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Lee ACH, Madariaga MLL, Lee SM, Ferguson MK. The risk analysis index is an independent predictor of outcomes after lung cancer resection. PLoS One 2024; 19:e0303281. [PMID: 38753607 PMCID: PMC11098335 DOI: 10.1371/journal.pone.0303281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The Risk Analysis Index (RAI) is a frailty assessment tool based on an accumulation of deficits model. We mapped RAI to data from the Society of Thoracic Surgeons (STS) Database to determine whether RAI correlates with postoperative outcomes following lung cancer resection. METHODOLOGY/PRINCIPAL FINDINGS This was a national database retrospective observational study based on data from the STS Database. Study patients underwent surgery 2018 to 2020. RAI was divided into four increasing risk categories. The associations between RAI and each of postoperative complications and administrative outcomes were examined using logistic regression models. We also compared the performance of RAI to established risk indices (American Society of Anesthesiology (ASA) and Charlson Comorbidity Index (CCI)) using areas under the Receiver Operating Characteristic (ROC) curves (AUC). Results: Of 29,420 candidate patients identified in the STS Database, RAI could be calculated for 22,848 (78%). Almost all outcome categories exhibited a progressive increase in marginal probability as RAI increased. On multivariable analyses, RAI was significantly associated with an incremental pattern with almost all outcomes. ROC analyses for RAI demonstrated "good" AUC values for mortality (0.785; 0.748) and discharge location (0.791), but only "fair" values for all other outcome categories (0.618 to 0.690). RAI performed similarly to ASA and CCI in terms of AUC score categories. CONCLUSIONS/SIGNIFICANCE RAI is associated with clinical and administrative outcomes following lung cancer resection. However, its overall accuracy as a surgical risk predictor is only moderate and similar to ASA and CCI. We do not recommend routine use of RAI for assessment of individual patient risk for major lung resection.
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Affiliation(s)
- Andy Chao Hsuan Lee
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, United States of America
| | - Maria Lucia L. Madariaga
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, United States of America
| | - Sang Mee Lee
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, United States of America
| | - Mark K. Ferguson
- Section of Thoracic Surgery, Department of Surgery, University of Chicago, Chicago, Illinois, United States of America
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Sandrucci S. Frailty: How to assess, prognostic role. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:106862. [PMID: 36922252 DOI: 10.1016/j.ejso.2023.03.002] [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: 03/02/2023] [Indexed: 03/07/2023]
Abstract
Despite the clear clinical significance of frailty in surgical populations, there is no consensus on how best to define or measure frailty, even within the geriatric literature. A diversity of measures exists to measure some or all these domains, but only research-focused tools have been validated in surgical populations. These tools are too resource-intensive for rapid, cost-effective, preoperative screening of entire populations considering elective surgery. This narrative review deals with the definition of frailty and the different assessment methods of the phenotypic definition and the accumulation of deficits definition. Moreover, as in the area of surgery frailty seems to be an independent risk factor for mortality, morbidity, length of stay, and postoperative complication, different studies reporting the association of preoperative frailty with postoperative outcomes after cancer surgery and the association with postoperative mortality within 30 days are considered. Preoperative care should include a focus on the goals of treatment and care options. Patient-oriented functional and cognitive outcomes as well as the development and implementation of interventions that could potentially improve adverse postoperative effects must be further investigated.
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Affiliation(s)
- Sergio Sandrucci
- General Surgery Department, CDSS University of Turin, Torino, Italy.
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Varela S, Thommen R, Rumalla K, Faraz Kazim S, Couldwell WT, Schmidt MH, Bowers CA. The risk analysis index demonstrates superior discriminative ability in predicting extended length of stay in pituitary adenoma resection patients when compared to the 5-point modified frailty index. World Neurosurg X 2024; 21:100259. [PMID: 38292022 PMCID: PMC10826816 DOI: 10.1016/j.wnsx.2023.100259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 07/06/2023] [Accepted: 11/28/2023] [Indexed: 02/01/2024] Open
Abstract
Objective To compare the predictive abilities of two frailty indices on post-operative morbidity and mortality in patients undergoing pituitary adenoma resection. Methods The National Surgical Quality Improvement Program (NSQIP) database was used to retrospectively collect data for patients undergoing pituitary adenoma resection between 2015-2019. To compare the predictive abilities of two of the most common frailty indices, the 5-point modified frailty index (mFI-5) and the risk analysis index (RAI), receiver operating curve analysis (ROC) and area under the curve (AUC)/Cstatistic were used. Results In our cohort of 1,454 patients, the RAI demonstrated superior discriminative ability to the mFI-5 in predicting extended length of stay (C-statistic 0.59, 95% CI 0.56-0.62 vs. C-statistic 0.51, 95% CI: 0.48-0.54, p = 0.0002). The RAI only descriptively appeared superior to mFI-5 in determining mortality (C-statistic 0.89, 95% CI 0.74-0.99 vs. Cstatistic 0.63, 95% CI 0.61-0.66, p=0.11), and NHD (C-statistic 0.68, 95% CI 0.60-0.76 vs. C-statistic 0.60, 95% CI: 0.57-0.62, p=0.15). Conclusions Pituitary adenomas account for one of the most common brain tumors in the general population, with resection being the preferred treatment for patients with most hormone producing tumors or those causing compressive symptoms. Although pituitary adenoma resection is generally safe, patients who experience post-operative complications frequently share similar pre-operative characteristics and comorbidities. Therefore, appropriate pre-operative risk stratification is imperative for adequate patient counseling and informed consent in these patients. Here we present the first known report showing the superior discriminatory ability of the RAI in predicting eLOS when compared to the mFI-5.
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Affiliation(s)
- Samantha Varela
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Rachel Thommen
- School of Medicine, New York Medical College (NYMC), Valhalla, NY, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
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Clark CM, Eimer MC, Intorre FM. Transitions of Care: Strategies for Medication Optimization and Deprescribing in Older Adults. J Gerontol Nurs 2023; 49:5-10. [PMID: 38015150 DOI: 10.3928/00989134-20231107-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Older adults have an increased risk of adverse drug events related to polypharmacy and potentially inappropriate medication (PIM) use. These patients are even more vulnerable as they transition through different health care settings. In 2023, the American Geriatrics Society published an updated version of the Beers Criteria®, providing updated guidance on identifying and managing PIMs. Nurses and nurse practitioners play important roles in medication management across the continuum of care. The current article aims to illustrate key concepts regarding medication safety and deprescribing for older adult patients during transitions of care. [Journal of Gerontological Nursing, 49(12), 5-10.].
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Thorpe C, Niznik J, Li A. Deprescribing research in nursing home residents using routinely collected healthcare data: a conceptual framework. BMC Geriatr 2023; 23:469. [PMID: 37542226 PMCID: PMC10401751 DOI: 10.1186/s12877-023-04194-5] [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: 06/20/2022] [Accepted: 07/24/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Efforts are needed to strengthen evidence and guidance for appropriate deprescribing for older nursing home (NH) residents, who are disproportionately affected by polypharmacy and inappropriate prescribing. Given the challenges of conducting randomized drug withdrawal studies in this population, data from observational studies of routinely collected healthcare data can be used to identify patients who are apparent candidates for deprescribing and evaluate subsequent health outcomes. To improve the design and interpretation of observational studies examining determinants, risks, and benefits of deprescribing specific medications in older NH residents, we sought to propose a conceptual framework of the determinants of deprescribing in older NH residents. METHODS We conducted a scoping review of observational studies examining patterns and potential determinants of discontinuing or de-intensifying (i.e., reducing) medications for NH residents. We searched PubMed through September 2021 and included studies meeting the following criteria: conducted among adults aged 65 + in the NH setting; (2) observational study designs; (3) discontinuation or de-intensification as the primary outcome with key determinants as independent variables. We conceptualized deprescribing as a behavior through a social-ecological lens, potentially influenced by factors at the intrapersonal, interpersonal, organizational, community, and policy levels. RESULTS Our search in PubMed identified 250 potentially relevant studies published through September 2021. A total of 14 studies were identified for inclusion and were subsequently synthesized to identify and group determinants of deprescribing into domains spanning the five core social-ecological levels. Our resulting framework acknowledges that deprescribing is strongly influenced by intrapersonal, patient-level clinical factors that modify the expected benefits and risks of deprescribing, including index condition attributes (e.g., disease severity), attributes of the medication being considered for deprescribing, co-prescribed medications, and prognostic factors. It also incorporates the hierarchical influences of interpersonal differences relating to healthcare providers and family caregivers, NH facility and health system organizational structures, community trends and norms, and finally healthcare policies. CONCLUSIONS Our proposed framework will serve as a useful tool for future studies seeking to use routinely collected healthcare data sources and observational study designs to evaluate determinants, risks, and benefits of deprescribing for older NH residents.
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Affiliation(s)
- Carolyn Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Joshua Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA.
| | - Anna Li
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Mack DS, Baek J, Tjia J, Lapane KL. Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness. Med Care 2021; 59:425-436. [PMID: 33560713 PMCID: PMC8791012 DOI: 10.1097/mlr.0000000000001505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits. OBJECTIVE To describe regional variation in statin use among residents with life-limiting illness. RESEARCH DESIGN Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files. SETTING Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States. SUBJECTS Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170). MEASURES Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals. RESULTS Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization. CONCLUSIONS Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.
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Affiliation(s)
- Deborah S. Mack
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jonggyu Baek
- Division of Biostatistics and Health Services Research, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jennifer Tjia
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Kate L. Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Niznik JD, Li X, Gilliam MA, Hanson LC, Aspinall SL, Colon-Emeric C, Thorpe CT. Are Nursing Home Residents With Dementia Appropriately Treated for Fracture Prevention? J Am Med Dir Assoc 2021; 22:28-35.e3. [PMID: 33321079 PMCID: PMC8358966 DOI: 10.1016/j.jamda.2020.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 12/21/2022]
Abstract
Clinicians struggle with whether to prescribe osteoporosis medications for fracture prevention for older nursing home (NH) residents with dementia, given the lack of evidence in this population. To better understand real-world clinical practice, we conducted a retrospective cohort study examining patterns of fracture prevention medication use for older NH residents with dementia and high fracture risk. Data sources included 2015-16 Medicare claims, Part D prescriptions, and Minimum Data Set (MDS) assessments. Among NH residents aged 65+ with dementia and prior fracture or high fracture risk based on the MDS FRAiL (Fracture Risk Assessment in Long-term care), we assessed medications for fracture prevention using prescription data from 1 year prior through 90 days after the first MDS assessment. Multivariable logistic regression was used to evaluate factors associated with receiving treatment. Most of the sample (n = 72,639) was >80 years (78%), female (82%), and white (88%); 63% had moderate/severe dementia and 60% had an osteoporosis diagnosis. Only 11.6% received fracture prevention medications. In adjusted analyses, treated residents were more likely to be female, Hispanic or other non-black minority, <90 years old, and newly admitted to the NH. Other associated factors included osteoporosis diagnosis, walker or wheelchair use, bone disorders (eg, Paget disease), >5 medications, steroid or proton pump inhibitor use, and regions outside of the Northeast. Resident characteristics suggestive of comorbidity burden and worsening dementia were associated with reduced likelihood of treatment. Low use of fracture prevention medications for NH residents with dementia may reflect an attempt by prescribers reconcile medication use with changing goals of care, or inappropriate underuse in patients who still have high fracture risk. Additional research is needed to help clinicians better evaluate when to use these medications in this heterogeneous and vulnerable population.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Xintong Li
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Meredith A Gilliam
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA; VA Center for Medication Safety, Hines, IL, USA; Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
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8
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Alekseeva YV, Semiglazova TY, Kasparov BS, Tkachenko EV, Proshchayeu KI, Brish NA, Filatova LV, Semiglazov VV, Voronina EA, Kasymov RH, Belyaev AM. The Role of Comprehensive Geriatric Assessment in the Treatment of Cancer Patients of Elderly and Senile Age. ADVANCES IN GERONTOLOGY 2020. [DOI: 10.1134/s2079057020040025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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9
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García-Gollarte JF, García-Andrade MM, Santaeugenia-González SJ, Solá Hermida JC, Baixauli-Alacreu S, Santabalbina FJT. Risk Factors for Mortality in Nursing Home Residents: An Observational Study. Geriatrics (Basel) 2020; 5:geriatrics5040071. [PMID: 33050016 PMCID: PMC7709674 DOI: 10.3390/geriatrics5040071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/29/2020] [Accepted: 10/03/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose: Identifying mortality risk factors in people living in nursing homes could help healthcare professionals to individualize or develop specific plans for predicting future care demands and plan end-of-life care in this population. This study aims to identify mortality risk factors in elderly nursing home (NH) residents, based on variables adapted to this environment, routinely collected and easily accessible to their healthcare professionals. Methods: A prospective, longitudinal, observational study of NH residents aged 65 years and older was carried out collecting sociodemographic, functional and cognitive status, nutritional variables, comorbidities, and other health variables. These variables were analyzed as mortality risk factors by Cox proportional hazard models. Results: A total of 531 residents (75.3% female; average age 86.7 years (SD: 6.6)) were included: 25.6% had total dependence, 53.4% had moderate to severe cognitive impairment, 84.5% were malnourished or at risk of malnutrition, and 79.9% were polymedicated. Risk of mortality (hazard ratio, HR) increased in totally dependent residents (HR = 1.52; p = 0.02) and in those with moderate or severe cognitive impairment ((HR = 1.59; p = 0.031) and (HR = 1.93; p = 0.002), respectively). Male gender (HR = 1.88; p < 0.001), age ≥80 years (HR = 1.73; p = 0.034), hypertension (HR = 1.53; p = 0.012), atrial fibrillation/arrhythmia (HR = 1.43; p = 0.048), and previous record of pneumonia (HR = 1.65; p = 0.029) were also found to be mortality drivers. Conclusion: Age and male gender (due to the higher prevalence of associated comorbidity in these two variables), certain comorbidities (hypertension, atrial fibrillation/arrhythmia, and pneumonia), higher functional and cognitive impairment, and frequency of medical emergency service care increased the risk of mortality in our study. Given their importance and their easy identification by healthcare professionals in nursing homes, these clinical variables should be used for planning care in institutionalized older adults.
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Affiliation(s)
- José Fermín García-Gollarte
- Medical Department Grupo Ballesol, Universidad Católica de Valencia, La Eliana, 46183 Valencia, Spain;
- Correspondence:
| | | | - Sebastiá J. Santaeugenia-González
- Chronic Care Program, Ministry of Health, Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care, 08500 Barcelona, Spain;
| | - José Carlos Solá Hermida
- Medical Department Grupo Ballesol, Universidad Católica de Valencia, La Eliana, 46183 Valencia, Spain;
| | - Susana Baixauli-Alacreu
- Department of Nursing, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain;
| | - Francisco José Tarazona Santabalbina
- Geriatric Service, Hospital Universitario de la Ribera, 46600 Alzira, Spain;
- Division of Geriatric Medicine, 7GPR+3M Doha, Qatar
- CIBERFES, Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable, 0 28029 Madrid, Spain
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10
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Thorpe CT, Sileanu FE, Mor MK, Zhao X, Aspinall S, Ersek M, Springer S, Niznik JD, Vu M, Schleiden LJ, Gellad WF, Hunnicutt J, Thorpe JM, Hanlon JT. Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life. J Am Geriatr Soc 2020; 68:2609-2619. [PMID: 32786004 DOI: 10.1111/jgs.16727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING VA NHs, known as community living centers (CLCs). PARTICIPANTS Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Sherrie Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Veterans Experience Center and the Center for Health Equity Research and Promotion; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sydney Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of New England College of Pharmacy, Portland, Maine
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michelle Vu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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11
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Vu M, Sileanu FE, Aspinall SL, Niznik JD, Springer SP, Mor MK, Zhao X, Ersek M, Hanlon JT, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes. J Am Med Dir Assoc 2020; 22:132-140.e5. [PMID: 32723537 DOI: 10.1016/j.jamda.2020.05.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Geriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing. DESIGN National, retrospective cohort study. SETTING AND PARTICIPANTS Older Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg. MEASURES Deprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing. RESULTS Within our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood. CONCLUSIONS AND IMPLICATIONS Real-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.
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Affiliation(s)
- Michelle Vu
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Veteran Affairs Pharmacy Benefits Management Service, Center for Medication Safety, Hines, IL, USA
| | - Florentina E Sileanu
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Sherrie L Aspinall
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Veteran Affairs Pharmacy Benefits Management Service, Center for Medication Safety, Hines, IL, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Joshua D Niznik
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina School of Medicine, Chapel Hill, NC, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Sydney P Springer
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of New England College of Pharmacy, Portland, ME, USA
| | - Maria K Mor
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Mary Ersek
- Corporal Michael J. Crescenz Veterans Affair's Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA, USA; University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Joseph T Hanlon
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Loren J Schleiden
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Joshua M Thorpe
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Carolyn T Thorpe
- Veteran Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA.
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12
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Burke RE, Canamucio A, Medvedeva E, Manges KA, Ersek M. External Validation of the Skilled Nursing Facility Prognosis Score for Predicting Mortality, Hospital Readmission, and Community Discharge in Veterans. J Am Geriatr Soc 2020; 68:2090-2094. [DOI: 10.1111/jgs.16650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Robert E. Burke
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Anne Canamucio
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Elina Medvedeva
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
| | - Kirstin A. Manges
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
- National Clinician Scholars Program University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Mary Ersek
- Center for Health Equity Promotion and Research, Corporal Michael Crescenz VA Medical Center Philadelphia Pennsylvania USA
- Division of General Internal Medicine, Department of Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
- University of Pennsylvania School of Nursing Philadelphia Pennsylvania USA
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13
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Shah R, Borrebach JD, Hodges JC, Varley PR, Wisniewski MK, Shinall MC, Arya S, Johnson J, Nelson JB, Youk A, Massarweh NN, Johanning JM, Hall DE. Validation of the Risk Analysis Index for Evaluating Frailty in Ambulatory Patients. J Am Geriatr Soc 2020; 68:1818-1824. [PMID: 32310317 DOI: 10.1111/jgs.16453] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty is a marker of dependency, disability, hospitalization, and mortality in community-dwelling older adults. However, existing tools for measuring frailty are too cumbersome for rapid point-of-care assessment. The Risk Analysis Index (RAI) of frailty is validated in surgical populations, but its performance outside surgical populations is unknown. OBJECTIVE Validate the RAI in ambulatory patients. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of outpatient surgical clinics within the University of Pittsburgh Medical Center Healthcare System between July 1, 2016, and December 31, 2016. Frailty was assessed using the RAI. Current Procedural Terminology codes following RAI assessment identified patients with and without minor office-based procedures (eg, joint injection, laryngoscopy). MAIN OUTCOMES AND MEASURES All-cause 1-year mortality, assessed by stratified Cox proportional hazard models. RESULTS Of 28,059 patients, 13,861 were matched to a minor, office-based procedure and 14,198 did not undergo any procedure. The mean (SD) age was 56.7 (17.2) years; women constituted 15,797 (56.3%) of the cohort. Median time (interquartile range 25th-75th percentile) to measure RAI was 30 (22-47) seconds. Mortality among the frail was two to five times that of patients with normal RAI scores. For example, the hazard ratio for frail ambulatory patients without a minor procedure was 3.69 (95% confidence interval [CI] = 2.51-5.41), corresponding to 30-, 180-, and 365-day mortality rates of 2.9%, 11.2%, and 17.4%, respectively, compared to 0.3%, 2.3%, and 4.0% among patients with normal RAI scores. Discrimination of mortality (overall, and censored at 30, 180, and 365 days) was excellent, ranging from c = 0.838 (95% CI = 0.773-0.902) for 30-day mortality after minor procedures to c = 0.909 (95% CI = 0.855-0.964) without a procedure. CONCLUSION RAI is a valid, easily administered tool for point-of-care frailty assessment in ambulatory populations that may help clinicians and patients make better informed decisions about care choices-especially among patients considered high risk with a potentially limited life span. J Am Geriatr Soc 68:1818-1824, 2020.
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Affiliation(s)
- Rupen Shah
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Jeffrey D Borrebach
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jacob C Hodges
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh,, Pennsylvania, USA
| | - Mary Kay Wisniewski
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, and Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Jonas Johnson
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joel B Nelson
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey Veterans Affairs Medical Center; Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M Johanning
- Department of Surgery, University of Nebraska Medical Center and Nebraska Western Iowa Veterans Affairs Health System, Omaha, Nebraska, USA
| | - Daniel E Hall
- Wolff Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Surgery, University of Pittsburgh, Pittsburgh,, Pennsylvania, USA.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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14
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Niznik JD, Zhao X, He M, Aspinall SL, Hanlon JT, Hanson LC, Nace D, Thorpe JM, Thorpe CT. Risk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents With Severe Dementia. J Am Geriatr Soc 2020; 68:699-707. [PMID: 31769507 PMCID: PMC7477721 DOI: 10.1111/jgs.16241] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND/OBJECTIVE Reevaluation of the appropriateness of acetylcholinesterase inhibitors (AChEIs) is recommended in older adults with severe dementia, given the lack of strong evidence to support their continued effectiveness and risk for medication-induced adverse events. We sought to evaluate the impact of deprescribing AChEIs on risk of all-cause events (hospitalizations, emergency department visits, and mortality) and serious falls or fractures in older nursing home (NH) residents with severe dementia. DESIGN Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS) version 3.0, Area Health Resource File, and Nursing Home Compare. Marginal structural models with inverse probability of treatment weights were used to evaluate the association of deprescribing AChEIs and all-cause negative events as well as serious falls or fractures. SETTING US Medicare-certified NHs. PARTICIPANTS Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106). RESULTS The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). Deprescribing AChEIs was associated with an increased likelihood of all-cause negative events in unadjusted models (odds ratio [OR] = 1.17; 95% confidence interval [CI] = 1.11-1.23; P < .01), but not in fully adjusted models (adjusted OR [aOR] = 1.00; 95% CI = 0.94-1.06; P = .94). By contrast, deprescribing was associated with a reduced likelihood of serious falls or fractures in unadjusted models (OR = 0.59; 95% CI = 0.52-0.66; P < .001) and remained significant in adjusted models (aOR = 0.64; 95% CI = 0.56-0.73; P < .001). CONCLUSION Deprescribing AChEIs was not associated with a significant increase in the likelihood for all-cause negative events and was associated with a reduced likelihood of falls and fractures in older NH residents with dementia. Our findings suggest that deprescribing AChEIs is a reasonable approach to reduce the risk of serious falls or fractures without increasing the risk for all-cause events. J Am Geriatr Soc 68:699-707, 2020.
