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Lakra A, Tram MK, Bernasek TL, Lyons ST, O'Connor CM. Frailty is Associated With Increased Complication, Readmission, and Hospitalization Costs Following Primary Total Knee Arthroplasty. J Arthroplasty 2023; 38:S182-S186.e2. [PMID: 36858131 DOI: 10.1016/j.arth.2023.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/05/2023] [Accepted: 02/11/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Frailty has been associated with poor postoperative outcomes in various medical conditions and surgical procedures. However, the relationship between frailty and outcomes after primary total knee arthroplasty (TKA) has not been well-described. This study investigated the association of the Hospital Frailty Risk Score (HFRS) with postoperative events and hospitalization costs after primary TKA. METHODS Using a nationwide readmissions database, we identified 884,479 patients discharged after primary TKA for osteoarthritis between January 2017 and November 2019. HFRS was calculated for each patient to determine frailty status. We used multivariate logistic regressions to evaluate the association of frailty with 30-readmission rate and negative binomial regressions to evaluate lengths of hospital stay and hospitalization costs. The 30-day reoperation and complication rates were compared using chi-square tests. RESULTS Frailty was associated with increased odds of 30-day readmissions (odds ratio [OR]: 1.89, 95% confidence interval [CI]: 1.82-1.96), longer lengths of stay (OR: 1.43, 95% CI: 1.43-1.44), and higher hospitalization costs (OR: 1.16, 95% CI: 1.16-1.17). Frail patients also had significantly higher rates of 30-day reoperations (0.6 versus 0.4%), surgical complications (0.6 versus 0.4%), medical complications (3.4 versus 1.3%), and other complications (0.9 versus 0.5%) (P < .01). CONCLUSIONS Frailty, as measured using HFRS, was associated with increased adverse events and health care burdens in patients undergoing TKA. The HFRS could be used to swiftly identify high-risk patients undergoing TKA and to potentially help optimize patients prior to elective TKA. TYPE OF STUDY Level III retrospective cohort study.
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Affiliation(s)
- Akshay Lakra
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York
| | - Michael K Tram
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York
| | - Thomas L Bernasek
- Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
| | - Steven T Lyons
- Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
| | - Casey M O'Connor
- Albany Medical Center, Department of Orthopedic Surgery, Albany, New York; Florida Orthopaedic Institute, University of South Florida, Tampa, Florida
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Huan-Tze L, Yun-Ru L, Kuan-Der L, Huey-En T. Frailty in chronic myeloid leukemia: evidence from 2016-2018 Nationwide Inpatient Sample of the US. BMC Geriatr 2023; 23:334. [PMID: 37254068 DOI: 10.1186/s12877-023-03962-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/10/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Frailty is a marker of poor prognosis in older adults with hematologic malignancies and contributes to the severe vulnerability of the aging population to adverse health outcomes. This study aimed to determine the association between frailty and outcomes in hospitalized patients with chronic myeloid leukemia (CML). METHODS The International Classification of Diseases (ICD-10) identified data on hospitalized patients 20 years or older admitted with CML between 2016 and 2018 in the US National Inpatient Sample (NIS) database. The cohort was further divided into groups of patients with or without frailty. Logistic regression analysis was performed to determine associations between study variables and clinical outcomes. A stratified analysis of the association between frailty and in-hospital mortality by age group was also performed. RESULTS A total of 13,849 hospitalized patients with CML were included, 49.6% of whom had frailty. The mean age of the patients was 65.1 years, and 7,619 (56.2%) of them were male. Frailty was associated with nearly 4 times the risk of in-hospital mortality, 3 times the risk of unfavorable discharge, 3 times the risk of prolonged LOS,, and significantly more in total hospital costs. In addition, frailty was associated with a significantly increased risk of in-hospital mortality in all age subgroups (< 40 years, 40-59 years, and > 60 years) compared with no frailty. CONCLUSIONS Frailty strongly predicts poor clinical outcomes in US patients with CML.
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Affiliation(s)
- Lin Huan-Tze
- Department of Internal Medicine, Division of Hematology and Oncology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Liu Yun-Ru
- Joint Biobank, Office of Human Research, Taipei Medical University, Taipei, Taiwan
| | - Lee Kuan-Der
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung City, 40705, Taiwan
| | - Tzeng Huey-En
- Department of Internal Medicine, Division of Hematology and Oncology, Taipei Medical University Hospital, Taipei, Taiwan.
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung City, 40705, Taiwan.
- Department of Medicine, Division of Hematology/Medical Oncology, Taichung Veterans General Hospital, Taichung City, Taiwan.
- Ph.D. Program for Cancer Molecular Biology and Drug Discovery, and Graduate Institute of Cancer Biology and Drug Discovery, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan.
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
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Jónsdóttir F, Blöndal AB, Guðmundsson A, Bates I, Stevenson JM, Sigurðsson MI. Epidemiology and association with outcomes of polypharmacy in patients undergoing surgery: retrospective, population-based cohort study. BJS Open 2023; 7:7166807. [PMID: 37194458 DOI: 10.1093/bjsopen/zrad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/10/2023] [Accepted: 03/16/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the prevalence of preoperative polypharmacy and the incidence of postoperative polypharmacy/hyper-polypharmacy in surgical patients and their association with adverse outcomes. METHODS This was a retrospective, population-based cohort study among patients older than or equal to 18 years undergoing surgery at a university hospital between 2005 and 2018. Patients were categorized based on the number of medications: non-polypharmacy (fewer than 5); polypharmacy (5-9); and hyper-polypharmacy (greater than or equal to 10). The 30-day mortality, prolonged hospitalization (greater than or equal to 10 days), and incidence of readmission were compared between medication-use categories. RESULTS Among 55 997 patients, the prevalence of preoperative polypharmacy was 32.3 per cent (95 per cent c.i. 33.5 to 34.3) and the prevalence of hyper-polypharmacy was 25.5 per cent (95 per cent c.i. 25.2 to 25.9). Thirty-day mortality was higher for patients exposed to preoperative hyper-polypharmacy (2.3 per cent) and preoperative polypharmacy (0.8 per cent) compared with those exposed to non-polypharmacy (0.6 per cent) (P < 0.001). The hazards ratio (HR) of long-term mortality was higher for patients exposed to hyper-polypharmacy (HR 1.32 (95 per cent c.i. 1.25 to 1.40)) and polypharmacy (HR 1.07 (95 per cent c.i. 1.01 to 1.14)) after adjustment for patient and procedural variables. The incidence of longer hospitalization (greater than or equal to 10 days) was higher for hyper-polypharmacy (11.3 per cent) and polypharmacy (6.3 per cent) compared with non-polypharmacy (4.1 per cent) (P < 0.001). The 30-day incidence of readmission was higher for patients exposed to hyper-polypharmacy (10.2 per cent) compared with polypharmacy (6.1 per cent) and non-polypharmacy (4.8 per cent) (P < 0.001). Among patients not exposed to polypharmacy, the incidence of new postoperative polypharmacy/hyper-polypharmacy was 33.4 per cent (95 per cent c.i. 32.8 to 34.1), and, for patients exposed to preoperative polypharmacy, the incidence of postoperative hyper-polypharmacy was 16.3 per cent (95 per cent c.i. 16.0 to 16.7). CONCLUSION Preoperative polypharmacy and new postoperative polypharmacy/hyper-polypharmacy are common and associated with adverse outcomes. This highlights the need for increased emphasis on optimizing medication usage throughout the perioperative interval. REGISTRATION NUMBER NCT04805151 (http://clinicaltrials.gov).
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Affiliation(s)
- Freyja Jónsdóttir
- Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
- Pharmacy Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Anna B Blöndal
- Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
| | - Aðalsteinn Guðmundsson
- Division of Geriatrics, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Ian Bates
- School of Pharmacy, University College London, London, UK
| | - Jennifer M Stevenson
- Institute of Pharmaceutical Science, King's College, London, UK
- Pharmacy Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Martin I Sigurðsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Anaesthesia and Intensive Care Medicine, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
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Koo AB, Elsamadicy AA, Renedo D, Sarkozy M, Sherman J, Reeves BC, Havlik J, Antonios J, Sujijantarat N, Hebert R, Malhotra A, Matouk C. Higher Hospital Frailty Risk Score is associated with increased complications and healthcare resource utilization after endovascular treatment of ruptured intracranial aneurysms. J Neurointerv Surg 2023; 15:255-261. [PMID: 35292571 PMCID: PMC8931798 DOI: 10.1136/neurintsurg-2021-018484] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/15/2022] [Indexed: 12/29/2022]
Abstract
AIM To use the Hospital Frailty Risk Score (HFRS) to investigate the impact of frailty on complication rates and healthcare resource utilization in patients who underwent endovascular treatment of ruptured intracranial aneurysms (IAs). METHODS A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. All adult patients (≥18 years) undergoing endovascular treatment for IAs after subarachnoid hemorrhage were identified using ICD-10-CM codes. Patients were categorized into frailty cohorts: low (HFRS <5), intermediate (HFRS 5-15) and high (HFRS >15). Patient demographics, adverse events, length of stay (LOS), discharge disposition, and total cost of admission were assessed. Multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, increased cost, and non-routine discharge. RESULTS Of the 33 840 patients identified, 7940 (23.5%) were found to be low, 20 075 (59.3%) intermediate and 5825 (17.2%) high frailty by HFRS criteria. The rate of encountering any adverse event was significantly greater in the higher frailty cohorts (low: 59.9%; intermediate: 92.4%; high: 99.2%, p<0.001). There was a stepwise increase in mean LOS (low: 11.7±8.2 days; intermediate: 18.7±14.1 days; high: 26.6±20.1 days, p<0.001), mean total hospital cost (low: $62 888±37 757; intermediate: $99 670±63 446; high: $134 937±80 331, p<0.001), and non-routine discharge (low: 17.3%; intermediate: 44.4%; high: 69.4%, p<0.001) with increasing frailty. On multivariate regression analysis, a similar stepwise impact was found in prolonged LOS (intermediate: OR 2.38, p<0.001; high: OR 4.49, p<0.001)], total hospital cost (intermediate: OR 2.15, p<0.001; high: OR 3.62, p<0.001), and non-routine discharge (intermediate: OR 2.13, p<0.001; high: OR 4.17, p<0.001). CONCLUSIONS Our study found that greater frailty as defined by the HFRS was associated with increased complications, LOS, total costs, and non-routine discharge.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniela Renedo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Josiah Sherman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Joseph Antonios
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nanthiya Sujijantarat
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Rabelo LG, Bjornsdottir A, Jonsdottir AB, Einarsson SG, Karason S, Sigurdsson MI. Frailty assessment tools and associated postoperative outcomes in older patients undergoing elective surgery: A prospective pilot study. Acta Anaesthesiol Scand 2023; 67:150-158. [PMID: 36307919 DOI: 10.1111/aas.14162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/02/2022] [Accepted: 10/22/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is a need for a feasible tool to assess the risk of frailty prior to surgery. We aimed to identify the ratio of abnormal results for three clinically applicable screening tools to assess the risk of frailty, and their association with adverse outcomes in a cohort of elderly surgical patients. METHODS In this prospective pilot study, patients ≥65 years undergoing preoperative evaluation for elective surgery were included and subjected to three frailty screening tests; Program of Research to Integrate Services for the Maintenance of Autonomy 7-item questionnaire (PRISMA7), Timed Up and Go (TUG), and Clock Drawing Test (CDT). The primary outcome was the incidence of abnormal testing, and secondary outcomes were the association between abnormal tests and mortality, readmission, delirium, surgical complications and non-home discharge. RESULTS Out of 99 patients, 41%, 37%, and 43% had abnormal PRISMA7, TUG, and CDT screening, respectively. Postoperative delirium was more likely to occur in patients with abnormal TUG screening (19% vs. 3%, p = .011) and CDT (17% vs. 2%, p = .019). When analyzing screening tool combinations, patients with abnormal PRISMA7 and TUG had a higher rate of non-home discharge (38% vs. 17%, p = .029); and patients with abnormal TUG and CDT had a higher rate of postoperative delirium (25% vs. 3%, p = .006) and any surgical complication (58% vs. 38%, p = .037); and patients with abnormal results from all three tools had a higher rate of postoperative delirium (21% vs. 5%, p = .045) and non-home discharge (42% vs. 18%, p = .034). CONCLUSION Approximately 40% of elderly surgical patients have abnormal PRISMA7, TUG, and CDT screening tests for frailty, and they are associated individually or in combination with increased risk of adverse postoperative outcomes. The results will aid in designing studies to further risk-stratify patients at risk of frailty and attempt to modify associated outcomes.
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Affiliation(s)
- Luis G Rabelo
- Division of Anaesthesia and Intensive Care Medicine, Perioperative Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Anna B Jonsdottir
- Geriatric and Rehabilitation Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Sveinn G Einarsson
- Division of Anaesthesia and Intensive Care Medicine, Perioperative Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Sigurbergur Karason
- Division of Anaesthesia and Intensive Care Medicine, Perioperative Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Division of Anaesthesia and Intensive Care Medicine, Perioperative Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Abstract
UNLABELLED A hip fracture causes high morbidity and mortality. Frailty is associated with adverse outcomes and increased costs. Frailty measured using the Hospital Frailty Risk Score (HFRS) is associated with higher costs and adverse outcomes. HFRS is useful as a fuss-free frailty measurement in the management of older adults with hip fractures. INTRODUCTION Hip fractures account for an increasing number of hospital admissions around the world and are associated with high rates of morbidity and mortality. Frailty is increasingly recognized to be associated with adverse outcomes and increased costs. The purpose of this study is to determine the association of the Hospital Frailty Risk Score (HFRS) with the healthcare cost and outcomes in older adults who present with a hip fracture. METHODS A retrospective analysis was performed on 1014 patients ≥ 60 years who presented with a hip fracture between January 2016 to June 2020. Each patient was classified into HFRS low, intermediate or high frailty cohorts. Demographics, hip fracture type, comorbidities, Charlson Comorbidity Index (CCI), American Society of Anesthesiologist score (ASA), costs, length of stay, time to surgery, complications, readmission rate and mortality were compared between the cohorts. RESULTS Median total hospitalization costs were significantly higher in the highest HFRS (SGD$22,432) patients as compared to intermediate (SGD$18,759) and low HFRS (SGD$15,671) patients. The difference between the high and low groups remains significant after adjusting for covariates using quantile regression. Similar results were shown for median length of stay (14 vs 10 vs 8 days), total number of complications (2 vs 1 vs 0) and adjusted time to surgery (p < 0.05). HFRS was not associated with 30-day readmission or 30-day or 1-year mortality. CONCLUSION Frailty is associated with a marked increase in total costs in hip fracture patients. HFRS proved useful in estimating LOS and outcomes for older patients with hip fractures.
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Affiliation(s)
- Beatrix Ling Ling Wong
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore
| | - Gavin Kane O'Neill
- Department of Orthopaedic Surgery, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Diarmuid Murphy
- Department of Orthopaedic Surgery, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Reshma Aziz Merchant
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore
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Kochar B, Jylhävä J, Söderling J, Ritchie CS, Ludvigsson JF, Khalili H, Olén O. Prevalence and Implications of Frailty in Older Adults With Incident Inflammatory Bowel Diseases: A Nationwide Cohort Study. Clin Gastroenterol Hepatol 2022; 20:2358-2365.e11. [PMID: 34999206 PMCID: PMC9294971 DOI: 10.1016/j.cgh.2022.01.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/20/2021] [Accepted: 01/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We aimed to compare the risk of frailty in older adults with incident inflammatory bowel disease (IBD) and matched non-IBD comparators and assess the association between frailty and future hospitalizations and mortality. METHODS In a cohort of patients with incident IBD ≥60 years of age from 2007 to 2016 in Sweden identified using nationwide registers, we defined frailty using Hospital Frailty Risk Score. We compared prevalence of frailty in patients with IBD with age, sex, place of residency- and calendar year-matched population comparators. In the IBD cohort, we used Cox proportional hazards modeling to examine the associations between frailty risk and hospitalizations or mortality. RESULTS We identified 10,590 patients with IBD, 52% female with a mean age of 71 years of age, matched to 103,398 population-based comparators. Among patients with IBD, 39% had no risk for frailty, 49% had low risk for frailty, and 12% had higher risk for frailty. Mean Hospital Frailty Risk Score was 1.9 in IBD and 0.9 in matched comparators (P < .01). Older adults with IBD at higher risk for frailty had a 20% greater risk for mortality at 3 years compared with those who were not frail. Compared with nonfrail older patients with IBD, patients at higher risk for frailty had increased mortality (hazard ratio [HR], 3.22, 95% confidence interval [CI], 2.86-3.61), all-cause hospitalization (HR, 2.42; 95% CI, 2.24-2.61), and IBD-related hospitalization (HR, 1.50; 95% CI, 1.35-1.66). These associations were not attenuated after adjusting for comorbidities. CONCLUSIONS Frailty is more prevalent in older adults with IBD than in matched comparators. Among older patients with IBD, frailty is associated with increased risk for hospitalizations and mortality.
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Affiliation(s)
- Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Clinical Translational Epidemiology Unit, Mongan Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Center for Aging and Serious Illness, Mongan Institute, Boston, Massachusetts
| | - Juulia Jylhävä
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Söderling
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christine S Ritchie
- Harvard Medical School, Boston, Massachusetts; Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet Stockholm, Sweden; Center for Aging and Serious Illness, Mongan Institute, Boston, Massachusetts
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Pediatrics, Örebro University Hospital, Örebro, Sweden; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom; Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hamed Khalili
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts; Clinical Translational Epidemiology Unit, Mongan Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Ola Olén
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatric Gastroenterology and Nutrition, Sachs' Children and Youth Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
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