 34792589 PMCID: PMC8603078 DOI: 10.1001/jamanetworkopen.2021.35174] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Detecting cognitive decline earlier among older adults can facilitate enrollment in clinical trials and early interventions. Clinical notes in longitudinal electronic health records (EHRs) provide opportunities to detect cognitive decline earlier than it is noted in structured EHR fields as formal diagnoses. OBJECTIVE To develop and validate a deep learning model to detect evidence of cognitive decline from clinical notes in the EHR. DESIGN, SETTING, AND PARTICIPANTS Notes documented 4 years preceding the initial mild cognitive impairment (MCI) diagnosis were extracted from Mass General Brigham's Enterprise Data Warehouse for patients aged 50 years or older and with initial MCI diagnosis during 2019. The study was conducted from March 1, 2020, to June 30, 2021. Sections of notes for cognitive decline were labeled manually and 2 reference data sets were created. Data set I contained a random sample of 4950 note sections filtered by a list of keywords related to cognitive functions and was used for model training and testing. Data set II contained 2000 randomly selected sections without keyword filtering for assessing whether the model performance was dependent on specific keywords. MAIN OUTCOMES AND MEASURES A deep learning model and 4 baseline models were developed and their performance was compared using the area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). RESULTS Data set I represented 1969 patients (1046 [53.1%] women; mean [SD] age, 76.0 [13.3] years). Data set II comprised 1161 patients (619 [53.3%] women; mean [SD] age, 76.5 [10.2] years). With some overlap of patients deleted, the unique population was 2166. Cognitive decline was noted in 1453 sections (29.4%) in data set I and 69 sections (3.45%) in data set II. Compared with the 4 baseline models, the deep learning model achieved the best performance in both data sets, with AUROC of 0.971 (95% CI, 0.967-0.976) and AUPRC of 0.933 (95% CI, 0.921-0.944) for data set I and AUROC of 0.997 (95% CI, 0.994-0.999) and AUPRC of 0.929 (95% CI, 0.870-0.969) for data set II. CONCLUSIONS AND RELEVANCE In this diagnostic study, a deep learning model accurately detected cognitive decline from clinical notes preceding MCI diagnosis and had better performance than keyword-based search and other machine learning models. These results suggest that a deep learning model could be used for earlier detection of cognitive decline in the EHRs.
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Affiliation(s)
- Liqin Wang
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - John Laurentiev
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jie Yang
- School of Public Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying-Chih Lo
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rebecca E. Amariglio
- Department of Neurology, Brigham and Women’s Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deborah Blacker
- Department of Epidemiology, Harvard T. H. Chan School of Public Health and Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reisa A. Sperling
- Department of Neurology, Brigham and Women’s Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gad A. Marshall
- Department of Neurology, Brigham and Women’s Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Li Zhou
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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