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Affiliation(s)
- Joshua D. Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, North Carolina
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Meiqi He
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sherrie L. Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
- VA Center for Medication Safety, Hines, Illinois
| | - Joseph T. Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of Pittsburgh School of Medicine, Geriatric Division, Pittsburgh, Pennsylvania
| | - Laura C. Hanson
- University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, North Carolina
| | - David Nace
- University of Pittsburgh School of Medicine, Geriatric Division, Pittsburgh, Pennsylvania
| | - Joshua M. Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T. Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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15
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Niznik JD, Hunnicutt JN, Zhao X, Mor MK, Sileanu F, Aspinall SL, Springer SP, Ersek MJ, Gellad WF, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes. J Am Geriatr Soc 2020; 68:736-745. [PMID: 32065387 DOI: 10.1111/jgs.16360] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING VA CLCs. PARTICIPANTS A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7-day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90-day cumulative incidence of deintensification. RESULTS More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0-7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50-.66). Compared with non-sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31-1.88), except for basal insulin (aRR = .59; 95% CI = .52-.66). The only resident factor associated with increased likelihood of deintensification was documented end-of-life status (aRR = 1.12; 95% CI = 1.01-1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75-.96), obesity (aRR = .88; 95% CI = .78-.99), and peripheral vascular disease (aRR = .90; 95% CI = .81-.99) were associated with decreased likelihood of deintensification. CONCLUSION Deintensification of treatment regimens occurred in less than one-half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736-745, 2020.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Jacob N Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Florentina Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sydney P Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Portland, Maine
| | - Mary J Ersek
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Veterans Experience Center; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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16
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Springer SP, Mor MK, Sileanu F, Zhao X, Aspinall SL, Ersek M, Niznik JD, Hanlon JT, Hunnicutt J, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Incidence and Predictors of Aspirin Discontinuation in Older Adult Veteran Nursing Home Residents at End of Life. J Am Geriatr Soc 2020; 68:725-735. [PMID: 32052858 DOI: 10.1111/jgs.16346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/22/2019] [Accepted: 01/01/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission. DESIGN Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments. SETTING All VA nursing homes (referred to as community living centers [CLCs]) in the United States. PARTICIPANTS Older (≥65 y) CLC residents with LLE/AD, admitted for 7 days or longer in fiscal years 2009 to 2015, who had a history of coronary artery disease and/or stroke/transient ischemic attack, and used aspirin within the first week of CLC admission (n = 13 844). MEASUREMENTS The primary dependent variable was aspirin discontinuation within the first 90 days after CLC admission, defined as 14 consecutive days of no aspirin receipt. Independent variables included an indicator for explicit documentation of LP, sociodemographics, environment of care characteristics, cardiovascular risk factors, bleeding risk factors, individual markers of poor prognosis (eg, cancer, weight loss), and facility characteristics. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation. RESULTS Cumulative incidence of aspirin discontinuation was 27% (95% confidence interval [CI] = 26%-28%) in the full sample, 34% (95% CI = 33%-36%) in residents with explicit documentation of LP, and 24% (95% CI = 23%-25%) in residents with no such documentation. The associations of independent variables with aspirin discontinuation differed in residents with vs without explicit LP documentation at admission. CONCLUSION Just over one-quarter of patients discontinued aspirin, possibly reflecting the unclear role of aspirin in end of life among prescribers. Future research should compare outcomes of aspirin deprescribing in this population. J Am Geriatr Soc 68:725-735, 2020.
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Affiliation(s)
- Sydney P Springer
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Department of Pharmacy Practice, Portland, ME
| | - Maria K Mor
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Florentina Sileanu
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA.,University of Pennsylvania School of Nursing, Department of Biobehavioral Health Sciences, Philadelphia, PA
| | - Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, NC
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Jacob Hunnicutt
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Department of Pharmacy Practice, Portland, ME
| | - Loren J Schleiden
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of North Carolina Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of North Carolina Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC
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17
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Comparison of Surgeon Assessment to Frailty Measurement in Abdominal Aortic Aneurysm Repair. J Surg Res 2019; 248:38-44. [PMID: 31841735 DOI: 10.1016/j.jss.2019.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 09/13/2019] [Accepted: 11/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Endovascular abdominal aortic aneurysm repair (EVAR) allows us to intervene on patients otherwise considered poor candidates for open repair. Despite its importance in determining operative approach, no comparison has been made between the subjective "eyeball test" and an objective measurement of preoperative frailty for EVAR patients. MATERIALS AND METHODS Patients undergoing elective EVAR were identified in the Vascular Quality Initiative (VQI) database (2003-2017). Patients were classified "unfit" based on a surgeon-reported variable. Frailty was defined using the VQI-derived Risk Analysis Index, which includes sex, age, BMI, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. The association between fitness and/or frailty and adverse outcomes was determined by logistic regression. RESULTS A total of 11,694 patients undergoing elective EVAR were included of which only 18.1% were "unfit," whereas 34.6% were "frail" and overall 43.6% "unfit or frail." Patients deemed "unfit" or "frail" had significantly increased odds of mortality, complications, and nonhome discharge (P < 0.001), and both frailty and unfitness generated negative predictive values for these outcomes greater than 93%. In adjusted logistic regression, the addition of objective frailty significantly improved model performance in predicting nonhome discharge (C-statistic 0.65 versus 0.71, P < 0.001) and complications (0.59 versus 0.61, P = 0.01), but similarly predicted mortality (0.74 versus 0.73, P = 0.99). CONCLUSIONS Preoperative frailty assessment provides a useful objective measure of risk stratification as an adjunct to a physician's clinical intuition. The addition of frailty expands the pool of high-risk patients who are more likely to experience adverse postoperative events after elective EVAR and may benefit from uniquely tailored perioperative interventions.
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18
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Thomas KS, Ogarek JA, Teno JM, Gozalo PL, Mor V. Development and Validation of the Nursing Home Minimum Data Set 3.0 Mortality Risk Score (MRS3). J Gerontol A Biol Sci Med Sci 2019. [PMID: 29514187 DOI: 10.1093/gerona/gly044] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background To develop a score to predict mortality using the Minimum Data Set 3.0 (MDS 3.0) that can be readily calculated from items collected during nursing home (NH) residents' admission assessments. Participants We developed a training cohort of Medicare beneficiaries newly admitted to United States NHs during 2012 (N = 1,426,815) and a testing cohort from 2013 (N = 1,160,964). Methods Data came from the MDS 3.0 assessments linked to the Medicare Beneficiary Summary File. Using the training dataset, we developed a composite MDS 3.0 Mortality Risk Score (MRS3) consisting of 17 clinical items and patients' age groups based on their relation to 30-day mortality. We assessed the calibration and discrimination of the MRS3 in predicting 30- and 60-day mortality and compared its performance to the Charlson Comorbidity Index and the clinician's assessment of 6-month prognosis measured at admission. Results The 30- and 60-day mortality rates for the testing population were 2.8% and 5.6%, respectively. Results from logistic regression models suggest that the MRS3 performed well in predicting death within 30 and 60 days (C-Statistics of 0.744 [95% confidence limit (CL) = 0.741, 0.747] and 0.709 [95% CL = 0.706, 0.711], respectively). The MRS3 was a superior predictor of mortality compared to the Charlson Comorbidity Index (C-statistics of 0.611 [95% CL = 0.607, 0.615] and 0.608 [95% CL = 0.605, 0.610]) and the clinicians' assessments of patients' 6-month prognoses (C-statistics of 0.543 [95% CL = 0.542, 0.545] and 0.528 [95% CL = 0.527, 0.529]). Conclusions The MRS3 is a good predictor of mortality and can be useful in guiding decision-making, informing plans of care, and adjusting for patients' risk of mortality.
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Affiliation(s)
- Kali S Thomas
- Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Jessica A Ogarek
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Joan M Teno
- Division of General Internal Medicine and Geriatrics, Oregon Health Science University, Portland, Oregon
| | - Pedro L Gozalo
- Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Center of Innovation in Long-Term Services and Supports, U.S. Department of Veterans Affairs Medical Center, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
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19
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Abstract
PURPOSE OF REVIEW A patient's prognosis and risk of adverse drug effects are important considerations for individualizing care of older patients with diabetes. This review summarizes the evidence for risk assessment and proposes approaches for clinicians in the context of current clinical guidelines. RECENT FINDINGS Diabetes guidelines vary in their recommendations for how life expectancy should be estimated and used to inform the selection of glycemic targets. Readily available prognostic tools may improve estimation of life expectancy but require validation among patients with diabetes. Treatment decisions based on prognosis are difficult for clinicians to communicate and for patients to understand. Determining hypoglycemia risk involves assessing major risk factors; models to synthesize these factors have been developed. Applying risk assessment to individualize diabetes care is complex and currently relies heavily on clinician judgment. More research is need to validate structured approaches to risk assessment and determine how to incorporate them into patient-centered diabetes care.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA.
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology & Clinical Research, Baltimore, MD, USA
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elbert S Huang
- Division of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
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Abbasi R, Khajouei R, Mirzaee M. Evaluating the demographic and clinical minimum data sets of Iranian National Electronic Health Record. BMC Health Serv Res 2019; 19:450. [PMID: 31272424 PMCID: PMC6611003 DOI: 10.1186/s12913-019-4284-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 06/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Designing a standard data set is necessary to overcome the dispersion of data among different health information systems. The objective of this study was to evaluate the current demographic and clinical minimum data sets (MDSs) of Iranian National Electronic Health Record (known as SEPAS) and to identify most necessary data elements. METHODS Data were collected using a list of current demographic and clinical data of SEPAS and a self-administered questionnaire. All faculty members of six health related fields and the hospital authorities, and IT and HIM administrators of 6 hospitals in Kerman University of Medical Sciences were invited to participate in this study. The content validity of the questionnaire was confirmed by six medical informatics and HIM experts and the reliability was determined by Cronbach's alpha (α =0.95). SPSS v18 was used to generate descriptive statistics. RESULTS Survey results indicated that 15 data elements should become mandatory elements of MDS for communicating data to SEPAS. These elements include patient's name, surname, father's name, nationality, cell number, job, residential address, residence place, passport number (for non-Iranian patients), diagnosis date, death time, death place and the unit of the hospital where the patient died. Moreover, participants suggested 33 additional demographic and clinical data elements to be communicated mandatorily to SEPAS. CONCLUSION The results of this study showed that the minimum data sets of Iranian national electronic health record needs to be revised. Using the proposed MDSs by this study can improve the quality and efficiency of information and reduce redundancy by adding necessary data and preventing communication of unnecessary data. The method employed in this study can be used for investigating, refining and completing the MDSs of other health information systems.
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Affiliation(s)
- Reza Abbasi
- Health Information Management Research Center, Kashan University of Medical Sciences, Kashan, Iran.,Department of Health Information Sciences, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Khajouei
- Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran. .,Department of Health Information Sciences, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran.
| | - Moghadameh Mirzaee
- Department of Biostatistics and Epidemiology, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
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21
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Hanratty B, Craig D, Brittain K, Spilsbury K, Vines J, Wilson P. Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BackgroundFlexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.AimTo conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.Objectives(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?Data sourcesSearches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.DesignMapping review and rapid, systematic evidence syntheses.SettingCare homes with and without nursing in high-income countries.Review methodsPublished literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.ResultsSeven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.LimitationsThis review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.ConclusionsThis review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.Future workFuture work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.Study registrationThis study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Katie Brittain
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | | | - John Vines
- Northumbria School of Design, Northumbria University, Newcastle upon Tyne, UK
| | - Paul Wilson
- Alliance Manchester Business School, University of Manchester, Manchester, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, University of Manchester, Manchester, UK
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22
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George EL, Chen R, Trickey AW, Brooke BS, Kraiss L, Mell MW, Goodney PP, Johanning J, Hockenberry J, Arya S. Variation in center-level frailty burden and the impact of frailty on long-term survival in patients undergoing elective repair for abdominal aortic aneurysms. J Vasc Surg 2019; 71:46-55.e4. [PMID: 31147116 DOI: 10.1016/j.jvs.2019.01.074] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/10/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Frailty is increasingly recognized as a key determinant in predicting postoperative outcomes. Centers that see more frail patients may not be captured in risk adjustment, potentially accounting for poorer outcomes in hospital comparisons. We aimed to (1) determine the effect of frailty on long-term mortality in patients undergoing elective abdominal aortic aneurysm (AAA) repair and (2) evaluate the variability in frailty burden among centers in the Vascular Quality Initiative (VQI) database. METHODS Patients undergoing elective open and endovascular AAA repair (2003-2017) were identified, and those with complete data on component variables of the VQI-derived Risk Analysis Index (VQI-RAI) and centers with ≥10 AAA repairs were included. VQI-RAI characteristics are sex, age, body mass index, renal failure, congestive heart failure, dyspnea, preoperative ambulation, and functional status. Frailty was defined as VQI-RAI ≥35 based on prior work in surgical patients using other quality improvement databases. This corresponds to the top 12% of patients at risk in the VQI. Center-level VQI-RAI differences were assessed by analysis of variance test. Relationships between frailty and survival were compared by Kaplan-Meier analysis and the log-rank test for open and endovascular procedures. Multivariable hierarchical Cox proportional hazards regression models were calculated with random intercepts for center, controlling for frailty, race, insurance, AAA diameter, procedure type, AAA case mix, and year. RESULTS A total of 15,803 patients from 185 centers were included. Mean VQI-RAI scores were 27.6 (standard deviation, 5.9; range, 4-56) and varied significantly across centers (F = 2.41, P < .001). The percentage of frail patients per center ranged from 0% to 40.0%. In multivariable analysis, frailty was independently associated with long-term mortality (hazard ratio, 2.88; 95% confidence interval, 2.6-3.2) after accounting for covariates and center-level variance. Open AAA repair was not associated with long-term mortality after adjusting for frailty (hazard ratio, 0.98; 95% confidence interval, 0.86-1.13). There was a statistically significant difference in the percentage of frail patients compared with nonfrail patients who were discharged to a rehabilitation facility or nursing home after both open (40.5% vs 17.8%; P < .0001) and endovascular repair (17.7% vs 4.6%; P < .0001). CONCLUSIONS There is considerable variability of preoperative frailty among VQI centers performing elective AAA repair. Adjusting for center-level variation, frailty but not procedure type had a significant association with long-term mortality; however, frailty and procedure type were both associated with nonhome discharge. Routine measurement of frailty preoperatively by centers to identify high-risk patients may help mitigate procedural and long-term outcomes and improve shared decision-making regarding AAA repair.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif
| | - Rui Chen
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, Calif
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, Calif
| | | | - Larry Kraiss
- Division of Vascular Surgery, University of Utah, Salt Lake, Utah
| | - Matthew W Mell
- Division of Vascular and Endovascular Surgery, University of California Davis, Sacramento, Calif
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jason Johanning
- Division of Vascular Surgery, University of Nebraska, Lincoln, Neb
| | | | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford University, Stanford, Calif; Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University, Stanford, Calif.
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Cole A, Arthur A, Seymour J. Comparing the predictive ability of the Revised Minimum Dataset Mortality Risk Index (MMRI-R) with nurses' predictions of mortality among frail older people: a cohort study. Age Ageing 2019; 48:394-400. [PMID: 30806455 DOI: 10.1093/ageing/afz011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 11/30/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES to establish the accuracy of community nurses' predictions of mortality among older people with multiple long-term conditions, to compare these with a mortality rating index and to assess the incremental value of nurses' predictions to the prognostic tool. DESIGN a prospective cohort study using questionnaires to gather clinical information about patients case managed by community nurses. Nurses estimated likelihood of mortality for each patient on a 5-point rating scale. The dataset was randomly split into derivation and validation cohorts. Cox proportional hazard models were used to estimate risk equations for the Revised Minimum Dataset Mortality Risk Index (MMRI-R) and nurses' predictions of mortality individually and combined. Measures of discrimination and calibration were calculated and compared within the validation cohort. SETTING two NHS Trusts in England providing case-management services by nurses for frail older people with multiple long-term conditions. PARTICIPANTS 867 patients on the caseload of 35 case-management nurses. 433 and 434 patients were assigned to the derivation and validation cohorts, respectively. Patients were followed up for 12 months. RESULTS 249 patients died (28.72%). In the validation cohort, MMRI-R demonstrated good discrimination (Harrell's c-index 0.71) and nurses' predictions similar discrimination (Harrell's c-index 0.70). There was no evidence of superiority in performance of either method individually (P = 0.83) but the MMRI-R and nurses' predictions together were superior to nurses' predictions alone (P = 0.01). CONCLUSIONS patient mortality is associated with higher MMRI-R scores and nurses' predictions of 12-month mortality. The MMRI-R enhanced nurses' predictions and may improve nurses' confidence in initiating anticipatory care interventions.
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Affiliation(s)
- Andy Cole
- Nottingham University School of Health Sciences, B-Floor South Block Link, Queen’s Medical Centre, Nottingham, UK
| | - Antony Arthur
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Jane Seymour
- The University of Sheffield, School of Nursing and Midwifery, Sheffield, UK
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24
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Paque K, Elseviers M, Vander Stichele R, Pardon K, Vinkeroye C, Deliens L, Christiaens T, Dilles T. Balancing medication use in nursing home residents with life-limiting disease. Eur J Clin Pharmacol 2019; 75:969-977. [DOI: 10.1007/s00228-019-02649-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022]
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Moore DC, Keegan TJ, Dunleavy L, Froggatt K. Factors associated with length of stay in care homes: a systematic review of international literature. Syst Rev 2019; 8:56. [PMID: 30786917 PMCID: PMC6381725 DOI: 10.1186/s13643-019-0973-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 02/10/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A number of studies have explored factors associated with resident length of stay in care homes; however the findings of these studies have not been synthesized. The aim of this paper is to provide a systematic review of factors associated with length of stay until death and the strength of evidence supporting each of these factors. METHODOLOGY This is a systematic review; databases included MEDLINE, EMBASE, PsycINFO, CINAHL, Proquest, the Cochrane Library and Web of Science were searched. Observational studies, either prospective or retrospective, that explored multiple factors associated with length of stay until death in care homes were included. Studies that met the inclusion criteria were sourced, data extracted and assessed for quality. Data synthesis combined the direction and significance of association with the quality of the study, resulting in strong, moderate, weak or inconclusive evidence for each factor identified. RESULTS Forty-seven studies were identified as meeting the inclusion criteria. After quality assessment, 14 studies were judged to be of a high quality, 31 of a moderate quality and 2 of a low quality. Three factors had strong evidence to support their association with shorter lengths of stay: shortness of breath, receipt of oxygen therapy and admission to a facility providing nursing care. CONCLUSIONS This review summarized the factors associated with length of stay. It found stronger evidence for physical functioning being associated with shorter lengths of stay than for cognitive functioning. An understanding of expected length of stay for older adults admitted to a care home is important for estimating lifetime costs and the implications of reforming funding arrangements for social care. Further research is needed to explore heterogeneity in this area.
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Affiliation(s)
| | - Thomas J Keegan
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Katherine Froggatt
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
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26
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van der Windt DJ, Bou-Samra P, Dadashzadeh ER, Chen X, Varley PR, Tsung A. Preoperative risk analysis index for frailty predicts short-term outcomes after hepatopancreatobiliary surgery. HPB (Oxford) 2018; 20:1181-1188. [PMID: 30005992 DOI: 10.1016/j.hpb.2018.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/10/2018] [Accepted: 05/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Risk Analysis Index (RAI) for frailty is a rapid survey for comorbidities and performance status, which predicts mortality after general surgery. We aimed to validate the RAI in predicting outcomes after hepatopancreatobiliary surgery. METHODS Associations of RAI, determined in 162 patients prior to undergoing hepatopancreatobiliary surgery, with prospectively collected 30-day post-operative outcomes were analyzed with multivariate logistic and linear regression. RESULTS Patients (age 62 ± 14, 51% female) had a median RAI of 7, range 0-25. With every unit increase in RAI, length of stay increased by 5% (95% CI: 2-7%), odds of ICU admission increased by 10% (0-20%), ICU length of stay increased by 21% (9-34%), and odds of discharge to a nursing facility increased by 8% (0-17%) (all P < 0.05). Particularly in patients who suffered a first post-operative complication, RAI was associated with additional complications (1.6 unit increase in Comprehensive Complication Index per unit increase in RAI, P = 0.002). In a direct comparison in a subset of 74 patients, RAI and the ACS-NSQIP Risk Calculator performed comparably in predicting outcomes. CONCLUSION While RAI and ACS-NSQIP Risk Calculator comparatively predicted short-term outcomes after HPB surgery, RAI has been specifically designed to identify frail patients who can potentially benefit from preoperative prehabilitation interventions.
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Affiliation(s)
- Dirk J van der Windt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick Bou-Samra
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Xilin Chen
- Pittsburgh Surgical Outcomes Research Center (PittSORCe), University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Luo H, Lou VWQ, Li Y, Chi I. Development and Validation of a Prognostic Tool for Identifying Residents at Increased Risk of Death in Long-Term Care Facilities. J Palliat Med 2018; 22:258-266. [PMID: 30383467 DOI: 10.1089/jpm.2018.0219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To promote better care at the end stage of life in long-term care facilities, a culturally appropriate tool for identifying residents at the end of life is crucial. OBJECTIVE This study aimed to develop and validate a prognostic tool, the increased risk of death (IRD) scale, based on the minimum data set (MDS). DESIGN A retrospective study using data between 2005 and 2013 from six nursing homes in Hong Kong. SETTING/SUBJECTS A total of 2380 individuals were randomly divided into two equal-sized subsamples: Sample 1 was used for the development of the IRD scale and Sample 2 for validation. MEASUREMENTS The measures were MDS 2.0 items and mortality data from the discharge tracking forms. The nine items in the IRD scale (decline in cognitive status, decline in activities of daily living, cancer, renal failure, congestive heart failure, emphysema/chronic obstructive pulmonary disease, edema, shortness of breath, and loss of weight), were selected based on bivariate Cox proportional hazards regression. RESULTS The IRD scale was a strong predictor of mortality in both Sample 1 (HRsample1 = 1.50, 95% confidence interval [CI]: 1.37-1.65) and Sample 2 (HRsample2 = 1.31, 1.19-1.43), after adjusting for covariates. Hazard ratios (HRs) for residents who had an IRD score of 3 or above for Sample 1 and Sample 2 were 3.32 (2.12-5.21) and 2.00 (1.30-3.09), respectively. CONCLUSIONS The IRD scale is a promising tool for identifying nursing home residents at increased risk of death. We recommend the tool to be incorporated into the care protocol of long-term care facilities in Hong Kong.
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Affiliation(s)
- Hao Luo
- 1 Department of Social Work and Social Administration, The University of Hong Kong , Hong Kong, China
| | - Vivian W Q Lou
- 2 Department of Social Work and Social Administration and Sau Po Centre on Ageing, The University of Hong Kong , Hong Kong, China
| | - Yuekang Li
- 1 Department of Social Work and Social Administration, The University of Hong Kong , Hong Kong, China
| | - Iris Chi
- 3 Suzanne Dworak-Peck School of Social Work, University of Southern California , Los Angeles, California
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28
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Niznik JD, Zhang S, Mor MK, Zhao X, Ersek M, Aspinall SL, Gellad WF, Thorpe JM, Hanlon JT, Schleiden LJ, Springer S, Thorpe CT. Adaptation and Initial Validation of Minimum Data Set (MDS) Mortality Risk Index to MDS Version 3.0. J Am Geriatr Soc 2018; 66:2353-2359. [PMID: 30335184 DOI: 10.1111/jgs.15579] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the predictive validity of an adapted version of the Minimum Data Set (MDS) Mortality Risk Index-Revised (MMRI-R) based on MDS version 3.0 assessment items (MMRI-v3) and to compare the predictive validity of the MMRI-v3 with that of a single MDS item indicating limited life expectancy (LLE). DESIGN Retrospective, cross-sectional study of MDS assessments. Other data sources included the Veterans Affairs (VA) Residential History File and Vital Status File. SETTING VA nursing homes (NHs). PARTICIPANTS Veterans aged 65 and older newly admitted to VA NHs between July 1, 2012, and September 30, 2015. MEASUREMENTS The dependent variable was death within 6 months of admission date. Independent variables included MDS items used to calculate MMRI-v3 scores (renal failure, chronic heart failure, sex, age, dehydration, cancer, unintentional weight loss, shortness of breath, activity of daily living scale, poor appetite, acute change in mental status) and the MDS item indicating LLE. RESULTS The predictive ability of the MMRI-v3 for 6-month mortality (c-statistic 0.81) is as good as that of the original MMRI-R (c-statistic 0.76). Scores generated using the MMRI-v3 had greater predictive ability than that of the single MDS indicator for LLE (c-statistic 0.76); using the 2 together resulted in greater predictive ability (c-statistic 0.86). CONCLUSION The MMRI-v3 is a useful tool in research and clinical practice that accurately predicts 6-month mortality in veterans residing in Veterans Affairs NHs. Identification of residents with LLE has great utility for studying palliative care interventions and may be helpful in guiding allocation of these services in clinical practice. J Am Geriatr Soc 66:2353-2359, 2018.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania.,Geriatric Division, School of Medicine, Pittsburgh, Pennsylvania
| | - Song Zhang
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Mary Ersek
- National PROMISE Center; Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania.,Veterans Affairs Center for Medication Safety, Hines, Illinois
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania.,Geriatric Division, School of Medicine, Pittsburgh, Pennsylvania
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sydney Springer
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,School of Pharmacy, Pittsburgh, Pennsylvania
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29
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C-LACE2: computational risk assessment tool for 30-day post hospital discharge mortality. HEALTH AND TECHNOLOGY 2018. [DOI: 10.1007/s12553-018-0263-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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ten Koppel M, Onwuteaka-Philipsen BD, Pasman HR, Bernabei R, Carpenter I, Denkinger MD, Onder G, van der Roest HG, Topinkova E, van Hout HPJ. Are older long term care residents accurately prognosticated and consequently informed about their prognosis? Results from SHELTER study data in 5 European countries. PLoS One 2018; 13:e0200590. [PMID: 30020976 PMCID: PMC6051611 DOI: 10.1371/journal.pone.0200590] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/01/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Informing residents in long term care facilities (LTCFs) about their prognosis can help them prepare for the end of life. This study aimed to examine which proportion of European LTCF residents, close to death, are accurately prognosticated and consequently informed about their prognosis; and to examine factors related to accurate prognostication and discussion of prognosis. METHODS A subsample of SHELTER study data was used, consisting of: 500 residents from 5 European countries, who died within 6 months after their last assessment, and had a valid answer on the item 'End stage disease, 6 or fewer months to live'. This item was used to indicate whether an accurate prognosis was established and discussed with residents. Generalized estimating equations were used to examine factors related to establishment and discussion of accurate prognosis. RESULTS 86.4% of residents close to death did not receive an accurate prognosis. Residents with cancer; fatigue; dehydration; and normal mode of nutritional intake were more likely to have an accurate prognosis established and discussed. Accurate prognostication and prognosis discussion was less likely for residents who: had a diagnosis under 'other'; initiated interactions; and residents from Germany, Italy and the Netherlands. CONCLUSIONS The great majority of residents close to death did not receive an accurate prognosis. Prognostication tools might help clinicians to increase their prognostic accuracy and communication training might help to discuss prognosis with residents.
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Affiliation(s)
- Maud ten Koppel
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - Bregje D. Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - H. Roeline Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Roberto Bernabei
- Centro Medicina dell’Invecchiamento, Università Cattolica Sacro Cuore, Rome, Italy
| | - Iain Carpenter
- Centre for Health Services Studies, University of Kent, Canterbury, United Kingdom
| | - Michael D. Denkinger
- Agaplesion Bethesda Clinic, Geriatric Centre Ulm/Alb-Donau, Ulm University, Ulm, Germany
| | - Graziano Onder
- Centro Medicina dell’Invecchiamento, Università Cattolica Sacro Cuore, Rome, Italy
| | - Henriëtte G. van der Roest
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Eva Topinkova
- Department of Geriatrics, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hein P. J. van Hout
- Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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Bartley MM, Suarez L, Shafi RMA, Baruth JM, Benarroch AJM, Lapid MI. Dementia Care at End of Life: Current Approaches. Curr Psychiatry Rep 2018; 20:50. [PMID: 29936639 DOI: 10.1007/s11920-018-0915-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia. RECENT FINDINGS Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia. Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.
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Affiliation(s)
| | - Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Reem M A Shafi
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Joshua M Baruth
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amanda J M Benarroch
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Maria I Lapid
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Shah R, Attwood K, Arya S, Hall DE, Johanning JM, Gabriel E, Visioni A, Nurkin S, Kukar M, Hochwald S, Massarweh NN. Association of Frailty With Failure to Rescue After Low-Risk and High-Risk Inpatient Surgery. JAMA Surg 2018; 153:e180214. [PMID: 29562073 DOI: 10.1001/jamasurg.2018.0214] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Failure to rescue (FTR), or death after a potentially preventable complication, is a nationally endorsed, publicly reported quality measure. However, little is known about the impact of frailty on FTR, in particular after low-risk surgical procedures. Objective To assess the association of frailty with FTR in patients undergoing inpatient surgery. Design, Setting, and Participants This study assessed a cohort of 984 550 patients undergoing inpatient general, vascular, thoracic, cardiac, and orthopedic surgery in the National Surgical Quality Improvement Program between January 1, 2005, and December 31, 2012. Frailty was assessed using the Risk Analysis Index (RAI), and patients were stratified into 5 groups (RAI score, ≤10, 11-20, 21-30, 31-40, and >40). Procedures were categorized as low mortality risk (≤1%) or high mortality risk (>1%). The association between RAI scores, the number of postoperative complications (0, 1, 2, or 3 or more), and FTR was evaluated using hierarchical modeling. Main Outcomes and Measures The number of postoperative complications and inpatient FTR. Results A total of 984 550 patients were included, with a mean (SD) age of 58.2 (17.1) years; women were 549 281 (55.8%) of the cohort. For patients with RAI scores of 10 or less, major complication rates after low-risk surgery were 3.2%; rates of those with RAI scores of 11 to 20, 21 to 30, 31 to 40, and more than 40 were 8.6%, 13.5%, 23.8%, and 36.4%, respectively. After high-risk surgery, these rates were 13.5% for those with scores of 10 or less, 23.7% for those with scores of 11 to 20, 31.1% for those with scores of 21 to 30, 42.5% for those with scores of 31 to 40, and 54.4% for those with scores of more than 40. Stratifying by the number of complications, significant increases in FTR were observed across RAI categories after both low-risk and high-risk procedures. After a low-risk procedure, odds of FTR after 1 major complication for patients with RAI scores of 11 to 20 increased 5-fold over those with RAI scores of 10 or less (odds ratio [OR], 5.3; 95% CI, 3.9-7.1). Odds ratios were 8.1 (95% CI, 5.6-11.7) for patients with RAI scores of 21 to 30; 22.3 (95% CI, 13.9-35.6) for patients with scores of 31 to 40; and 43.9 (95% CI, 19-101.1) for patients with scores of more than 40. For patients undergoing a high-risk procedure, the corresponding ORs were likewise consistently elevated (RAI score 11-20: OR, 2.5; 95% CI, 2.3-2.7; vs RAI score 21-30: 5.1; 95% CI, 4.6-5.5; vs RAI score 31-40: 8.9; 95% CI, 8.1-9.9; vs RAI score >40: 18.4; 95% CI, 15.7-21.4). Conclusions and Relevance Frailty has a dose-response association with complications and FTR, which is apparent after low-risk and high-risk inpatient surgery. Systematic assessment of frailty in preoperative patients may help refine estimates of surgical risk that could identify patients who might benefit from perioperative interventions designed to enhance physiologic reserve and potentially mitigate aspects of procedural risk, and would provide a framework for shared decision-making regarding the value of a given surgical procedure.
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Affiliation(s)
- Rupen Shah
- Department of Surgery, Henry Ford Health System, Detroit, Michigan.,Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Kristopher Attwood
- Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, New York
| | - Shipra Arya
- Division of Vascular and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, Georgia.,Surgical Service Line, Atlanta VA Medical Center, Decatur, Georgia
| | - Daniel E Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Surgery, University of Pittsburgh, Pittsburgh
| | | | - Emmanuel Gabriel
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Anthony Visioni
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Steven Nurkin
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Moshim Kukar
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Steven Hochwald
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Nader N Massarweh
- VA Health Services Research and Development Service, Center for Innovations in Quality, Effectiveness and Safety, Michael E DeBakey VA Medical Center, Houston, Texas.,Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Esses G, Andreopoulos E, Lin HM, Arya S, Deiner S. A Comparison of Three Frailty Indices in Predicting Morbidity and Mortality After On-Pump Aortic Valve Replacement. Anesth Analg 2018; 126:39-45. [PMID: 28857797 DOI: 10.1213/ane.0000000000002411] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aortic valve replacement is a high-risk surgery (3%-5%, 30-day mortality) performed on approximately 30,000 elderly patients a year in the United States. Currently, preoperative risk assessment is based on a composite of medical examination and a subjective evaluation for frailty ("eyeball test"). Objective frailty assessment using validated indices has the potential to improve risk stratification. The purpose of this study was to (1) establish whether frailty can predict 30-day mortality and composite morbidity in patients undergoing aortic valve replacement and (2) compare the predictive ability of 3 frailty indices in this population. METHODS This study was a retrospective cohort study of 3088 patients 65 years old and older undergoing aortic valve replacement surgery (based on current procedure terminology codes) between the years 2006 and 2012 extracted from the American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index, risk analysis index, and Ganapathi indices. Outcomes measured were 30-day mortality and composite morbidity (myocardial infarction, cardiac arrest, pulmonary embolism, pneumonia, reintubation, renal insufficiency, coma >24 hours, urinary tract infections, sepsis, deep vein thrombosis, deep wound surgical site infection, superficial site infection, and reoperation). RESULTS Frailty was a better predictor of mortality than morbidity, and it was not markedly different among any of the 3 indices. Frailty was associated with an increased risk of 30-day mortality and longer lengths of stay. CONCLUSIONS Frailty can predict mortality in patients undergoing aortic valve replacement. Choice of frailty index does not make a difference in this patient population.
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Affiliation(s)
| | - Evie Andreopoulos
- Population Health Science and Policy and Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hung-Mo Lin
- Population Health Science and Policy and Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shipra Arya
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Stacie Deiner
- Departments of Anesthesiology, Neurosurgery, Geriatrics & Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
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Thomas R, Pieri A, Cain H. A systematic review of generic and breast cancer specific life expectancy models in the elderly. Eur J Surg Oncol 2017; 43:1816-1827. [DOI: 10.1016/j.ejso.2017.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/05/2017] [Accepted: 06/23/2017] [Indexed: 12/20/2022] Open
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Gómez-Batiste X, Martínez-Muñoz M, Blay C, Amblàs J, Vila L, Costa X, Espaulella J, Villanueva A, Oller R, Martori JC, Constante C. Utility of the NECPAL CCOMS-ICO © tool and the Surprise Question as screening tools for early palliative care and to predict mortality in patients with advanced chronic conditions: A cohort study. Palliat Med 2017; 31:754-763. [PMID: 27815556 DOI: 10.1177/0269216316676647] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Surprise Question (SQ) identifies patients with palliative care needs. The NECPAL CCOMS-ICO© (NECPAL) tool combines the Surprise Question with additional clinical parameters for a more comprehensive assessment. The capacity of these screening tools to predict mortality is still unknown. AIM To explore the predictive validity of the NECPAL and SQ to determine 12- to 24-month mortality. DESIGN Longitudinal, prospective and observational cohort study. SETTING/PARTICIPANTS Three primary care centres, one general hospital, one intermediate care centre, and four nursing homes. Population cohort with advanced chronic conditions and limited life prognosis. Patients were classified according to SQ and NECPAL criteria and followed for 24 months. RESULTS Data available to assess 1059 of 1064 recruited patients (99.6%) at 12 and 24 months: 837 patients were SQ+ and 780 were NECPAL+. Mortality rates at 24 months were as follows: 44.6% (SQ+) versus 15.8% (SQ-) and 45.8% (NECPAL+) versus 18.3% (NECPAL-) ( p = 0.000). SQ+ and NECPAL+ identification was significantly correlated with 24-month mortality risk (hazard ratios: 2.719 and 2.398, respectively). Both tools were highly sensitive (91.4, CI: 88.7-94.1 and 87.5, CI: 84.3-90.7) with high negative predictive values (84.2, CI: 79.4-89.0 and 81.7, CI: 77.2-86.2), with low specificity and positive predictive value. The prognostic accuracy of SQ and NECPAL was 52.9% and 55.2%, respectively. The predictive validity was slightly better for NECPAL. CONCLUSION SQ and NECPAL are valuable screening instruments to identify patients with limited life prognosis who may require palliative care. More research is needed to increase its prognostic utility in combination with other parameters.
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Affiliation(s)
- Xavier Gómez-Batiste
- 1 The Qualy Observatory/WHO Collaborating Centre for Public Health Palliative Care Programs (WHOCC), Catalan Institute of Oncology (CIO), Department of Health (DoH), Barcelona, Spain.,2 Chair of Palliative Care, University of Vic, Barcelona, Spain
| | - Marisa Martínez-Muñoz
- 1 The Qualy Observatory/WHO Collaborating Centre for Public Health Palliative Care Programs (WHOCC), Catalan Institute of Oncology (CIO), Department of Health (DoH), Barcelona, Spain.,2 Chair of Palliative Care, University of Vic, Barcelona, Spain
| | - Carles Blay
- 2 Chair of Palliative Care, University of Vic, Barcelona, Spain.,3 Programme for the Prevention and Care of Patients with Chronic Conditions, Department of Health (DoH), Government of Catalonia, Barcelona, Spain
| | - Jordi Amblàs
- 2 Chair of Palliative Care, University of Vic, Barcelona, Spain.,4 Hospital de la Santa Creu, Hospital General de Vic, Barcelona, Spain
| | - Laura Vila
- 2 Chair of Palliative Care, University of Vic, Barcelona, Spain.,5 Institut Català de la Salut - SAP Osona, Barcelona, Spain
| | - Xavier Costa
- 2 Chair of Palliative Care, University of Vic, Barcelona, Spain.,5 Institut Català de la Salut - SAP Osona, Barcelona, Spain
| | - Joan Espaulella
- 2 Chair of Palliative Care, University of Vic, Barcelona, Spain.,4 Hospital de la Santa Creu, Hospital General de Vic, Barcelona, Spain
| | | | - Ramon Oller
- 7 Department of Economics and Business, University of Vic, Barcelona, Spain
| | | | - Carles Constante
- 8 Department of Health (DoH), Government of Catalonia, Barcelona, Spain
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Taylor LJ, Nabozny MJ, Steffens NM, Tucholka JL, Brasel KJ, Johnson SK, Zelenski A, Rathouz PJ, Zhao Q, Kwekkeboom KL, Campbell TC, Schwarze ML. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surg 2017; 152:531-538. [PMID: 28146230 DOI: 10.1001/jamasurg.2016.5674] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Although many older adults prefer to avoid burdensome interventions with limited ability to preserve their functional status, aggressive treatments, including surgery, are common near the end of life. Shared decision making is critical to achieve value-concordant treatment decisions and minimize unwanted care. However, communication in the acute inpatient setting is challenging. Objective To evaluate the proof of concept of an intervention to teach surgeons to use the Best Case/Worst Case framework as a strategy to change surgeon communication and promote shared decision making during high-stakes surgical decisions. Design, Setting, and Participants Our prospective pre-post study was conducted from June 2014 to August 2015, and data were analyzed using a mixed methods approach. The data were drawn from decision-making conversations between 32 older inpatients with an acute nonemergent surgical problem, 30 family members, and 25 surgeons at 1 tertiary care hospital in Madison, Wisconsin. Interventions A 2-hour training session to teach each study-enrolled surgeon to use the Best Case/Worst Case communication framework. Main Outcomes and Measures We scored conversation transcripts using OPTION 5, an observer measure of shared decision making, and used qualitative content analysis to characterize patterns in conversation structure, description of outcomes, and deliberation over treatment alternatives. Results The study participants were patients aged 68 to 95 years (n = 32), 44% of whom had 5 or more comorbid conditions; family members of patients (n = 30); and surgeons (n = 17). The median OPTION 5 score improved from 41 preintervention (interquartile range, 26-66) to 74 after Best Case/Worst Case training (interquartile range, 60-81). Before training, surgeons described the patient's problem in conjunction with an operative solution, directed deliberation over options, listed discrete procedural risks, and did not integrate preferences into a treatment recommendation. After training, surgeons using Best Case/Worst Case clearly presented a choice between treatments, described a range of postoperative trajectories including functional decline, and involved patients and families in deliberation. Conclusions and Relevance Using the Best Case/Worst Case framework changed surgeon communication by shifting the focus of decision-making conversations from an isolated surgical problem to a discussion about treatment alternatives and outcomes. This intervention can help surgeons structure challenging conversations to promote shared decision making in the acute setting.
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Affiliation(s)
| | | | - Nicole M Steffens
- Denver Public Health, Denver Health and Hospital Authority, Denver, Colorado
| | | | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
| | - Sara K Johnson
- Department of Medicine, University of Wisconsin, Madison
| | - Amy Zelenski
- Department of Medicine, University of Wisconsin, Madison
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison
| | | | | | - Margaret L Schwarze
- Department of Surgery, University of Wisconsin, Madison7Department of Medical History and Bioethics, University of Wisconsin, Madison
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Sridharan ND, Chaer RA, Wu BB, Eslami MH, Makaroun MS, Avgerinos ED. An Accumulated Deficits Model Predicts Perioperative and Long-term Adverse Events after Carotid Endarterectomy. Ann Vasc Surg 2017; 46:97-103. [PMID: 28689950 DOI: 10.1016/j.avsg.2017.06.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/02/2017] [Accepted: 06/16/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is increasing recognition that decreased reserve in multiple organ systems, known as accumulated deficits (AD), may better stratify perioperative risk than traditional risk indices. We hypothesized that an AD model would predict both perioperative adverse events and long-term survival after carotid endarterectomy (CEA), particularly important in asymptomatic patients. METHODS Consecutive patients undergoing CEA between 1st January 2000 and 31st December 2010 were retrospectively identified. Seven of the deficit items from the Canadian Study of Health and Aging-frailty index (coronary disease, renal insufficiency, pulmonary disease, peripheral vascular disease, heart failure, hypertension, and diabetes) were tabulated for each patient. Predictors of perioperative and long-term outcomes were evaluated using regression analysis. RESULTS About 1,782 CEAs in 1,496 patients (mean age: 71.3 ± 9.3 years, 56.3% male, 35.4% symptomatic) were included. The risk of major adverse events (stroke, death, or myocardial infarction) at 30 days for patients with ≤3 deficits was 2.53% vs. 8.81% for patients with ≥4 deficits (P < 0.001). For patients with ≥5 deficits, the risk was 15.18%. Each additional deficit increased the odds of a 30-day major adverse event and hospital stay >2 days by 1.64 (P < 0.001) and 1.15 (P < 0.001), respectively. In multivariate analysis, the presence of ≥4 deficits was more predictive of perioperative major adverse events (odds ratio [OR] = 3.62, P < 0.001) than symptomatology within 6 months (OR = 1.57, P = 0.08) or octogenarian status (OR = 2.00, P = 0.02). Kaplan-Meier analysis showed significantly decreased survival over time with accumulating deficits (P < 0.001). Patients with ≥4 deficits have a hazards ratio for death of 2.6 compared to patients with ≤3 deficits (P < 0.001). Overall survival is estimated at 79.5% (95% confidence interval [CI]: 0.77-0.82) at 5 years in patients with ≤3 deficits versus 52.4% (95% CI: 0.46-0.58) in patients with ≥4 deficits, respectively. In subgroup analysis of asymptomatic patients, 5-year survival for octogenarian male patients with ≥4 deficits was only 26.8%. For asymptomatic males aged 70-79 years with ≥4 deficits, 5-year survival was 59.9%. CONCLUSIONS An AD model is more predictive of perioperative adverse events after CEA than age or symptomatic status. This model remains predictive of long-term survival. In asymptomatic male octogenarians with 4 or more AD, 5-year survival is severely limited.
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Affiliation(s)
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Bryan Boyuan Wu
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
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Hall DE, Arya S, Schmid KK, Blaser C, Carlson MA, Bailey TL, Purviance G, Bockman T, Lynch TG, Johanning J. Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations. JAMA Surg 2017; 152:175-182. [PMID: 27893030 PMCID: PMC7140150 DOI: 10.1001/jamasurg.2016.4202] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Growing consensus suggests that frailty-associated risks should inform shared surgical decision making. However, it is not clear how best to screen for frailty in preoperative surgical populations. Objective To develop and validate the Risk Analysis Index (RAI), a 14-item instrument used to measure surgical frailty. It can be calculated prospectively (RAI-C), using a clinical questionnaire, or retrospectively (RAI-A), using variables from the surgical quality improvement databases (Veterans Affairs or American College of Surgeons National Surgical Quality Improvement Projects). Design, Setting, and Participants Single-site, prospective cohort from July 2011 to September 2015 at the Veterans Affairs Nebraska-Western Iowa Heath Care System, a Level 1b Veterans Affairs Medical Center. The study included all patients presenting to the medical center for elective surgery. Exposures We assessed the RAI-C for all patients scheduled for surgery, linking these scores to administrative and quality improvement data to calculate the RAI-A and the modified Frailty Index. Main Outcomes and Measures Receiver operator characteristics and C statistics for each measure predicting postoperative mortality and morbidity. Results Of the participants, the mean (SD) age was 60.7 (13.9) years and 249 participants (3.6%) were women. We assessed the RAI-C 10 698 times, from which we linked 6856 unique patients to mortality data. The C statistic predicting 180-day mortality for the RAI-C was 0.772. Of these 6856 unique patients, we linked 2785 to local Veterans Affairs Surgeons National Surgical Quality Improvement Projects data and calculated the C statistic for both the RAI-A (0.823) and RAI-C (0.824), along with the correlation between the 2 scores (r = 0.478; P < .001). Of these 2785 patients, there were sufficient data to calculate the modified Frailty Index for 1021, in which the C statistics were 0.865 (RAI-A), 0.797 (RAI-C), and 0.811 (modified Frailty Index). The correlation between the RAI-A and RAI-C was 0.547, and the correlations of the modified Frailty Index to the RAI-A and RAI-C were 0.301 and 0.269, respectively (all P < .001). A cutoff of RAI-C of at least 21 classified 18.3% patients as "frail" with a sensitivity of 0.50 and specificity of 0.82, whereas the RAI-A was less sensitive (0.25) and more specific (0.97), classifying only 3.7% as "frail." Conclusions and Relevance The RAI-C and RAI-A represent effective tools for measuring frailty in surgical populations with predictive ability on par with other frailty tools. Moderate correlation between the measures suggests convergent validity. The RAI-C offers the advantage of prospective, preoperative assessment that is proved feasible for large-scale screening in clinical practice. However, further efforts should be directed at determining the optimal components of preoperative frailty assessment.
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Affiliation(s)
- Daniel E Hall
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania2University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shipra Arya
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia4Emory University, Atlanta, Georgia
| | | | | | - Mark A Carlson
- University of Nebraska Medical Center, Omaha6Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Travis L Bailey
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska7University of Utah School of Medicine, Salt Lake City
| | - Georgia Purviance
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | - Tammy Bockman
- Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | | | - Jason Johanning
- University of Nebraska Medical Center, Omaha6Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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Abstract
Treatment with an implantable cardioverter-defibrillator (ICD) represents a prognostic but not symptomatic therapy. It should therefore be restricted to patients where an improvement of prognosis is possible and reasonable. ICD implantation should only be performed in patients with a life expectancy of at least 1 year at reasonable quality of life. The decision in which patient improvement of prognosis is no longer a desirable target is problematic, both medically and ethically. It is not entirely clear in which elderly patient an ICD therapy can convey prognostic benefit despite comorbidity and competitive life-threatening diseases, as it is unclear how old age should be defined. In primary prophylaxis of sudden cardiac death, data on a prognostic benefit of the ICD in elderly patients are less clear than in secondary prophylaxis since short-term mortality due to other causes is higher in the elderly. However, elderly ICD patients have a similar rate of appropriate ICD therapy as younger patients. Complications at ICD implantation or long-term lead failure do not occur more frequently in elderly patients and therefore do not represent a reason to withhold ICD implantation in elderly patients or to set an age limit above which ICD implantation should no longer be performed. The ICD indication in elderly patients should be individualized depending on remaining life expectancy, comorbidity, "biological age" and patient preferences which play a particularly important role in elderly patients. Aspects of a potential improvement in quality of life by the ICD which may also serve as a system for antibradycardiac or resynchronization treatment should be included into considerations. Deactivation of at least shock therapy should be discussed in elderly patients fitted with an ICD if the subject is brought up by the patient or if clinical deterioration suggests the need to talk about a "do not resuscitate" order. This talk should be performed before death is imminent and before an electrical storm in terminal illness leads to multiple shocks by the active device.
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Affiliation(s)
- Carsten W Israel
- Klinik für Innere Medizin - Kardiologie, Diabetologie & Nephrologie, Evangelisches Krankenhaus Bielefeld, Burgsteig 13, 33617, Bielefeld, Deutschland.
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Min H, Avramovic S, Wojtusiak J, Khosla R, Fletcher RD, Alemi F, Kheirbek R. A Comprehensive Multimorbidity Index for Predicting Mortality in Intensive Care Unit Patients. J Palliat Med 2016; 20:35-41. [PMID: 27925837 DOI: 10.1089/jpm.2015.0392] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Accurate prediction of mortality for patients admitted to the intensive care units (ICUs) is an important component of medical care. However, little is known about the role of multimorbidity in predicting end of life for high-risk and vulnerable patients. OBJECTIVE The aim of the study was to derive and validate a multimorbidity risk model in an attempt to predict all-cause mortality at 6 and 12 months posthospital discharge. METHODS This is a retrospective, observational, clinical cohort study. Data were collected on 442,692 ICU patients who received care through the Veterans Administration between January 2003 and December 2013. The primary outcome was all-cause mortality at 6 and 12 months posthospital discharge. We divided the data into derivation (80%) and validation (20%) sets. Using multivariable logistic regression models, we compared prognostic models based on age, principal diagnosis groups, physiological markers, immunosuppressants, comorbidity categories, and a newly developed multimorbidity index (MMI) based on 5695 comorbidities. The cross-validated area under the receiver operating characteristic curve (AUC) was used to report the accuracy of predicting all-cause mortality at 6 and 12 months of hospital discharge. RESULTS The average age of patients was 68.87 years (standard deviation = 12.1), 95.9% were males, 44.9% were widowed, divorced, or separated. The relative order of accuracy in predicting mortality was the MMI (AUC = 0.84, CI = 0.83-0.84), VA Inpatient Evaluation Center index (AUC = 0.80, CI = 0.79-0.81), principal diagnosis groups (AUC = 0.74, CI = 0.73-0.74), comorbidities (AUC = 0.69, CI = 0.68-0.70), physiological markers (AUC = 0.65, CI = 0.64-0.65), age (AUC = 0.60, CI = 0.60-0.61),and immunosuppressant use (AUC = 0.59, CI = 0.58-0.59). CONCLUSIONS The MMI improved the accuracy of predicting short- and long-term all-cause mortality for ICU patients. Further prospective studies are needed to validate the index in different clinical settings and test generalizability of results in patients outside the VA system of care.
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Affiliation(s)
- Hua Min
- 1 Department of Health Administration and Policy, George Mason University , Fairfax, Virginia
| | - Sanja Avramovic
- 1 Department of Health Administration and Policy, George Mason University , Fairfax, Virginia
| | - Janusz Wojtusiak
- 1 Department of Health Administration and Policy, George Mason University , Fairfax, Virginia
| | - Rahul Khosla
- 2 Veterans Affairs Medical Center , Washington, DC.,3 School of Medicine and Health Sciences, George Washington University , Washington, DC
| | - Ross D Fletcher
- 2 Veterans Affairs Medical Center , Washington, DC.,4 School of Medicine, Georgetown University , Washington, DC
| | - Farrokh Alemi
- 1 Department of Health Administration and Policy, George Mason University , Fairfax, Virginia.,2 Veterans Affairs Medical Center , Washington, DC
| | - Raya Kheirbek
- 2 Veterans Affairs Medical Center , Washington, DC.,3 School of Medicine and Health Sciences, George Washington University , Washington, DC
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41
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Vihinen M. How to Define Pathogenicity, Health, and Disease? Hum Mutat 2016; 38:129-136. [PMID: 27862583 DOI: 10.1002/humu.23144] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/13/2016] [Accepted: 11/03/2016] [Indexed: 11/07/2022]
Abstract
Scientific and clinical communities produce ever increasing amounts of data and details about health and disease. Our ability to understand and utilize this information is limited because of imprecise language and lack of well-defined concepts. This problem involves also the principal concepts of health, disease, and pathogenicity. Here, a systematic model is presented for pathogenicity, as well as for health and disease. It has three components: extent, modulation, and severity, which jointly define the continuum of pathogenicity. The model is population based, and once implemented, it can be used for numerous purposes such as diagnosis, patient stratification, prognosis, finding phenotype-genotype correlations, or explaining adverse drug reactions. The new model has several benefits including health economy by allowing evidence-based personalized/precision medicine.
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Affiliation(s)
- Mauno Vihinen
- Department of Experimental Medical Science, Lund University, BMC B13, Lund, SE-22184, Sweden
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Hsu AT, Manuel DG, Taljaard M, Chalifoux M, Bennett C, Costa AP, Bronskill S, Kobewka D, Tanuseputro P. Algorithm for predicting death among older adults in the home care setting: study protocol for the Risk Evaluation for Support: Predictions for Elder-life in the Community Tool (RESPECT). BMJ Open 2016; 6:e013666. [PMID: 27909039 PMCID: PMC5168641 DOI: 10.1136/bmjopen-2016-013666] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Older adults living in the community often have multiple, chronic conditions and functional impairments. A challenge for healthcare providers working in the community is the lack of a predictive tool that can be applied to the broad spectrum of mortality risks observed and may be used to inform care planning. OBJECTIVE To predict survival time for older adults in the home care setting. The final mortality risk algorithm will be implemented as a web-based calculator that can be used by older adults needing care and by their caregivers. DESIGN Open cohort study using the Resident Assessment Instrument for Home Care (RAI-HC) data in Ontario, Canada, from 1 January 2007 to 31 December 2013. PARTICIPANTS The derivation cohort will consist of ∼437 000 older adults who had an RAI-HC assessment between 1 January 2007 and 31 December 2012. A split sample validation cohort will include ∼122 000 older adults with an RAI-HC assessment between 1 January and 31 December 2013. MAIN OUTCOME MEASURES Predicted survival from the time of an RAI-HC assessment. All deaths (n≈245 000) will be ascertained through linkage to a population-based registry that is maintained by the Ministry of Health in Ontario. STATISTICAL ANALYSIS Proportional hazards regression will be estimated after assessment of assumptions. Predictors will include sociodemographic factors, social support, health conditions, functional status, cognition, symptoms of decline and prior healthcare use. Model performance will be evaluated for 6-month and 12-month predicted risks, including measures of calibration (eg, calibration plots) and discrimination (eg, c-statistics). The final algorithm will use combined development and validation data. ETHICS AND DISSEMINATION Research ethics approval has been granted by the Sunnybrook Health Sciences Centre Review Board. Findings will be disseminated through presentations at conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02779309, Pre-results.
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Affiliation(s)
- Amy T Hsu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences (ICES), Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Douglas G Manuel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences (ICES), Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mathieu Chalifoux
- ICES uOttawa, Institute for Clinical Evaluative Sciences (ICES), Ottawa, Ontario, Canada
| | - Carol Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences (ICES), Ottawa, Ontario, Canada
| | - Andrew P Costa
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Susan Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario Canada
| | - Daniel Kobewka
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
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Alemi F, Levy C, Citron BA, Williams AR, Pracht E, Williams A. Improving Prognostic Web Calculators: Violation of Preferential Risk Independence. J Palliat Med 2016; 19:1325-1330. [PMID: 27623488 DOI: 10.1089/jpm.2016.0126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Web-based applications are available for prognostication of individual patients. These prognostic models were developed for groups of patients. No one is the average patient, and using these calculators to inform individual patients could provide misleading results. OBJECTIVE This article gives an example of paradoxical results that may emerge when indices used for prognosis of the average person are used for care of an individual patient. METHODS We calculated the expected mortality risks of stomach cancer and its associated comorbidities. Mortality risks were calculated using data from 140,699 Veterans Administration nursing home residents. RESULTS On average, a patient with hypertension has a higher risk of mortality than one without hypertension. Surprisingly, among patients with lung cancer, hypertension is protective and reduces risk of mortality. This paradoxical result is explained by how group-level, average prognosis could mislead individual patients. In particular, average prognosis of lung cancer patients reflects the impact of various comorbidities that co-occur in lung cancer patients. The presence of hypertension, a relatively mild comorbidity of lung cancer, indicates that more serious comorbidities have not occurred. It is not that hypertension is protective; it is the absence of more serious comorbidities that is protective. The article shows how the presence of these anomalies can be checked through the mathematical concept of preferential risk independence. CONCLUSION Instead of reporting average risk scores, web-based calculators may improve accuracy of predictions by reporting the unconfounded risks.
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Affiliation(s)
- Farrokh Alemi
- 1 The District of Columbia Veteran Administration Medical Center , Washington.,2 Department of Health Administration and Policy, George Mason University , Fairfax, Virginia
| | - Cari Levy
- 3 Denver Veteran Administration Medical Center , Denver, Colorado
| | - Bruce A Citron
- 4 Bay Pines Veteran Administration Healthcare System , Bay Pines, Florida
| | - Arthur R Williams
- 2 Department of Health Administration and Policy, George Mason University , Fairfax, Virginia.,5 Center of Innovation on Disability and Rehabilitation Research, James A. Haley, Veterans, Administration Medical Center , Tampa, Florida
| | - Etienne Pracht
- 6 Department of Health Care Policy and Management, University of South Florida , Tampa, Florida
| | - Allison Williams
- 4 Bay Pines Veteran Administration Healthcare System , Bay Pines, Florida
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Preoperative frailty predicts postoperative complications and mortality in urology patients. World J Urol 2016; 35:21-26. [DOI: 10.1007/s00345-016-1845-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 05/04/2016] [Indexed: 11/26/2022] Open
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Parker-Oliver D. Bearing Witness to the Exit: Depriving Death of Its Strangeness. J Palliat Med 2016; 19:337-40. [DOI: 10.1089/jpm.2015.0463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Debra Parker-Oliver
- Curtis W. and Ann H. Department of Family and Community Medicine, University of Missouri, Columbia, Missouri
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46
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Eslami MH, Rybin D, Doros G, Farber A. An externally validated robust risk predictive model of adverse outcomes after carotid endarterectomy. J Vasc Surg 2016; 63:345-54. [DOI: 10.1016/j.jvs.2015.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 09/14/2015] [Indexed: 01/12/2023]
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47
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Hess J. Systemische Tumortherapie bei älteren Patienten. Urologe A 2015; 54:1758-64. [DOI: 10.1007/s00120-015-4009-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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48
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Dutta R, Hooper J, Dutta D. Use of the MMRI-R prognostic tool for older patients discharged to nursing homes from hospital: a prospective cohort study. Age Ageing 2015; 44:673-6. [PMID: 25687602 DOI: 10.1093/ageing/afv012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 12/03/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND the Minimum Dataset Mortality Risk Index-Revised (MMRI-R) is a prognostic score predicting 6-month mortality in US nursing homes. It has not been validated in the UK nor at the hospital-nursing home interface. METHODS prospective cohort study of consecutive patients discharged from hospital or intermediate care to nursing homes from January 2012 to January 2014. MMRI-R scoring was done prior to discharge and subsequent deaths were ascertained. Calibration plots, receiver operative characteristic curves with area under the curve (AUC) and an optimal cutpoint were obtained. Kaplan-Meier curves were plotted with scores stratified by the cutpoint. RESULTS a total of 183 patients were followed up for a median of 230 days. Median age was 87 years and 55.7% were female. Median MMRI-R score was 55. By the end of follow-up, 99 patients (54.1%) were dead. The Hosmer-Lemeshow test showed P-values of 0.4406 for 3-month and 0.8904 for 6-month mortality. The AUC was 0.70 (95% CI: 0.622-0.777) for 3-month death prediction and 0.723 (95% CI: 0.649-0.797) for death at 6 months. Of patients with MMRI-R scores >48 (the cutpoint), 43.6% were dead at 3 months and 53.6% by 6 months. The corresponding figures for scores <48 were 9.6 and 16.4% (P < 0.001, log-rank test). CONCLUSION the MMRI-R can be used at the acute hospital/nursing home interface, and can help predict 3-month and 6-month mortality. The finding of an MMRI-R score of ≥48 should trigger end-of-life discussions.
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Affiliation(s)
- Ruma Dutta
- Worcestershire Royal Hospital - Elderly Care, Charles Hastings Way Worcester WR5 1DD, Worcester, Worcestershire WR5 1DD, UK
| | - Julie Hooper
- Timberdine Nursing and Rehabilitation Unit, Worcester, Worcestershire, UK
| | - Dipankar Dutta
- Gloucestershire Royal Hospital - General and Old Age Medicine, Gloucester, Gloucestershire, UK
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49
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Heppenstall CP, Broad JB, Boyd M, Gott M, Connolly MJ. Progress towards predicting 1-year mortality in older people living in residential long-term care. Age Ageing 2015; 44:497-501. [PMID: 25652076 DOI: 10.1093/ageing/afu206] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 09/11/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND frail older people living in residential long-term care (LTC) have limited life expectancy. Identifying those with poor prognosis may improve management and facilitate transition to a palliative approach to care. OBJECTIVE to develop methods for predicting mortality in LTC. DESIGN a population-based cohort study. SETTING LTC facilities, Auckland, New Zealand. SUBJECTS five hundred randomly selected older people in a census-type survey of those living in LTC in 2008. METHODS mortality data were obtained from New Zealand Ministry of Health. Two methods for assessing mortality risk were developed using demographic, functional and health service information: (i) two geriatricians blinded to identifying data and to mortality, independently reviewed survey, medications and pre-survey hospitalisations data, and grouped residents according to perceived risk of death within 12 months; (ii) multivariate logistic regression model used the same survey and medication items as the geriatricians. RESULTS for the geriatricians' assessment, each quintile of perceived risk was associated with a significant increase in mortality (P < 0.001). Area under the curve (AUC) for both physicians was 0.64. The logistic regression model included age, gender, assistance with feeding and requiring night attention, all variables which are easily available from LTC records. AUC for the model was 0.70, but when validated against the entire OPAL cohort, it was 0.65. When either or both geriatrician and the model together predicted high risk of death, 1-year mortality was >50%. CONCLUSION two methods with the potential to identify older people with limited prognosis are described. Use of these methods allowed identification of over half of those who died within 12 months.
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Affiliation(s)
- Claire Patricia Heppenstall
- Department of Medicine, University of Otago, Christchurch, 1st Floor, Princess Margaret Hopital, PO Box 800, Christchurch 8140, New Zealand
| | - Joanna B Broad
- Freemasons Department of Geriatric Medicine, University of Auckland, Auckland 0740, New Zealand
| | - Michal Boyd
- Freemasons Department of Geriatric Medicine, University of Auckland, Auckland 0740, New Zealand Waitemata District Health Board, Auckland, New Zealand Department of Nursing, University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- Department of Health Sciences, University of Auckland, Auckland, New Zealand
| | - Martin J Connolly
- Freemasons Department of Geriatric Medicine, University of Auckland, Auckland 0740, New Zealand Waitemata District Health Board, Auckland, New Zealand
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Park Y, Franklin JM, Schneeweiss S, Levin R, Crystal S, Gerhard T, Huybrechts KF. Antipsychotics and mortality: adjusting for mortality risk scores to address confounding by terminal illness. J Am Geriatr Soc 2015; 63:516-23. [PMID: 25752911 DOI: 10.1111/jgs.13326] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine whether adjustment for prognostic indices specifically developed for nursing home (NH) populations affect the magnitude of previously observed associations between mortality and conventional and atypical antipsychotics. DESIGN Cohort study. SETTING A merged data set of Medicaid, Medicare, Minimum Data Set (MDS), Online Survey Certification and Reporting system, and National Death Index for 2001 to 2005. PARTICIPANTS Dual-eligible individuals aged 65 and older who initiated antipsychotic treatment in a NH (N=75,445). MEASUREMENTS Three mortality risk scores (Mortality Risk Index Score, Revised MDS Mortality Risk Index, Advanced Dementia Prognostic Tool) were derived for each participant using baseline MDS data, and their performance was assessed using c-statistics and goodness-of-fit tests. The effect of adjusting for these indices in addition to propensity scores (PSs) on the association between antipsychotic medication and mortality was evaluated using Cox models with and without adjustment for risk scores. RESULTS Each risk score showed moderate discrimination for 6-month mortality, with c-statistics ranging from 0.61 to 0.63. There was no evidence of lack of fit. Imbalances in risk scores between conventional and atypical antipsychotic users, suggesting potential confounding, were much lower within PS deciles than the imbalances in the full cohort. Accounting for each score in the Cox model did not change the relative risk estimates: 2.24 with PS-only adjustment versus 2.20, 2.20, and 2.22 after further adjustment for the three risk scores. CONCLUSION Although causality cannot be proven based on nonrandomized studies, this study adds to the body of evidence rejecting explanations other than causality for the greater mortality risk associated with conventional antipsychotics than with atypical antipsychotics.
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Affiliation(s)
- Yoonyoung Park
- Department of Epidemiology, School of Public Health, Harvard University, Boston, Massachusetts; Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts
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