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Bosco E, Riester MR, Beaudoin FL, Schoenfeld AJ, Gravenstein S, Mor V, Zullo AR. Comparative safety of tramadol and other opioids following total hip and knee arthroplasty. BMC Geriatr 2024; 24:319. [PMID: 38580920 PMCID: PMC10996118 DOI: 10.1186/s12877-024-04933-2] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 03/29/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Tramadol is increasingly used to treat acute postoperative pain among older adults following total hip and knee arthroplasty (THA/TKA). However, tramadol has a complex pharmacology and may be no safer than full opioid agonists. We compared the safety of tramadol, oxycodone, and hydrocodone among opioid-naïve older adults following elective THA/TKA. METHODS This retrospective cohort included Medicare Fee-for-Service beneficiaries ≥ 65 years with elective THA/TKA between January 1, 2010 and September 30, 2015, 12 months of continuous Parts A and B enrollment, 6 months of continuous Part D enrollment, and no opioid use in the 6 months prior to THA/TKA. Participants initiated single-opioid therapy with tramadol, oxycodone, or hydrocodone within 7 days of discharge from THA/TKA hospitalization, regardless of concurrently administered nonopioid analgesics. Outcomes of interest included all-cause hospitalizations or emergency department visits (serious adverse events (SAEs)) and a composite of 10 surgical- and opioid-related SAEs within 90-days of THA/TKA. The intention-to-treat (ITT) and per-protocol (PP) hazard ratios (HRs) for tramadol versus other opioids were estimated using inverse-probability-of-treatment-weighted pooled logistic regression models. RESULTS The study population included 2,697 tramadol, 11,407 oxycodone, and 14,665 hydrocodone initiators. Compared to oxycodone, tramadol increased the rate of all-cause SAEs in ITT analyses only (ITT HR 1.19, 95%CLs, 1.02, 1.41; PP HR 1.05, 95%CLs, 0.86, 1.29). Rates of composite SAEs were not significant across comparisons. Compared to hydrocodone, tramadol increased the rate of all-cause SAEs in the ITT and PP analyses (ITT HR 1.40, 95%CLs, 1.10, 1.76; PP HR 1.34, 95%CLs, 1.03, 1.75), but rates of composite SAEs were not significant across comparisons. CONCLUSIONS Postoperative tramadol was associated with increased rates of all-cause SAEs, but not composite SAEs, compared to oxycodone and hydrocodone. Tramadol does not appear to have a superior safety profile and should not be preferentially prescribed to opioid-naïve older adults following THA/TKA.
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Affiliation(s)
- Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, 02912, USA.
| | - Francesca L Beaudoin
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, 02912, USA
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, 02912, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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McConeghy KW, Hur K, Dahabreh IJ, Jiang R, Pandey L, Gellad WF, Glassman P, Good CB, Miller DR, Zullo AR, Gravenstein S, Cunningham F. Early Mortality After the First Dose of COVID-19 Vaccination: A Target Trial Emulation. Clin Infect Dis 2024; 78:625-632. [PMID: 38319989 PMCID: PMC10954332 DOI: 10.1093/cid/ciad604] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Vaccine hesitancy persists alongside concerns about the safety of coronavirus disease 2019 (COVID-19) vaccines. We aimed to examine the effect of COVID-19 vaccination on risk of death among US veterans. METHODS We conducted a target trial emulation to estimate and compare risk of death up to 60 days under two COVID-19 vaccination strategies: vaccination within 7 days of enrollment versus no vaccination through follow-up. The study cohort included individuals aged ≥18 years enrolled in the Veterans Health Administration system and eligible to receive a COVID-19 vaccination according to guideline recommendations from 1 March 2021 through 1 July 2021. The outcomes of interest included deaths from any cause and excluding a COVID-19 diagnosis. Observations were cloned to both treatment strategies, censored, and weighted to estimate per-protocol effects. RESULTS We included 3 158 507 veterans. Under the vaccination strategy, 364 993 received vaccine within 7 days. At 60 days, there were 156 deaths per 100 000 veterans under the vaccination strategy versus 185 deaths under the no vaccination strategy, corresponding to an absolute risk difference of -25.9 (95% confidence limit [CL], -59.5 to 2.7) and relative risk of 0.86 (95% CL, .7 to 1.0). When those with a COVID-19 infection in the first 60 days were censored, the absolute risk difference was -20.6 (95% CL, -53.4 to 16.0) with a relative risk of 0.88 (95% CL, .7 to 1.1). CONCLUSIONS Vaccination against COVID-19 was associated with a lower but not statistically significantly different risk of death in the first 60 days. These results agree with prior scientific knowledge suggesting vaccination is safe with the potential for substantial health benefits.
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Affiliation(s)
- Kevin W McConeghy
- Center of Innovation Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Kwan Hur
- VA Center for Medication Safety, Department of Veterans Affairs, Chicago, Illinois, USA
| | - Issa J Dahabreh
- CAUSALab, Harvard T. H. Chan School of Public Health, Boston, Massachusett, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rong Jiang
- VA Center for Medication Safety, Department of Veterans Affairs, Chicago, Illinois, USA
| | - Lucy Pandey
- VA Center for Medication Safety, Department of Veterans Affairs, Chicago, Illinois, USA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Centers for High Value Health Care, and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, Pennsylvania, USA
| | - Peter Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington, DC, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Chester B Good
- VA Center for Medication Safety, Department of Veterans Affairs, Chicago, Illinois, USA
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Centers for High Value Health Care, and Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, Pennsylvania, USA
| | - Donald R Miller
- VA Center for Medication Safety, Department of Veterans Affairs, Chicago, Illinois, USA
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, Massachusetts, USA
| | - Andrew R Zullo
- Center of Innovation Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island, USA
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Stefan Gravenstein
- Center of Innovation Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Francesca Cunningham
- VA Center for Medication Safety, Department of Veterans Affairs, Chicago, Illinois, USA
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Berry SD, Hayes K, Lee Y, Zhang Y, Kim DH, Ko D, Kiel DP, Daielo L, Zhang T, Zullo AR. Fall risk and cardiovascular outcomes of first-line antihypertensive medications in nursing home residents. J Am Geriatr Soc 2024; 72:682-692. [PMID: 38051600 PMCID: PMC10947930 DOI: 10.1111/jgs.18702] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/19/2023] [Accepted: 10/29/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND Little evidence exists about the comparative effects of first-line antihypertensive medications (i.e., renin-angiotensin-aldosterone converting enzyme inhibitors (RAASi), amlodipine, or thiazide diuretics) in older adults with limited life expectancy. We compared the rates of injurious falls and short-term cardiovascular events between different first-line antihypertensive medication classes in adults receiving care in nursing homes (NH). METHODS This was a retrospective cohort of Medicare fee-for-service beneficiaries receiving care in NHs. Patients newly dispensed first-line antihypertensive medications were identified using Part D claims (2015-2018) and linked with clinical assessments (i.e., Minimum Data Set). Fall-related injuries (FRI), hip fractures, and major adverse cardiac events (MACE) outcomes were identified using hospitalization claims. Patients were followed from the date of antihypertensive dispensing until the occurrence of outcomes, death, disenrollment, or 6-month follow-up. Inverse-probability-of-treatment-weighted (IPTW) cause-specific hazards regression models were used to compare outcomes between patients who were new users of RAASi, amlodipine, or thiazides. RESULTS Our cohort included 16,504 antihypertensive users (RAASi, n = 9574; amlodipine, n = 5049; thiazide, n = 1881). Mean age was 83.5 years (± 8.2), 70.6% were female, and 17.2% were non-white race. During a mean follow-up of 5.3 months, 326 patients (2.0%) experienced an injurious fall, 1590 (9.6%) experienced MACE, and 2123 patients (12.9%) died. The intention-to-treat IPTW hazard ratio (HR) for injurious falls for amlodipine (vs RAASi) use was 0.85 (95% confidence interval (CI) 0.66-1.08) and for thiazides (vs RAASi) was 1.22 (95% CI 0.88-1.66). The rates of MACE were similar between those taking anti-hypertensive medications. Thiazides were discontinued more often than other classes; however, inferences were largely unchanged in as-treated analyses. Subgroup analyses were generally consistent. CONCLUSIONS Older adults with limited life expectancy experience similar rates of injurious falls and short-term cardiovascular events after initiating any of the first-line antihypertensive medications.
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Affiliation(s)
- Sarah D. Berry
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Roslindale, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Kaleen Hayes
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
| | - Yuan Zhang
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
| | - Dae H. Kim
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Roslindale, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Darae Ko
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Roslindale, Massachusetts
- Section of Cardiovascular Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Douglas P. Kiel
- Hebrew Senior Life, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Roslindale, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Lori Daielo
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
| | - Tingting Zhang
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice & Center for Gerontology, Brown University School of Public Health, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
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Tat DP, Zullo AR, Mor V, Hayes KN. Sliding Scale Insulin Use in Nursing Homes Before and After Onset of the COVID-19 Pandemic. J Am Med Dir Assoc 2024; 25:459-464. [PMID: 38307122 PMCID: PMC10923121 DOI: 10.1016/j.jamda.2024.01.004] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 02/04/2024]
Abstract
OBJECTIVE To characterize sliding-scale insulin (SSI) use in US nursing homes (NHs) before and after the COVID-19 pandemic. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS A total of 129,829 US NH residents on SSI (01/2018-06/2022) across 12 NH chains with a common electronic health record system. METHODS Among all residents with at least 1 administration of SSI documented in the electronic medication administration record, we described resident demographics, frequency of SSI monotherapy vs combination therapy with another diabetes medication, number of daily capillary blood glucose readings ("fingersticks"), and hypoglycemia (capillary blood glucose <70 mg/dL) and hyperglycemia after first SSI use. We used interrupted time series analysis (ITS) with segmented linear regression models to examine whether the monthly prevalence of SSI use changed at and after the onset of the COVID-19 pandemic (March 2020). RESULTS There were 129,829 unique NH residents with SSI use [51% women, average age 71.3 (SD 11.7) years]. Of these, 36% of residents received SSI monotherapy and 64% received SSI combination therapy. Residents on SSI received an average of 3.96 (SD 1.41) fingersticks per day. Overall, 26% of SSI users experienced a hypoglycemic event within 30 days of the first SSI dose. The ITS analysis identified a step decrease in the rate of SSI use following the onset of the COVID-19 pandemic (43 fewer SSI users per 1000 insulin users) but no change in overall trend over time from before the onset of the pandemic. CONCLUSIONS AND IMPLICATIONS SSI use and fingerstick burden are high in NH residents. Hypoglycemia occurred commonly among residents on SSI. Future research should compare the safety and effectiveness of SSI monotherapy vs other diabetes medication regimens to guide person-centered prescribing decisions in NHs.
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Affiliation(s)
- Darlene P Tat
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA
| | - Andrew R Zullo
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Vincent Mor
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Kaleen N Hayes
- Brown University School of Public Health, Center for Gerontology and Healthcare Research, Providence, RI, USA.
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Zhang T, Zullo AR, Hayes KKN, Kim DH, Lee Y, Daiello LA, Kiel DP, Berry SD. Use of Diabetes Medications before and after a Heart Failure-Related Hospitalization among Nursing Home Residents. J Am Med Dir Assoc 2024; 25:454-458. [PMID: 37553080 PMCID: PMC10839110 DOI: 10.1016/j.jamda.2023.06.033] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVES Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) offer cardiovascular benefits, whereas thiazolidinediones (TZDs) and sulfonylureas (SUs) increase cardiovascular risk. The objective of this study was to describe the use of SGLT-2is, GLP-1RAs, TZDs, and SUs before and after a heart failure (HF)-related hospitalization in nursing home (NH) residents with type 2 diabetes (T2D). DESIGN This was a cohort study using a 20% sample of Medicare claims linked with Minimum Data Set resident assessments. SETTING AND PARTICIPANTS The study population was long-stay NH residents with T2D and an HF-related hospitalization between January 1, 2013, and August 31, 2018. For individuals with multiple HF hospitalizations, 1 hospitalization was randomly selected. METHODS We ascertained diabetes medications using Medicare Part D claims during the 120 days before and after hospital discharge (or skilled nursing facility discharge, where applicable). We calculated (1) the proportion of study participants who received a medication class of interest during pre- and posthospitalization periods; (2) the proportion of continuous users; and (3) the proportion of posthospitalization users who were new users. RESULTS A total of 12,990 NH residents with T2D and an HF-related hospitalization were included (mean age 78 years, 66% female, 19% Black). Before hospitalization, 1.5% received TZDs, 14.1% received SUs, 1.2% received GLP-1RAs, and 0.3% received SGLT-2is. Among prehospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 49%, 62%, 60%, and 40% continued the medications, respectively. Among posthospitalization users of TZDs, SUs, GLP-1RAs, and SGLT-2is, 37%, 10%, 28%, and 11%, respectively, were new users. CONCLUSIONS Among NH residents with hospitalized HF, GLP-1RAs and SGLT-2is were seldom used. TZDs and SUs were still used by many residents with T2D after HF hospitalizations. IMPLEMENTATIONS Barriers may exist in the use of newer diabetes medications to prevent heart failure in NH residents with T2D, which warrants further studies in older adults with multimorbidity.
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Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Kaleen Kaley N Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Graduate, Department of Pharmaceutical Sciences, University of Toronto, Toronto, Canada
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Douglas P Kiel
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
| | - Sarah D Berry
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA
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Silva JBB, Riester MR, Zullo AR. Antibiotic Prescribing Patterns for Urinary Tract Infections and Pneumonia by Prescriber Type and Specialty in Nursing Home Care, 2016-2018. J Am Med Dir Assoc 2024:S1525-8610(24)00075-6. [PMID: 38428833 DOI: 10.1016/j.jamda.2024.01.019] [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: 08/07/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE To identify whether differences in antibiotic prescribing practices by prescriber type and specialization in nursing home (NH) care exist for urinary tract infection (UTI) and pneumonia. DESIGN Retrospective cohort. SETTING AND PARTICIPANTS This national study included antibiotic dispensings to traditional Medicare beneficiaries aged ≥65 years with UTI or pneumonia infections residing long-term (≥100 days) in US NHs between 2016 and 2018. METHODS Minimum Data Set assessment data were linked to Medicare data [Part D prescription drug, inpatient hospital (MedPAR), prescriber characteristics, and enrollment]. We compared antibiotic prescribing patterns by prescriber type [physician vs advanced practice practitioner (AP)] and NH specialization (≥90% vs <90% of all associated medication dispensings to NH residents). Antibiotic dispensing measures included the total number of dispensings and duration of therapy (median number of days supplied) by antibiotic class. RESULTS There were 264,735 antibiotic dispensings prescribed by 32,437 prescribers for 140,360 residents in 14,035 NHs. NH specialists were less likely to prescribe fluoroquinolones for UTI (22.9% NH specialist physician, 23.9% non-NH specialist physician, 21.3% NH specialist AP, 24.2% non-NH specialist AP), but more likely to prescribe fluoroquinolones for pneumonia (38.9%, 37.8%, 38.8%, 37.3%, respectively). Over time, NH specialists reduced fluoroquinolone prescribing for pneumonia to a greater extent than non-NH specialists. The duration of therapy was similar across prescriber groups for UTI, but longer among non-NH specialist APs for several antibiotic classes for pneumonia, including tetracyclines, glycopeptides and lipoglycopeptides, and metronidazole. CONCLUSIONS AND IMPLICATIONS There were differences in antibiotic prescribing patterns by prescriber type and specialization in NH care between 2016 and 2018. Understanding how antibiotic prescribing differs based on prescriber characteristics is essential to inform antibiotic stewardship efforts. Tailoring antibiotic stewardship efforts to prescribers by NH specialization is rational given differences in antibiotic prescribing patterns based on NH specialization.
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Affiliation(s)
- Joe B B Silva
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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Harris DA, Chachlani P, Hayes KN, McCarthy EP, Wen KJ, Deng Y, Zullo AR, Djibo DA, McMahill-Walraven CN, Smith-Ray RL, Gravenstein S, Mor V. COVID-19 and influenza vaccine co-administration among older U.S. adults. Am J Prev Med 2024:S0749-3797(24)00067-9. [PMID: 38401746 DOI: 10.1016/j.amepre.2024.02.013] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION Co-administering COVID-19 and influenza vaccines is recommended by public health authorities and intended to improve uptake and convenience; however, the extent of vaccine co-administration is largely unknown. Investigations into COVID-19 and influenza vaccine co-administration are needed to describe compliance with newer recommendations and to identify potential gaps in the implementation of co-administration. METHODS A descriptive, repeated cross-sectional study between September 1, 2021 to November 30, 2021 (Period 1) and September 1, 2022 to November 30, 2022 (Period 2) was conducted. This study included community-dwelling Medicare beneficiaries ≥ 66 years who received an mRNA COVID-19 booster vaccine in Periods 1 and 2. The outcome was an influenza vaccine administered on the same day as the COVID-19 vaccine. Adjusted ORs and 99% CIs were estimated using logistic regression to describe the association between beneficiaries' characteristics and vaccine co-administration. Statistical analysis was performed in 2023. RESULTS Among beneficiaries who received a COVID-19 vaccine, 78.8% in Period 1 (N=6,292,777) and 89.1% in Period 2 (N=4,757,501), received influenza vaccine at some point during the study period (i.e., before, after, or on the same day as their COVID-19 vaccine), though rates were lower in non-White and rural individuals. Vaccine co-administration increased from 11.1% to 36.5% between periods. Beneficiaries with dementia (aORPeriod 2=1.31; 99%CI=1.29-1.32) and in rural counties (aORPeriod 2=1.19; 99%CI=1.17-1.20) were more likely to receive co-administered vaccines, while those with cancer (aORPeriod 2=0.90; 99%CI=0.89-0.91) were less likely. CONCLUSIONS Among Medicare beneficiaries vaccinated against COVID-19, influenza vaccination was high, but co-administration of the two vaccines was low. Future work should explore which factors explain variation in the decision to receive co-administered vaccines.
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Affiliation(s)
- Daniel A Harris
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.
| | - Preeti Chachlani
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Kaleen N Hayes
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Katherine J Wen
- Department of Medicine, Health, and Society, Vanderbilt University, Nashville, TN, USA
| | - Yalin Deng
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Andrew R Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | | | | | - Renae L Smith-Ray
- Walgreens Center for Health and Wellbeing Research, Walgreen Company, Deerfield, IL
| | - Stefan Gravenstein
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI; Providence Medical Center Veterans Administration Research Service, Providence, RI
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI; Providence Medical Center Veterans Administration Research Service, Providence, RI
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8
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Riester MR, D'Amico AM, Khan MA, Joyce NR, Pfeiffer MR, Margolis SA, Ott BR, Curry AE, Bayer TA, Zullo AR. Changes in the burden of medications that may impair driving among older adults before and after a motor vehicle crash. J Am Geriatr Soc 2024; 72:444-455. [PMID: 37905738 PMCID: PMC10922040 DOI: 10.1111/jgs.18643] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Medications are one of the most easily modifiable risk factors for motor vehicle crashes (MVCs) among older adults, yet limited information exists on how the use of potentially driver-impairing (PDI) medications changes following an MVC. Therefore, we examined the number and types of PDI medication classes dispensed before and after an MVC. METHODS This observational study included Medicare fee-for-service beneficiaries aged ≥67 years who were involved in a police-reported MVC in New Jersey as a driver between 2008 and 2017. Analyses were conducted at the "person-crash" level because participants could be involved in more than one MVC. We examined the use of 36 PDI medication classes in the 120 days before and 120 days after MVC. We described the number and prevalence of PDI medication classes in the pre-MVC and post-MVC periods as well as the most common PDI medication classes started and stopped following the MVC. RESULTS Among 124,954 person-crashes, the mean (SD) age was 76.0 (6.5) years, 51.3% were female, and 83.9% were non-Hispanic White. The median (Q1 , Q3 ) number of PDI medication classes was 2 (1, 4) in both the pre-MVC and post-MVC periods. Overall, 20.3% had a net increase, 15.9% had a net decrease, and 63.8% had no net change in the number of PDI medication classes after MVC. Opioids, antihistamines, and thiazide diuretics were the top PDI medication classes stopped following MVC, at incidences of 6.2%, 2.1%, and 1.7%, respectively. The top medication classes started were opioids (8.3%), skeletal muscle relaxants (2.2%), and benzodiazepines (2.1%). CONCLUSIONS A majority of crash-involved older adults were exposed to multiple PDI medications before and after MVC. A greater proportion of person-crashes were associated with an increased rather than decreased number of PDI medications. The reasons why clinicians refrain from stopping PDI medications following an MVC remain to be elucidated.
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Affiliation(s)
- Melissa R Riester
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Adam M D'Amico
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Marzan A Khan
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Nina R Joyce
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Melissa R Pfeiffer
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Seth A Margolis
- Department of Neuropsychology, Rhode Island Hospital, Providence, Rhode Island, USA
- Department of Psychiatry & Human Behavior, Brown University, Providence, Rhode Island, USA
| | - Brian R Ott
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Allison E Curry
- Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas A Bayer
- Division of Geriatrics and Palliative Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Andrew R Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Health Care Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
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9
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Zullo AR, Riester MR, Goldberg EM, Cupp MA, Berry SD, Beaudoin FL. Long-Term Care Pharmacy Market Shares and Differences in Skilled Nursing Facilities Served. J Aging Soc Policy 2024; 36:104-117. [PMID: 36841755 PMCID: PMC10450092 DOI: 10.1080/08959420.2023.2182997] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 08/09/2022] [Indexed: 02/27/2023]
Abstract
Medications and pharmacy services are critical to post-acute care (PAC) in skilled nursing facilities (SNFs), yet little is known about the long-term care (LTC) pharmacies that provide them. We estimated the market shares of LTC pharmacies and how SNFs differed between pharmacies. This cross-sectional study used data from SNFs that provided PAC services in Rhode Island (RI) in 2019. We applied the parametric g-formula to compare SNF pharmacy-related deficiencies and medication use measures between LTC pharmacies while standardizing for SNF membership in a chain and number of beds. Among 75 SNFs, 68 (91%) were served by either Omnicare (n = 32, 43%) or PharMerica (n = 36, 48%), and 7 (9%) by other LTC pharmacies. After covariate adjustment, PharMerica SNFs had the lowest prevalences of any pharmacy-related deficiency (PharMerica, 63.2%; Omnicare, 80.2%; other LTC pharmacy, 69.1%) and antianxiety medication use (PharMerica, 9.7%; Omnicare, 13.6%; other LTC pharmacy, 13.5%), but estimates were imprecise. The RI market is highly concentrated between LTC pharmacies. If similarly high LTC pharmacy market concentration exists nationally, there is enormous promise for efficiently delivering interventions to improve medication management in SNFs. However, it may also present a risk of harm if policies do not maintain sufficient competition and innovation is stifled.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, 121 South Main Street, Providence, RI,
USA
- Department of Epidemiology, Brown University School of
Public Health, 121 South Main Street, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports,
Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Building 32,
Providence, RI, USA
- Department of Pharmacy, Rhode Island Hospital, 593 Eddy
Street, Rhode Island Hospital, Providence, RI, USA
| | - Melissa R. Riester
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, 121 South Main Street, Providence, RI,
USA
| | - Elizabeth M. Goldberg
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, 121 South Main Street, Providence, RI,
USA
- Department of Emergency Medicine, Rhode Island Hospital,
593 Eddy Street, Rhode Island Hospital, Providence, RI, USA
| | - Meghan A. Cupp
- Department of Epidemiology, Brown University School of
Public Health, 121 South Main Street, Providence, RI, USA
| | - Sarah D. Berry
- Department of Medicine, 330 Brookline Avenue, Beth Israel
Deaconess Medical Center, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife,
1200 Centre Street, Boston, MA
| | - Francesca L. Beaudoin
- Department of Health Services, Policy, and Practice, Brown
University School of Public Health, 121 South Main Street, Providence, RI,
USA
- Department of Epidemiology, Brown University School of
Public Health, 121 South Main Street, Providence, RI, USA
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10
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Riester MR, Douglas CM, Silva JB, Datta R, Zullo AR. Clinicians who primarily practice in nursing homes and outcomes among residents with urinary tract infection or pneumonia. Antimicrob Steward Healthc Epidemiol 2023; 3:e253. [PMID: 38178878 PMCID: PMC10762639 DOI: 10.1017/ash.2023.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
Objective Assess the association between clinicians who primarily practice in nursing homes (NHs) and 14-day resident outcomes following initial antibiotic dispensing for pneumonia or urinary tract infection (UTI). Design Retrospective cohort. Setting U.S. NHs. Participants NH residents aged ≥65 years who were prescribed antibiotics for pneumonia or UTI between 1 January 2016 and 30 November 2018. Methods Medicare fee-for-service claims were linked to Minimum Data Set data. Clinicians who primarily practiced in NHs prescribed ≥90% of Part D dispensings to NH residents. Outcomes included death, all-cause and infection-specific hospitalization, and subsequent antibiotic dispensing. Adjusted risk ratios were estimated using inverse-probability-of-treatment-weighted (IPTW) modified Poisson regression models adjusting for 53 covariates. Results The study population included 28,826 resident-years who were prescribed antibiotics for pneumonia and 106,354 resident-years who were prescribed antibiotics for UTI. Among the pneumonia group, clinicians who primarily practiced in NHs were associated with a greater risk of death (RR 1.3; 95%CLs 1.0, 1.6), lower risks of all-cause (RR 0.9; 95%CLs 0.8, 0.9) and infection-specific hospitalization (RR 0.8; 95%CLs 0.7, 0.9), and similar risk of subsequent antibiotic dispensing (RR 1.0; 95%CLs 1.0, 1.1) after IPTW. No meaningful associations were observed between clinicians who primarily practiced in NHs and outcomes among the UTI group. Conclusions Clinicians who primarily practiced in NHs were associated with a lower risk of hospitalization but greater risk of mortality for NH residents with pneumonia. Further examination is needed to better understand drivers of differences in infection-related outcomes based on clinicians' training and primary practice setting.
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Affiliation(s)
- Melissa R. Riester
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Cody M. Douglas
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Joe B.B. Silva
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew R. Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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11
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Hayes KN, Zhang T, Kim DH, Daiello LA, Lee Y, Kiel DP, Berry SD, Zullo AR. Benefits and Harms of Standard Versus Reduced-Dose Direct Oral Anticoagulant Therapy for Older Adults With Multiple Morbidities and Atrial Fibrillation. J Am Heart Assoc 2023; 12:e029865. [PMID: 37929769 PMCID: PMC10727413 DOI: 10.1161/jaha.122.029865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/28/2023] [Accepted: 08/04/2023] [Indexed: 11/07/2023]
Abstract
Background Dose reduction of direct oral anticoagulant (DOAC) medications is inconsistently applied to older adults with multiple morbidities, potentially due to perceived harms and unknown benefits of standard dosing. Methods and Results Using 2013 to 2017 US Medicare claims linked to Minimum Data Set records, we conducted a retrospective cohort study. We identified DOAC initiators (apixaban, dabigatran, rivaroxaban) aged ≥65 years with nonvalvular atrial fibrillation residing in a nursing home. We estimated inverse-probability of treatment weights for DOAC dose using propensity scores. We examined safety (hospitalization for major bleeding) and effectiveness outcomes (all-cause mortality, thrombosis [myocardial infarction, stroke, systemic embolism, venous thromboembolism]). We estimated hazard ratios (HRs) and 95% CIs using cause-specific hazard-regression models. Of 21 878 DOAC initiators, 48% received reduced dosing. The mean age of residents was 82.0 years, 66% were female, and 31% had moderate/severe cognitive impairment. After estimating inverse-probability of treatment weights, standard dosing was associated with a higher rate of bleeding (HR, 1.18 [95% CI, 1.03-1.37]; 9.4 versus 8.0 events per 100 person-years). Standard-dose therapy was associated with the highest rates of bleeding among those aged >80 years (9.1 versus 6.7 events per 100 person-years) and with a body mass index <30 kg/m2 (9.4 versus 7.4 events per 100 person-years). There was no association of dosing with mortality (HR, 0.99 [95% CI, 0.96-1.06]) or thrombotic events (HR, 1.16 [95% CI, 0.96-1.41]). Conclusions In this nationwide study of nursing home residents with nonvalvular atrial fibrillation, we found a higher rate of bleeding and little difference in effectiveness of standard versus reduced-dose DOAC treatment. Our results support the use of reduced-dose DOACs for many older adults with multiple morbidities.
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Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
- Graduate Department of Pharmaceutical SciencesUniversity of Toronto Leslie Dan Faculty of PharmacyTorontoONCanada
| | - Tingting Zhang
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLife and Harvard Medical SchoolBostonMA
- Division of Gerontology, Department of MedicineBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonMA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMA
| | - Lori A. Daiello
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
- Department of NeurologyWarren Alpert Medical School of Brown University and Alzheimer’s Disease and Memory Disorders Center At Rhode Island HospitalProvidenceRI
| | - Yoojin Lee
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
| | - Douglas P. Kiel
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLife and Harvard Medical SchoolBostonMA
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLife and Harvard Medical SchoolBostonMA
| | - Andrew R. Zullo
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRI
- Department of EpidemiologyBrown University School of Public HealthProvidenceRI
- Center of Innovation in Long‐Term Services and SupportsProvidence Veterans Affairs Medical CenterProvidenceRI
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12
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Gadbois EA, Meehan A, Uth R, Baier RR, Gravenstein S, Zullo AR, Kabler H, Loiacono MM, Bardenheier BH. Identifying strategies that promote staff and resident influenza and COVID-19 vaccination in nursing homes: Perspectives from nursing home staff. Geriatr Nurs 2023; 54:205-210. [PMID: 37844537 DOI: 10.1016/j.gerinurse.2023.09.006] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 10/18/2023]
Abstract
Resident and staff influenza and COVID-19 vaccination are critical components of infection prevention in nursing homes. Our study sought to characterize strategies that nursing home staff use to promote vaccination. Twenty-six telephone/videoconference interviews were conducted with administrators, directors of nursing, infection preventionists, and Minimum Data Set coordinators at 14 nursing homes across the US. Transcripts were analyzed using content analysis and a detailed audit trail was maintained. Staff described resident and staff influenza and COVID-19 vaccine hesitancy and confidence as well as varying approaches to promote vaccination. These included incentives, education efforts, and having a "vaccine champion" responsible for vaccine promotion. While many strategies had been in place prior to COVID-19 in support of improving influenza vaccination, participants reported implementing additional approaches to promote COVID-19 vaccination. Findings may inform future efforts to promote vaccination, which will be critical to mitigate the burden of influenza and COVID-19 in nursing homes.
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Affiliation(s)
- Emily A Gadbois
- Brown University School of Public Health, 121 S. Main St., Providence, RI 02903, United States.
| | - Amy Meehan
- Brown University School of Public Health, 121 S. Main St., Providence, RI 02903, United States
| | - Rebecca Uth
- Brown University School of Public Health, 121 S. Main St., Providence, RI 02903, United States
| | - Rosa R Baier
- Brown University School of Public Health, 121 S. Main St., Providence, RI 02903, United States
| | - Stefan Gravenstein
- Brown University School of Public Health, 121 S. Main St., Providence, RI 02903, United States; Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI 02903, United States; Providence Veterans Affairs Medical Center, 830 Chalkstone Ave., Providence, RI 02908, United States
| | - Andrew R Zullo
- Brown University School of Public Health, 121 S. Main St., Providence, RI 02903, United States; Providence Veterans Affairs Medical Center, 830 Chalkstone Ave., Providence, RI 02908, United States; Department of Pharmacy, Rhode Island Hospital, 593 Eddy St., Providence, RI 02903, United States
| | - Heidi Kabler
- Medical Affairs, Sanofi, 1 Discovery Dr., Swiftwater, PA 18370, United States
| | - Matthew M Loiacono
- Global Medical Evidence Generation, Sanofi, 1 Discovery Dr., Swiftwater, PA 18370, United States
| | - Barbara H Bardenheier
- Brown University School of Public Health, 121 S. Main St., Providence, RI 02903, United States; Westat, Inc., 1600 Research Blvd., Rockville, MD 20850, United States
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13
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Hayes KN, Harris DA, Zullo AR, Djibo DA, Smith-Ray RL, Taitel MS, Singh TG, McMahill-Walraven C, Chachlani P, Wen KJ, McCarthy EP, Gravenstein S, McCurdy S, Baird KE, Moran D, Fenson D, Deng Y, Mor V. Data resource profile: COVid VAXines effects on the aged (COVVAXAGE). Int J Popul Data Sci 2023; 8:2170. [PMID: 38425722 PMCID: PMC10900297 DOI: 10.23889/ijpds.v8i6.2170] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Background To improve the assessment of COVID-19 vaccine use, safety, and effectiveness in older adults and persons with complex multimorbidity, the COVid VAXines Effects on the Aged (COVVAXAGE) database was established by linking CVS Health and Walgreens pharmacy customers to Medicare claims. Methods We deterministically linked CVS Health and Walgreens customers who had a pharmacy dispensation/encounter paid for by Medicare to Medicare enrollment and claims records. Linked data include U.S. Medicare claims, Medicare enrollment files, and community pharmacy records. The data currently span 01/01/2016 to 08/31/2022. "Research-ready" files were created, with weekly indicators for vaccinations, censoring, death, enrollment, demographics, and comorbidities. Data are updated quarterly. Results As of November 2022, records for 27,086,723 CVS Health and 23,510,025 Walgreens unique customer IDs were identified for potential linkage. Approximately 91% of customers were matched to a Medicare beneficiary ID (95% for those aged 65 years or older). In the final linked cohort, there were 38,250,873 unique beneficiaries representing ~60% of the Medicare population. Among those alive and enrolled in Medicare as of January 1, 2020 (n = 33,721,568; average age = 73 years, 74% White, 51% Medicare Fee-for-Service, and 11% dual-eligible for Medicaid), the average follow-up time was 130 weeks. The cohort contains 16,021,055 beneficiaries with evidence a first COVID-19 vaccine dose. Data are stored on the secure Medicare & Medicaid Resource Information Center Health & Aging Data Enclave. Data access Investigators with funded or in-progress funding applications to the National Institute on Aging who are interested in learning more about the database should contact Dr Vincent Mor [Vincent_mor@brown.edu] and Dr Kaleen Hayes [kaley_hayes@brown.edu]. A data dictionary can be provided under reasonable request. Conclusions The COVVAXAGE cohort is a large and diverse cohort that can be used for the ongoing evaluation of COVID-19 vaccine use and other research questions relevant to the Medicare population.
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Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
| | - Daniel A. Harris
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
| | - Andrew R. Zullo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA, 02903
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA, 02903
| | - Djeneba Audrey Djibo
- CVS Health Clinical Trial Services, Safety, Surveillance & Collaboration, Blue Bell, PA, USA, 19422
| | - Renae L. Smith-Ray
- Walgreens Center for Health & Wellbeing Research, Walgreen Company, Deerfield, IL, USA, 60015
| | - Michael S. Taitel
- Walgreens Center for Health & Wellbeing Research, Walgreen Company, Deerfield, IL, USA, 60015
| | - Tanya G. Singh
- Walgreens Center for Health & Wellbeing Research, Walgreen Company, Deerfield, IL, USA, 60015
| | - Cheryl McMahill-Walraven
- CVS Health Clinical Trial Services, Safety, Surveillance & Collaboration, Blue Bell, PA, USA, 19422
| | - Preeti Chachlani
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
| | - Katherine J. Wen
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
- Department of Medicine, Health, and Society, Vanderbilt University, Nashville, TN, USA, 37240
| | - Ellen P. McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA, 02131
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA, 02215
| | - Stefan Gravenstein
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA, 02903
- Division of Geriatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, 02903
| | | | | | | | | | - Yalin Deng
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
| | - Vincent Mor
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA, 02903
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA, 02903
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14
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Gantenberg JR, McConeghy KW, Howe CJ, Steingrimsson J, van Aalst R, Chit A, Zullo AR. Predicting Seasonal Influenza Hospitalizations Using an Ensemble Super Learner: A Simulation Study. Am J Epidemiol 2023; 192:1688-1700. [PMID: 37147861 PMCID: PMC10558190 DOI: 10.1093/aje/kwad113] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 08/17/2022] [Accepted: 04/27/2023] [Indexed: 05/07/2023] Open
Abstract
Accurate forecasts can inform response to outbreaks. Most efforts in influenza forecasting have focused on predicting influenza-like activity, with fewer on influenza-related hospitalizations. We conducted a simulation study to evaluate a super learner's predictions of 3 seasonal measures of influenza hospitalizations in the United States: peak hospitalization rate, peak hospitalization week, and cumulative hospitalization rate. We trained an ensemble machine learning algorithm on 15,000 simulated hospitalization curves and generated weekly predictions. We compared the performance of the ensemble (weighted combination of predictions from multiple prediction algorithms), the best-performing individual prediction algorithm, and a naive prediction (median of a simulated outcome distribution). Ensemble predictions performed similarly to the naive predictions early in the season but consistently improved as the season progressed for all prediction targets. The best-performing prediction algorithm in each week typically had similar predictive accuracy compared with the ensemble, but the specific prediction algorithm selected varied by week. An ensemble super learner improved predictions of influenza-related hospitalizations, relative to a naive prediction. Future work should examine the super learner's performance using additional empirical data on influenza-related predictors (e.g., influenza-like illness). The algorithm should also be tailored to produce prospective probabilistic forecasts of selected prediction targets.
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Affiliation(s)
- Jason R Gantenberg
- Correspondence to Dr. Jason R. Gantenberg, Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI 02912 (e-mail: )
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15
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Berry SD, Hecker EJ, McConnell ES, Xue TM, Tsai T, Zullo AR, Colón-Emeric C. Nursing Home PRevention of Injury in DEmentia (NH PRIDE): A pilot study of a remote injury prevention service for NH residents. J Am Geriatr Soc 2023; 71:3267-3277. [PMID: 37596877 PMCID: PMC10592133 DOI: 10.1111/jgs.18564] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 07/20/2023] [Accepted: 08/02/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Medication optimization, including prescription of osteoporosis medications and deprescribing medications associated with falls, may reduce injurious falls. Our objective was to describe a remote, injury prevention service (NH PRIDE) designed to optimize medication use in nursing homes (NHs), and to describe its implementation outcomes in a pilot study. METHODS This was a non-randomized trial (pilot study) including NH staff and residents from five facilities. Long-stay residents at high-risk for injurious falls were identified using a validated risk calculator and staff referral. A remote team reviewed the electronic health record (EHR) and provided recommendations as Injury Prevention Plans (IPP). A research nurse served as a care coordinator focused on resident engagement and shared decision-making. Outcomes included implementation measures, as identified in the EHR, and surveys and interviews with staff. RESULTS Across five facilities, 274 residents were screened for eligibility, and 46 residents (16.8%) were enrolled. Most residents were female (73.9%) and had dementia (63.0%). An IPP was completed for 45 residents (97.8%). The nurse made a total of 93 deprescribing recommendations in 36 residents (80% of residents had one or more deprescribing recommendation; mean 2.2 recommendations/resident). Twenty of 45 residents (44.4%) had a recommendation for osteoporosis treatment. Among residents with recommendations, 21/36 (58.3%) had one or more deprescribing orders written and 6/20 (30.0%) had an osteoporosis medication prescribed. At 4 months, most medication changes persisted. Adverse side effects were rare. Staff members identified several areas for program refinement, including aligning recommendations with provider workflow and engaging consultant psychiatrists. CONCLUSIONS A remote injury prevention service is safe and feasible to enhance deprescribing and osteoporosis treatment in long-stay NH residents at risk for injury. Additional investigation is needed to determine if this model could reduce injurious falls when deployed across NH chains.
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Affiliation(s)
- Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, MA
- Beth Israel Deaconess Medical Center, Department of Medicine & Harvard Medical School, Boston, MA
| | - Emily J. Hecker
- Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, Durham, NC
| | - Eleanor S. McConnell
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
- Duke University School of Nursing, Durham, NC
| | - Tingzhong-Michelle Xue
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
- Duke University School of Nursing, Durham, NC
| | - Timothy Tsai
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, MA
| | - Andrew R. Zullo
- Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Cathleen Colón-Emeric
- Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, Durham, NC
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
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Silva JBB, Howe CJ, Jackson JW, Bardenheier BH, Riester MR, van Aalst R, Loiacono MM, Zullo AR. Geospatial Distribution of Racial Disparities in Influenza Vaccination in Nursing Homes. J Am Med Dir Assoc 2023:S1525-8610(23)00742-9. [PMID: 37739348 PMCID: PMC10950839 DOI: 10.1016/j.jamda.2023.08.018] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVES This study aimed to assess the distribution of racial disparities in influenza vaccination between White and Black short-stay and long-stay nursing home residents among states and hospital referral regions (HRRs). DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS We included short-stay and long-stay older adults residing in US nursing homes during influenza seasons between 2011 and 2018. Included residents were aged ≥65 years and enrolled in Traditional Medicare. Analyses were conducted using resident-seasons, whereby residents could contribute to one or more influenza seasons if they resided in a nursing home across multiple seasons. METHODS Our comparison of interest was marginalized vs privileged racial group membership measured as Black vs White race. We obtained influenza vaccination documentation from resident Minimum Data Set assessments from October 1 through June 30 of a particular influenza season. Nonparametric g-formula was used to estimate age- and sex-standardized disparities in vaccination, measured as the percentage point (pp) difference in the proportions of individuals vaccinated between Black and White nursing home residents within states and HRRs. RESULTS The study included 7,807,187 short-stay resident-seasons (89.7% White and 10.3% Black) in 14,889 nursing homes and 7,308,111 long-stay resident-seasons (86.7% White and 13.3% Black) in 14,885 nursing homes. Among states, the median age- and sex-standardized disparity between Black and White residents was 10.1 percentage points (pps) among short-stay residents and 5.3 pps among long-stay residents across seasons. Among HRRs, the median disparity was 8.6 pps among short-stay residents and 5.0 pps among long-stay residents across seasons. CONCLUSIONS AND IMPLICATIONS Our analysis revealed that the magnitudes of vaccination disparities varied substantially across states and HRRs, from no disparity in vaccination to disparities in excess of 25 pps. Local interventions and policies should be targeted to high-disparity geographic areas to increase vaccine uptake and promote health equity.
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Affiliation(s)
- Joe B B Silva
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Chanelle J Howe
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center for Epidemiologic Research, Brown University School of Public Health, Providence, RI, USA
| | - John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Mental Health, Johns Hopkins Bloomberg School of Public health, Baltimore, MD, USA
| | - Barbara H Bardenheier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Robertus van Aalst
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Modelling, Epidemiology, and Data Science, Sanofi, Lyon, France; Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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17
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Chambers LC, Hallowell BD, Zullo AR, Paiva TJ, Berk J, Gaither R, Hampson AJ, Beaudoin FL, Wightman RS. Buprenorphine Dose and Time to Discontinuation Among Patients With Opioid Use Disorder in the Era of Fentanyl. JAMA Netw Open 2023; 6:e2334540. [PMID: 37721749 PMCID: PMC10507490 DOI: 10.1001/jamanetworkopen.2023.34540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/11/2023] [Indexed: 09/19/2023] Open
Abstract
Importance Buprenorphine treatment for opioid use disorder (OUD) has more than doubled since 2009. However, current US Food and Drug Administration buprenorphine dosing guidelines are based on studies among people using heroin, prior to the emergence of fentanyl in the illicit drug supply. Objective To estimate the association between buprenorphine dose and time to treatment discontinuation during a period of widespread fentanyl availability. Design, Setting, and Participants This retrospective cohort study used statewide Rhode Island Prescription Drug Monitoring Program data. Participants were Rhode Island residents initiating buprenorphine treatment for OUD between October 1, 2016, and September 30, 2020. Data analysis was performed from December 9, 2022, to August 10, 2023. Exposure Daily dose of buprenorphine (16 mg and 24 mg) defined starting on the day of initiation based on total quantity and days' supply dispensed. Patients were censored on any dose change. Main Outcomes and Measures Buprenorphine treatment discontinuation in the 180 days following initiation, defined as a gap in treatment of more than 27 days based on prescription fill dates and days' supply. Kaplan-Meier and Cox regression survival analyses were conducted to estimate the association between buprenorphine dose and time to treatment discontinuation, controlling for potential informative censoring and measured potential confounders. Results Among 6499 patients initiating buprenorphine treatment for OUD, most were aged 25 to 44 years (57%; n = 3682), were male (61%; n = 3950), and had private (47%; n = 3025) or Medicaid (33%; n = 2153) insurance. More than half of patients were prescribed a daily dose of interest at initiation (16 mg: 50%; n = 3264; 24 mg: 10%; n = 668). In Kaplan-Meier analyses, 58% of patients discontinued buprenorphine treatment within 180 days (16 mg: 59% vs 24 mg: 53%; log-rank test P = .005). In Cox regression analyses, patients prescribed a dose of 16 mg had a greater risk of treatment discontinuation than those prescribed 24 mg (adjusted hazard ratio, 1.20; 95% CI, 1.06-1.37). Conclusions and Relevance In this cohort study of patients initiating buprenorphine treatment from 2016 to 2020, patients prescribed a 24 mg dose of buprenorphine remained in treatment longer than those prescribed 16 mg. The value of higher buprenorphine doses than currently recommended needs to be considered for improving retention in treatment.
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Affiliation(s)
- Laura C. Chambers
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | | | - Andrew R. Zullo
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Taylor J. Paiva
- Substance Use Epidemiology Program, Rhode Island Department of Health, Providence
| | - Justin Berk
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rachel Gaither
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Aidan J. Hampson
- Division of Therapeutics and Medical Consequences, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Francesca L. Beaudoin
- Department of Epidemiology, Brown University, Providence, Rhode Island
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rachel S. Wightman
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
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18
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Abdelmeseh V, Brown BR, Huynh JP, Zullo AR. Comparative cost savings of biosimilar and dose rounding utilization in oncology care. J Oncol Pharm Pract 2023; 29:1437-1442. [PMID: 36259235 PMCID: PMC10113396 DOI: 10.1177/10781552221134257] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The exponential rise in cancer costs has led many centers to utilize dose rounding to the nearest vial size when the difference in dose is ≤10% to decrease costs. The recent approval of several biosimilar products has presented another opportunity to mitigate the rising costs of oncology care. Scarce information exists about the expected cost savings of combining dose rounding strategies (DRS) with biosimilar use (BU). We therefore assessed the cost savings of combining DRS and BU. METHODS Electronic health record data for two health systems in Rhode Island were used to identify patients who received ≥1 of trastuzumab, trastuzumab-anns, bevacizumab, or bevacizumab-awwb from October 1, 2015 to September 1, 2020. Costs were estimated using Medicare drug pricing. Multivariable generalized estimating equations adjusting for age, gender, presence of metastases, dosing weight, and dose administered were used to compare costs per dose between the four exposure groups: DRS + BU, DRS only, BU only, and neither DRS or BU. RESULTS A total of 1156 patients were administered 15,145 doses of drug. After covariate adjustment, average savings per dose was greatest in the DRS + BU group (vs. the neither DRS nor BU group); $331 for trastuzumab and $497 for bevacizumab. CONCLUSIONS Combining dose rounding with biosimilar substitution for trastuzumab and bevacizumab resulted in significant cost savings per dose and should be implemented by healthcare systems.
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Affiliation(s)
- Verona Abdelmeseh
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI, USA
- Department of Pharmacy and Health Sciences, University of Rhode Island, Kingston, RI, USA
| | - Britny R Brown
- Department of Pharmacy and Health Sciences, University of Rhode Island, Kingston, RI, USA
- Department of Pharmacy, Care New England—Women and Infants Hospital, Providence, RI, USA
| | - Justin P Huynh
- Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI, USA
- Department of Pharmacy and Health Sciences, University of Rhode Island, Kingston, RI, USA
| | - Andrew R Zullo
- Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI, USA
- Departments of Health Services, Policy, and Practice and Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Sarri G, Liu W, Zabotka L, Freitag A, Claire R, Wangge G, Elvidge J, Dawoud D, Bennett D, Wen X, Li X, Rentsch CT, Uddin MJ, Ali MS, Gokhale M, Déruaz-Luyet A, Moga DC, Guo JJ, Zullo AR, Patorno E, Lin KJ. Prognostic Factors of COVID-19: An Umbrella Review Endorsed by the International Society for Pharmacoepidemiology. Clin Pharmacol Ther 2023; 114:604-613. [PMID: 37342987 DOI: 10.1002/cpt.2977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, the urgency for updated evidence to inform public health and clinical care placed systematic literature reviews (SLRs) at the cornerstone of research. We aimed to summarize evidence on prognostic factors for COVID-19 outcomes through published SLRs and to critically assess quality elements in the findings' interpretation. An umbrella review was conducted via electronic databases from January 2020 to April 2022. All SLRs (and meta-analyses) in English were considered. Data screening and extraction were conducted by two independent reviewers. AMSTAR 2 tool was used to assess SLR quality. The study was registered with PROSPERO (CRD4202232576). Out of 4,564 publications, 171 SLRs were included of which 3 were umbrella reviews. Our primary analysis included 35 SLRs published in 2022, which incorporated studies since the beginning of the pandemic. Consistent findings showed that, for adults, older age, obesity, heart disease, diabetes, and cancer were more strongly predictive of risk of hospitalization, intensive care unit admission, and mortality due to COVID-19. Male sex was associated with higher risk of short-term adverse outcomes, but female sex was associated with higher risk of long COVID. For children, socioeconomic determinants that may unravel COVID-19 disparities were rarely reported. This review highlights key prognostic factors of COVID-19, which can help clinicians and health officers identify high-risk groups for optimal care. Findings can also help optimize confounding adjustment and patient phenotyping in comparative effectiveness research. A living SLR approach may facilitate dissemination of new findings. This paper is endorsed by the International Society for Pharmacoepidemiology.
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Affiliation(s)
| | - Wei Liu
- Office of Surveillance and Epidemiology, CDER, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Luke Zabotka
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Ravinder Claire
- National Institute for Health and Care Excellence, London, UK
| | | | - Jamie Elvidge
- National Institute for Health and Care Excellence, London, UK
| | - Dalia Dawoud
- National Institute for Health and Care Excellence, London, UK
- Cairo University, Cairo, Egypt
| | - Dimitri Bennett
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xuerong Wen
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Xiaojuan Li
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - Christopher T Rentsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Md Jamal Uddin
- Department of Statistics, Shahjalal University of Science and Technology, Sylhet, Bangladesh
- Department of General Educational Development (GED), Daffodil International University, Dhaka, Bangladesh
| | - M Sanni Ali
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Daniela C Moga
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Jeff Jianfei Guo
- Division of Pharmacy Practice & Administrative Sciences, College of Pharmacy, University of Cincinnati, Cincinnati, Ohio, USA
| | - Andrew R Zullo
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Elisabetta Patorno
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kueiyu Joshua Lin
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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20
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Shireman TI, Fashaw-Walters S, Zhang T, Zullo AR, Gerlach LB, Coe AB, Daiello L, Lo D, Strominger J, Bynum JPW. Federal Nursing Home Policies on Antipsychotics had Similar Impacts by Race and Ethnicity for Residents With Dementia. J Am Med Dir Assoc 2023; 24:1283-1289.e4. [PMID: 37127131 PMCID: PMC10523862 DOI: 10.1016/j.jamda.2023.03.027] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/15/2023] [Accepted: 03/20/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups. DESIGN Retrospective, cross-sectional trends study. SETTING AND PARTICIPANTS National long-stay nursing home residents with dementia from 2011 to 2017. METHODS We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015). RESULTS Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = -0.8807, P = .0023) and the slope declined further after the Partnership (β = -0.6611, P < .0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P = .9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P = .4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = -0.1485, P = .0371), and after the Five Star Rating change, NHB residents (β = -0.0428, P = .0312) and Hispanic residents (β = -0.0834, P < .0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = -0.086, P = .0275) and post-Five Star Rating (β = -0.0775, P < .0001) declined faster among Hispanic residents. CONCLUSIONS AND IMPLICATIONS We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Shekinah Fashaw-Walters
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Lori Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie Strominger
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Julie P W Bynum
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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21
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Riester MR, Deng Y, Zullo AR. Antibiotic Prescribing in United States Nursing Homes, 2013-2017. J Infect Dis 2023; 228:464-468. [PMID: 37017192 PMCID: PMC10428191 DOI: 10.1093/infdis/jiad087] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/06/2023] Open
Abstract
In this national cohort of older adults residing long-term in US nursing homes between 2013 and 2017, we calculated period prevalence estimates for antibiotic prescribing, rates of prescribing, and days of therapy. Among 1 375 062 residents, 66.2% were prescribed at least 1 antibiotic during the nursing home stay. The most prevalent antibiotic classes were fluoroquinolones, sulfonamides and related agents, and first-generation cephalosporins. Levofloxacin, ciprofloxacin, and sulfamethoxazole-trimethoprim were the most prevalent antibiotics. These results can inform antibiotic stewardship interventions to reduce antibiotic overprescribing, improve appropriateness, and reduce related adverse outcomes in nursing homes.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Yalin Deng
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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22
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Hayes KN, Harris DA, Zullo AR, Chachlani P, Wen KJ, Smith-Ray RL, Djibo DA, McCarthy EP, Pralea A, Singh TG, McMahill-Walraven C, Taitel MS, Deng Y, Gravenstein S, Mor V. Racial and ethnic disparities in COVID-19 booster vaccination among U.S. older adults differ by geographic region and Medicare enrollment. Front Public Health 2023; 11:1243958. [PMID: 37637796 PMCID: PMC10456997 DOI: 10.3389/fpubh.2023.1243958] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction COVID-19 booster vaccines are highly effective at reducing severe illness and death from COVID-19. Research is needed to identify whether racial and ethnic disparities observed for the primary series of the COVID-19 vaccines persist for booster vaccinations and how those disparities may vary by other characteristics. We aimed to measure racial and ethnic differences in booster vaccine receipt among U.S. Medicare beneficiaries and characterize potential variation by demographic characteristics. Methods We conducted a cohort study using CVS Health and Walgreens pharmacy data linked to Medicare claims. We included community-dwelling Medicare beneficiaries aged ≥66 years who received two mRNA vaccine doses (BNT162b2 and mRNA-1273) as of 8/1/2021. We followed beneficiaries from 8/1/2021 until booster vaccine receipt, death, Medicare disenrollment, or end of follow-up (12/31/2021). Adjusted Poisson regression was used to estimate rate ratios (RRs) and 95% confidence intervals (CIs) comparing vaccine uptake between groups. Results We identified 11,339,103 eligible beneficiaries (mean age 76 years, 60% female, 78% White). Overall, 67% received a booster vaccine (White = 68.5%; Asian = 67.0%; Black = 57.0%; Hispanic = 53.3%). Compared to White individuals, Black (RR = 0.78 [95%CI = 0.78-0.78]) and Hispanic individuals (RR = 0.72 [95% = CI 0.72-0.72]) had lower rates of booster vaccination. Disparities varied by geographic region, urbanicity, and Medicare plan/Medicaid eligibility. The relative magnitude of disparities was lesser in areas where vaccine uptake was lower in White individuals. Discussion Racial and ethnic disparities in COVID-19 vaccination have persisted for booster vaccines. These findings highlight that interventions to improve vaccine uptake should be designed at the intersection of race and ethnicity and geographic location.
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Affiliation(s)
- Kaleen N. Hayes
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Daniel A. Harris
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Andrew R. Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, United States
| | - Preeti Chachlani
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Katherine J. Wen
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
- Department of Medicine, Health, and Society, Vanderbilt University, Nashville, TN, United States
| | - Renae L. Smith-Ray
- Walgreens Center for Health and Wellbeing Research, Walgreen Company, Deerfield, IL, United States
| | | | - Ellen P. McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Alexander Pralea
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
| | - Tanya G. Singh
- Walgreens Center for Health and Wellbeing Research, Walgreen Company, Deerfield, IL, United States
| | | | - Michael S. Taitel
- Walgreens Center for Health and Wellbeing Research, Walgreen Company, Deerfield, IL, United States
| | - Yalin Deng
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Stefan Gravenstein
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, United States
- Division of Geriatrics, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, United States
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, United States
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23
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Hayes KN, Berry SD, Munshi MN, Zullo AR. Adoption of sodium-glucose cotransporter-2 inhibitors among prescribers caring for nursing home residents. J Am Geriatr Soc 2023; 71:2585-2592. [PMID: 37078149 PMCID: PMC10528819 DOI: 10.1111/jgs.18360] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/17/2023] [Accepted: 03/09/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitor (SGLT2I) use has increased among community-dwelling populations, but little is known about how clinicians have prescribed them for US nursing home (NH) residents. We described the adoption of SGLT2Is by prescribers caring for long-stay NH residents by clinician specialty and over time, compared with sulfonylureas, an older diabetes medication class. METHODS We conducted a retrospective cohort study of prescribers of SGLT2Is and sulfonylureas for all long-stay US NH residents aged 65 years or older (2017-2019). Using 100% of Medicare Part D claims linked to prescriber characteristics data, we identified all dispensings of SGLT2Is and sulfonylureas for long-stay NH residents and their associated prescribers. We described the distribution of prescriber specialties for each drug class over time as well as the number of NH residents prescribed SGLT2s versus sulfonylureas. We estimated the proportions of prescribers who prescribed both drug classes versus only sulfonylureas or only SGLT2Is. RESULTS We identified 36,427 unique prescribers (SGLT2I: N = 5811; sulfonylureas: N = 35,443) for 117,667 NH residents between 2017 and 2019. For both classes, family medicine and internal medicine physicians accounted for most prescriptions (75%-81%). Most clinicians (87%) prescribed only sulfonylureas, 2% prescribed SGLT2Is only, and 11% prescribed both. Geriatricians were least likely to prescribe only SGLT2Is. We observed an increase in the number of residents with SGLT2I use from n = 2344 in 2017 to n = 5748 in 2019. CONCLUSIONS Among NH residents, most clinicians have not incorporated SGLT2Is into their prescribing for diabetes, but the extent of use is increasing. Family medicine and internal medicine physicians prescribed the majority of diabetes medications for NH residents, and geriatricians were the least likely to prescribe only SGLT2Is. Future research should explore provider concerns regarding SGLT2I prescribing, particularly adverse events.
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Affiliation(s)
- Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Graduate Department of Pharmaceutical Sciences, University of Toronto Leslie Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Medha N. Munshi
- Harvard Medical School, Boston, Massachusetts, USA
- Joslin Diabetes Center, 1 Joslin Place, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
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Zhang T, Zullo AR, James HO, Lee Y, Taylor DCA, Daiello LA. The Burden and Treatment of Chronic Constipation Among US Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1247-1252.e5. [PMID: 37308090 PMCID: PMC10642798 DOI: 10.1016/j.jamda.2023.05.006] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To evaluate the burden of chronic constipation (CC) and the use of drugs to treat constipation (DTC) in 2 complementary data sources. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS US nursing home residents aged ≥65 years with CC. METHODS We conducted 2 retrospective cohort studies in parallel using (1) 2016 electronic health record (EHR) data from 126 nursing homes and (2) 2014-2016 Medicare claims, each linked with the Minimum Data Set (MDS). CC was defined as (1) the MDS constipation indicator and/or (2) chronic DTC use. We described the prevalence and incidence rate of CC and the use of DTC. RESULTS In the EHR cohort, we identified 25,739 residents (71.8%) with CC during 2016. Among residents with prevalent CC, 37% received a DTC, with an average duration of use of 19 days per resident-month during follow-up. The most frequently prescribed DTC classes included osmotic (22.6%), stimulant (20.9%), and emollient (17.9%) laxatives. In the Medicare cohort, a total of 245,578 residents (37.5%) had CC. Among residents with prevalent CC, 59% received a DTC and slightly more than half (55%) were prescribed an osmotic laxative. Duration of use was shorter (10 days per resident-month) in the Medicare (vs EHR) cohort. CONCLUSIONS AND IMPLICATIONS The burden of CC is high among nursing home residents. The differences in the estimates between the EHR and Medicare data confirm the importance of using secondary data sources that include over-the-counter drugs and other treatments unobservable in Medicare Part D claims to assess the burden of CC and DTC use in this population.
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Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, RI, USA
| | - Hannah O James
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | | | - Lori A Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
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Harris DA, Hayes KN, Zullo AR, Mor V, Chachlani P, Deng Y, McCarthy EP, Djibo DA, McMahill-Walraven CN, Gravenstein S. Comparative Risks of Potential Adverse Events Following COVID-19 mRNA Vaccination Among Older US Adults. JAMA Netw Open 2023; 6:e2326852. [PMID: 37531110 PMCID: PMC10398407 DOI: 10.1001/jamanetworkopen.2023.26852] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/21/2023] [Indexed: 08/03/2023] Open
Abstract
Importance Head-to-head safety comparisons of the mRNA vaccines for SARS-CoV-2 are needed for decision making; however, current evidence generalizes poorly to older adults, lacks sufficient adjustment, and inadequately captures events shortly after vaccination. Additionally, no studies to date have explored potential variation in comparative vaccine safety across subgroups with frailty or an increased risk of adverse events, information that would be useful for tailoring clinical decisions. Objective To compare the risk of adverse events between mRNA vaccines for COVID-19 (mRNA-1273 and BNT162b2) overall, by frailty level, and by prior history of the adverse events of interest. Design, Setting, and Participants This retrospective cohort study was conducted between December 11, 2020, and July 11, 2021, with 28 days of follow-up following the week of vaccination. A novel linked database of community pharmacy and Medicare claims data was used, representing more than 50% of the US Medicare population. Community-dwelling, fee-for-service beneficiaries aged 66 years or older who received mRNA-1273 vs BNT162b2 as their first COVID-19 vaccine were identified. Data analysis began on October 18, 2022. Exposure Dose 1 of mRNA-1273 vs BNT162b2 vaccine. Main Outcomes and Measures Twelve potential adverse events (eg, pulmonary embolism, thrombocytopenia purpura, and myocarditis) were assessed individually. Frailty was measured using a claims-based frailty index, with beneficiaries being categorized as nonfrail, prefrail, and frail. The risk of diagnosed COVID-19 was assessed as a secondary outcome. Generalized linear models estimated covariate-adjusted risk ratios (RRs) and risk differences (RDs) with 95% CIs. Results This study included 6 388 196 eligible individuals who received the mRNA-1273 or BNT162b2 vaccine. Their mean (SD) age was 76.3 (7.5) years, 59.4% were women, and 86.5% were White. A total of 38.1% of individuals were categorized as prefrail and 6.0% as frail. The risk of all outcomes was low in both vaccine groups. In adjusted models, the mRNA-1273 vaccine was associated with a lower risk of pulmonary embolism (RR, 0.96 [95% CI, 0.93-1.00]; RD, 9 [95% CI, 1-16] events per 100 000 persons) and other adverse events in subgroup analyses (eg, 11.0% lower risk of thrombocytopenia purpura among individuals categorized as nonfrail). The mRNA-1273 vaccine was also associated with a lower risk of diagnosed COVID-19 (RR, 0.86 [95% CI, 0.83-0.87]), a benefit that was attenuated by frailty level (frail: RR, 0.94 [95% CI, 0.89-0.99]). Conclusions and Relevance In this cohort study of older US adults, the mRNA-1273 vaccine was associated with a slightly lower risk of several adverse events compared with BNT162b2, possibly due to greater protection against COVID-19. Future research should seek to formally disentangle differences in vaccine safety and effectiveness and consider the role of frailty in assessments of COVID-19 vaccine performance.
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Affiliation(s)
- Daniel A. Harris
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Kaleen N. Hayes
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Andrew R. Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence Medical Center Veterans Administration Research Service, Providence, Rhode Island
| | - Preeti Chachlani
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Yalin Deng
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Ellen P. McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Stefan Gravenstein
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
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Riester MR, Beaudoin FL, Joshi R, Hayes KN, Cupp MA, Berry SD, Zullo AR. Evaluation of post-acute care and one-year outcomes among Medicare beneficiaries with hip fractures: a retrospective cohort study. BMC Med 2023; 21:232. [PMID: 37400841 DOI: 10.1186/s12916-023-02958-9] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture. METHODS This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates. RESULTS Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates. CONCLUSIONS In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA.
| | - Francesca L Beaudoin
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Richa Joshi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
| | - Kaleen N Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Graduate Department of Pharmaceutical Sciences, Faculty of Pharmacy, University of Toronto Leslie Dan, Toronto, ON, Canada
| | - Meghan A Cupp
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 200 Dyer Street, Box 2013, Providence, RI, 02912, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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Cupp MA, Beaudoin FL, Hayes KN, Riester MR, Berry SD, Joshi R, Zullo AR. Post-Acute Care Setting After Hip Fracture Hospitalization and Subsequent Opioid Use in Older Adults. J Am Med Dir Assoc 2023; 24:971-977.e4. [PMID: 37080246 PMCID: PMC10293035 DOI: 10.1016/j.jamda.2023.03.012] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Pain management in post-acute care (PAC) requires careful balance, with both opioid use and inadequate pain treatment linked to poor outcomes. We describe opioid use among older adults following discharge from PAC for hip fracture in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs). DESIGN Retrospective cohort. SETTING AND PARTICIPANTS Medicare beneficiaries with Medicare Provider Analysis (MedPAR) claims, aged 66 years and older with a hip fracture hospitalization between 2012 and 2018 followed by PAC in SNFs or IRFs and then discharge to the community. METHODS Individuals were followed from PAC discharge for up to 1 year to assess opioid use. Covariate-standardized risk ratios (RR) and risk differences (RD) for opioid use within 7 days of PAC discharge were estimated via parametric g-formula with modified Poisson regression, and hazard ratios (HRs) for any post-PAC opioid use and long-term opioid use via Fine-Gray sub-distribution hazards regression. RESULTS Of 101,021 individuals, 80% (n = 80,495) were discharged from SNFs and 20% (n = 20,526) from IRFs. Opioids were dispensed to 50,433 patients (50%) overall and the 1-year cumulative incidence was notably higher in IRF (68%) than SNF (46%) patients. The adjusted risk of discharge from PAC with an opioid was 41% lower after SNFs versus IRFs [RR: 0.59; 95% confidence limits (CLs): 0.57-0.61; and RD: -0.16; 95% CLs: -0.17 to -0.15]. The adjusted rate of any opioid use in the year after PAC discharge was 44% lower (HR: 0.56; 95% CLs: 0.54-0.57) and of long-term opioid use was 17% lower (HR: 0.83; 95% CLs: 0.80-0.87) after SNFs versus IRFs. CONCLUSIONS AND IMPLICATIONS Opioid use is highly prevalent upon discharge from PAC after hip fracture, with lower use after SNF versus IRF care. Future research should assess the benefits and harms of post-PAC opioid prescribing and whether care practices during PAC can be improved to optimize long-term opioid use.
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Affiliation(s)
- Meghan A Cupp
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Francesca L Beaudoin
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kaleen N Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Richa Joshi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Pharmacy, Rhode Island Hospital, Providence, RI, USA
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Duprey MS, Zullo AR, Gouskova NA, Lee Y, Capuano A, Kiel DP, Daiello LA, Kim DH, Berry SD. Development and validation of the fall-related injury risk in nursing homes (INJURE-NH) prediction tool. J Am Geriatr Soc 2023; 71:1851-1860. [PMID: 36883262 PMCID: PMC10258142 DOI: 10.1111/jgs.18277] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/21/2022] [Accepted: 01/15/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Existing models to predict fall-related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents. METHODS Retrospective cohort study of long-stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub-distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6-month and 2-year follow-up. Discrimination was evaluated via C-statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine-Gray model. Model performance was repeated in the validation sample. RESULTS Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow-up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2-year prediction model was good (C-index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6-month model were similar (C-index = 0.71). In the clinical tool to predict 2-year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14-2.41) and a history of non-hip fracture (HR 2.02; 95% CI 1.94-2.12). Performance results were similar in the validation sample. CONCLUSIONS We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies.
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Affiliation(s)
- Matthew S. Duprey
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40536
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
- Department of Pharmacy, Lifespan Rhode Island Hospital, Providence, RI 02903
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Natalia A. Gouskova
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
| | - Alyssa Capuano
- Department of Pharmacy, Lifespan Rhode Island Hospital, Providence, RI 02903
| | - Douglas P. Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215
| | - Lori A. Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI 02912
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, MA 02131
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215
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Zhang Y, Hayes KN, Riester MR, Silva JBB, Cupp MA, Lee Y, Zullo AR. Trends in COVID-19-related Medication Use in US Nursing Homes, 2018-2022. J Am Med Dir Assoc 2023:S1525-8610(23)00476-0. [PMID: 37336494 PMCID: PMC10209440 DOI: 10.1016/j.jamda.2023.05.013] [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: 02/03/2023] [Revised: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Little is known about how COVID-19 treatment patterns have evolved over time in nursing homes (NHs) despite the devastating effects of COVID-19 in this setting. The aim was to describe changes in COVID-19-related medication use over time among NH residents in the United States. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS This study used electronic health records (EHR) from 11 different US NH corporations between January 1, 2018, and March 31, 2022. METHODS The use of medications approved for COVID-19-related conditions or known to be used off-label for COVID-19 during the study period is identified. We described trends in the use of each drug and combined use per 1000 NH residents over calendar time (quarters [Q]). RESULTS A total of 59,022 unique residents with the use of an eligible medication were identified. Hydroxychloroquine use sharply increased from 9.8 in 2020Q1 to 30.2 orders per 1000 individuals in 2020Q2. Dexamethasone use increased sharply from 14.8 in 2020Q2 to a peak of 121.9 orders per 1000 individuals in 2020Q4. Azithromycin use increased from 44.1 in 2019Q3 to a peak of 99.9 orders per 1000 individuals in 2020Q4, with a drop in 2020Q3 of 51.3 per 1000 individuals in 2020Q3. Concurrent use of azithromycin and hydroxychloroquine increased sharply from 0.3 in 2020Q1 to 10.6 orders per 1000 residents in 2020Q2 and then drastically decreased to 0.6 per 1000 residents in 2020Q3. Concurrent use of dexamethasone and azithromycin rose considerably from 0.7 in 2020Q2 to 28.2 orders per 1000 residents in 2020Q4. CONCLUSIONS AND IMPLICATIONS As in other settings, COVID-19-related medication use in NHs appears to have changed in response to the shifting evidence base and availability of medications during the pandemic. Providers should continue to diligently modify their prescribing as new evidence accrues.
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Affiliation(s)
- Yuan Zhang
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Kaleen N Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Graduate Department of Pharmaceutical Sciences, University of Toronto, Toronto, Canada
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Joe B B Silva
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Meghan A Cupp
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, RI, USA
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Datta R, Pirruccio G, Fried TR, O’Leary JR, Zullo AR, Cohen A. Antimicrobial resistance in Escherichia coli and Klebsiella pneumoniae urine isolates from a national sample of home-based primary care patients with dementia. Infect Control Hosp Epidemiol 2023; 44:1-4. [PMID: 37211919 PMCID: PMC10663380 DOI: 10.1017/ice.2023.98] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Annual prevalences of antimicrobial resistance among urine isolates (3,913 Escherichia coli isolates and 1,736 Klebsiella pneumoniae isolates) from home-based primary care patients with dementia were high between 2014 and 2018 (ciprofloxacin, 18%-23% and 5%-7%, respectively; multidrug resistance, 9%-11% and 5%-6%, respectively). Multidrug resistance varied by region. Additional studies of antimicrobial resistance in home-care settings are needed.
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Affiliation(s)
- Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Gabrielle Pirruccio
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Terri R. Fried
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John R. O’Leary
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew R. Zullo
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Andrew Cohen
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Silva JBB, Howe CJ, Jackson JW, