Understanding the relationship between social risk factors and functional limitation among stroke survivors in the US

BACKGROUND

Stroke is the fifth leading cause of death and disability in the United States. Social risk factors contribute to recovery from stroke, however the relationship between social risk factors and functional limitation among stroke survivors remains unknown.

METHODS

Data on 2,888 adults with stroke from the National Health Interview Survey from 2016-2018 was analyzed. The primary independent variables included six social risk factors: economic instability, lack of community, educational deficit, food insecurity, social isolation, and inadequate access to care. The outcome measure was functional limitation count. Negative binomial regression models were run to test the relationship between the independent and dependent variables adjusting for covariates.

RESULTS

Overall, 56% of the study participants were aged 65+, 70% were Non-Hispanic White, and 95% had at least one comorbidity. The mean functional limitation count was 1.8. In the unadjusted model, each social risk factor was significantly associated with functional limitation. In the fully adjusted model, significant association with functional limitation was found in individuals reporting economic instability (Incidence rate ratio [IRR] 1.65, 95% CI 1.33, 2.06), food insecurity (IRR 1.28, 95% CI 1.15, 1.42), and social isolation (IRR 1.64, 95% CI 1.48, 1.82).

CONCLUSIONS

Social risk factors such as economic instability, food insecurity and social isolation are significantly associated with functional limitation in adults with stroke. Interventions designed to address both social and medical needs have the potential to improve physical functioning and other clinical outcomes in stroke survivors.

Understanding the Relationship Between Wealth and Cognitive Function by Race/Ethnicity Among Older United States Adults with Diabetes

Background

The prevalence of type 2 diabetes is increasing with the burden disproportionately falling on older adults and racial/ethnic minorities. Older adults with diabetes show greater cognitive decline and there are disparities in cognitive function by race/ethnicity that can be explained by social determinants such as wealth.

Objective

To understand whether there is a differential relationship between wealth and cognitive function by race/ethnicity among older U.S. adults with diabetes.

Methods

Data on 9,006 adults aged 50+ with diabetes from the Health and Retirement Study (2006-2016) were analyzed. The primary outcome, cognitive function, was a score ranging from range 0-27 categorized as: normal [12-27], mild cognitive impairment (MCI) [7-11], and dementia including Alzheimer's disease [0-6]. Three modeled outcomes were: 1) normal versus MCI, 2) normal versus dementia, 3) MCI versus dementia. Wealth was log transformed and used as continuous and binary (≥median,

Results

In adjusted models, greater wealth was significantly associated with lower odds of MCI and dementia for all groups. Similarly, having wealth less than the sample median was associated with higher odds of MCI and dementia compared to wealth≥sample median.

Conclusions

Increased wealth was significantly protective against MCI and dementia for all ethnic groups. Wealth less than the sample median was associated with greater odds of dementia for NHB and NHW.

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Key Words

• Alzheimer’s disease
• cognitive function
• dementia
• diabetes
• mild cognitive impairment
• older adults
• racial/ethnic disparities
• wealth

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MESH Headings

• Humans
• United States/epidemiology
• Adult
• Middle Aged
• Aged
• Ethnicity
• Diabetes Mellitus, Type 2/epidemiology
• Cognition
• Cognitive Dysfunction/epidemiology
• Cognitive Dysfunction/psychology
• Alzheimer Disease/epidemiology

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Affiliation(s)

Amelia Papadimitriou Department of Medicine, Medical School, Medical College of Wisconsin, Milwaukee, WI, USA
Aprill Z Dawson Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
Abigail Thorgerson Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
Sanjay Bhandari Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
Martin Martinez Department of Medicine, Medical School, Medical College of Wisconsin, Milwaukee, WI, USA
Leonard E Egede Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA

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The Associations Between Medical and Mental Health Conditions and Health Care Utilization in US Adults with Past-Year Criminal Legal Involvement

BACKGROUND

Every year, millions of US adults return home from prison or jail, and they visit the emergency department and experience hospitalizations at higher rates than the general population. Little is known about the primary conditions that drive this acute care use.

OBJECTIVE

To determine the individual and combined associations between medical and mental health conditions and acute health care utilization among individuals with recent criminal legal involvement in a nationally representative sample of US adults.

DESIGN

We examined the association between having medical or mental, or both, conditions (compared to none), and acute care utilization using negative binomial regression models adjusted for relevant socio-demographic covariates.

PARTICIPANTS

Adult respondents to the National Survey of Drug Use and Health (2015-2019) who reported past year criminal legal involvement.

MAIN MEASURES

Self-reported visits to the emergency department and nights spent hospitalized.

RESULTS

Among 9039 respondents, 12.4% had a medical condition only, 34.6% had a mental health condition only, and 19.2% had both mental and medical conditions. In adjusted models, incident rate ratio (IRR) for ED use for medical conditions only was 1.32 (95% CI 1.05, 1.66); for mental conditions only, the IRR was 1.36 (95% CI 1.18, 1.57); for both conditions, the IRR was 2.13 (95% CI 1.81, 2.51). For inpatient use, IRR for medical only: 1.73 (95% CI 1.08, 2.76); for mental only, IRR: 2.47 (95% CI 1.68, 3.65); for both, IRR: 4.26 (95% CI 2.91, 6.25).

CONCLUSION

Medical and mental health needs appear to contribute equally to increased acute care utilization among those with recent criminal legal involvement. This underscores the need to identify and test interventions which comprehensively address both medical and mental health conditions for individuals returning to the community to improve both health care access and quality.

Associations Between Hospital Volume and Overall Survival After Surgery in Older Patients with Breast Cancer

BACKGROUND

High-volume hospitals (HVHs) are associated with improved overall survival (OS) following surgery for breast cancer compared with low-volume hospitals (LVHs). We examined this association in patients age ≥ 80 years and described patient and treatment characteristics associated with HVHs.

PATIENTS AND METHODS

The National Cancer Database was queried for women age ≥ 80 years who underwent surgery for stage I-III breast cancer between 2005 and 2014. Hospital volume was defined as the average number of cases during the year of the patient's index operation and the year prior. Hospitals were categorized into HVHs and LVHs using penalized cubic spline analysis of OS. A cutoff of ≥ 270 cases/year defined HVHs.

RESULTS

Among 59,043 patients, 9110 (15%) were treated at HVHs and 49,933 (85%) at LVHs. HVHs were associated with more non-Hispanic Black and Hispanic patients, earlier stage disease (stage I 54.9% vs. 52.6%, p < 0.001), higher rates of breast-conserving surgery (BCS) (68.3% vs. 61.4%, p < 0.001), and adjuvant radiation (37.5% vs. 36.1%, p = 0.004). Improved OS was associated with surgery at a HVH (HR 0.85, CI 0.81-0.88), along with receipt of adjuvant chemotherapy (HR 0.73, CI 0.69-0.77), endocrine therapy (HR 0.70, CI 0.68-0.72), and radiation (HR 0.66, CI 0.64-0.68).

CONCLUSIONS

Among patients with breast cancer age ≥ 80 years, undergoing surgery at a HVH was associated with improved OS. Patients who completed surgery at HVHs had earlier stage disease and more commonly received adjuvant radiation when appropriate. Processes of care at HVHs should be identified to improve outcomes in all settings.

Relationship between Satisfaction Scores and Racial/Ethnic and Sex Concordance in Primary Care

Racial/ethnic and sex concordance between patients and providers has been suggested as an important consideration in improving satisfaction and increasing health equity. We aimed to guide local efforts by understanding the relationship between satisfaction with care and patient-provider racial/ethnic and sex concordance within our academic medical center's primary care clinic.

METHODS

Satisfaction data for encounters from August 2016 to August 2019 were matched to data from the medical record for patient demographics and comorbidities. Data on 33 providers were also obtained, and racial/ethnic and sex concordance between patients and providers was determined for each of the 3672 unique encounters. The primary outcome was top-box scoring on the CGCAHPS overall satisfaction scale (0-8 vs. 9-10). Generalized mixed-effects logistic regression, including provider- and patient-level factors as fixed effects and a random intercept effect for providers, were used to determine whether concordance had an independent relationship with satisfaction.

RESULTS

89.0% of the NHW-concordant pairs and 90.4% of the Minority Race/Ethnicity-concordant pairs indicated satisfaction, while 90.1% of the male-concordant and 85.1% of the female-concordant pairs indicated satisfaction. When fully adjusted, the female-concordant (OR = 0.58, 95% CI 0.35-0.94) and male-discordant (OR = 0.68, 95% CI 0.51-0.91) pairs reported significantly lower top-box satisfaction compared to the male-concordant pairs. Significant differences did not exist in racial/ethnic concordance.

CONCLUSIONS

In this sample, differences in sex concordance were noted; however, patient- and provider-level factors may be more influential in driving patient satisfaction than race/ethnicity in this health system.

Coronary artery calcification as a predictor of adverse outcomes in patients hospitalized with COVID-19

Background

Subclinical coronary artery calcification (CAC) is a risk factor for adverse cardiovascular events, but studies investigating its association with outcomes in hospitalized patients with COVID-19 are limited.

Methods

This was a retrospective study of 457 patients without history of clinical coronary artery disease (CAD) who underwent chest CT imaging during COVID-19 hospitalization at MCW/Froedtert-affiliated hospitals from July 1, 2020 to July 1, 2021. Visually estimated CAC (yes/no) and CAC burden (none/mild/moderate/severe) were recorded from radiology reports. Unadjusted and adjusted regression models were used to assess associations between CAC and hospital length of stay (LOS), ICU admission, mechanical ventilation, and mortality.

Results

The mean age was 63.1 ± 15.3 years. Presence of CAC was associated with mechanical ventilation (p = 0.01), ICU admission (p = 0.02), in-hospital or 30-day mortality (p < 0.01), and hospital LOS (p < 0.001). Compared to no CAC, hospital LOS was increased for mild (p = 0.01) and severe CAC (p = 0.02) after adjustment for covariates. Severe CAC was also associated with increased ICU admission (OR 3.97; p = 0.002) and mechanical ventilation (OR 3.08; p = 0.03) after adjustment. In unadjusted analysis, in-hospital or 30-day mortality increased with magnitude of CAC severity, with HR 2.43 (p = 0.003) for mild and HR 3.70 (p = 0.002) for severe CAC. However, associations with mortality were not significant after adjustment.

Conclusions

CAC is associated with increased ICU admission, mechanical ventilation, hospital LOS, and in-hospital or 30-day mortality for patients hospitalized with COVID-19. Patients with severe CAC, and without clinical history of CAD, represent a high-risk population for morbidity and mortality.

Dose response relationship between food insecurity and quality of life in United States adults: 2016-2017

BACKGROUND

Food insecurity is associated with worse general health rating, but little research exists investigating whether there is a dose response relationship across levels of food security and mental and physical health domains at the population level.

METHODS

Data from the Medical Expenditure Panel Survey (2016-2017) with US adults aged 18 years and older was used. The physical component score (PCS) and mental component score (MCS) of Quality of Life, served as the outcome measures. Four categories of food insecurity (high, marginal, low, very low food security) served as the primary independent variable. Linear regression was used to run unadjusted followed by adjusted models. Separate models were run for PCS and MCS.

RESULTS

In a sample of US adults, 16.1% reported some degree of food insecurity. For PCS, marginal (β = - 2.54 (p < 0.001), low (β = - 3.41, (p < 0.001), and very low (β = - 5.62, (p < 0.001) food security was associated with worse PCS scores, compared to adults with high food security. For MCS, marginal (β = - 3.90 (p < 0.001), low (β = - 4.79, (p < 0.001), and very low (β = - 9.72, (p < 0.001) food security was associated with worse MCS scores, compared to adults with high food security.

CONCLUSION

Increasing levels of food insecurity were associated with decreased physical and mental health quality of life scores. This relationship was not explained by demographic factors, socioeconomic factors, insurance, or comorbidity burden. This study suggests work is needed to mitigate the impact of social risk, such as food insecurity, on quality of life in adults, and understand pathways and mechanisms for this relationship.

Understanding the relationship between perceived discrimination, allostatic load, and all-cause mortality in US older adults: A mediation analysis

OBJECTIVE

To understand the relationship between perceived discrimination, allostatic load, and all-cause mortality; and to determine whether allostatic load is a mediator in the relationship between perceived discrimination and all-cause mortality among an older adult US population.

METHODS

Data from the Health and Retirement Study (2006-2012) was analyzed. Cox proportional hazard models were used to investigate the relationship between all-cause mortality and perceived discrimination, and all-cause mortality and allostatic load. Linear regression models were used to investigate the relationship between perceived discrimination and allostatic load. A mediation model with perceived discrimination and allostatic loads as independent variables was used to determine the association with all-cause mortality.

RESULTS

There were 5062 adults over the age of 50 included in the analysis. The relationship between perceived discrimination and allostatic load was statistically significant (b:0.14, [95%CI 0.10,0.19]; p < 0.001). The relationship between perceived discrimination and all-cause mortality was statistically significant (HR: 1.12, [95%CI 1.03,1.22]; p = 0.01). The relationship between allostatic load and all-cause mortality was statistically significant (HR: 1.11, [95%CI 1.08,1.13]; p < 0.001). The mediation model resulted in a decrease in hazard ratio and loss of statistical significance for perceived discrimination (HR: 1.09, [95%CI 0.98,1.21]; p = 0.13) when allostatic load (HR: 1.17, [95%CI 1.10,1.24]; p < 0.001) was added to the Cox regression model, indicating full mediation.

CONCLUSIONS

Allostatic load fully mediates the relationship between perceived discrimination and all-cause mortality. Understanding the role of allostatic load in this relationship provides an additional implication for screening and indications for tighter control of the modifiable components of allostatic load by healthcare providers, especially among individuals who experience discrimination.

Pharmacokinetics of Sublingual vs. Oral Estradiol in Transgender Women

OBJECTIVE

To investigate the pharmacokinetics of 17ß-estradiol administered orally versus sublingually in transgender women.

METHODS

Single doses of 17ß-estradiol were administered orally (1 mg) to ten transgender women, then sublingually (1 mg) after a one-week washout. Blood samples were taken at baseline and T = 1,2,3,4,6,8 hours after dosing. Samples were frozen and analyzed using LC-MS/MS (liquid chromatography mass spectrometry) and immunoassay.

RESULTS

Results demonstrated that sublingual estradiol had a significantly higher peak serum estradiol (E2) concentration at 144 pg/mL by LC-MS/MS compared to oral estradiol at 35 pg/mL by LC-MS/MS (p= 0.003). Sublingual estradiol peaked at hour 1 and oral estradiol peaked at hour 8 when measured by LC-MS/MS. The area under the curve (AUC) 0-8h for sublingual estradiol measured by LC-MS/MS showed a 1.8-fold higher level compared to the AUC 0-8h for oral estradiol measured by LC-MS/MS. Additionally, sublingual E2 was found to have an increased E2 to estrone (E1) ratio at all timepoints (1.1 ± 1.0 v. 0.7 ± 0.4, p= <0.0001), the clinical significance of which is unclear.

CONCLUSION

Oral estradiol administered sublingually has a different pharmacokinetic profile, with higher serum estradiol levels and AUC (0-8h) than traditionally administered oral E2. Multi-daily dosing may be necessary to suppress testosterone levels with sublingual estradiol. The appropriate dosing, efficacy and safety of sublingual estradiol compared to other estradiol preparations is unknown.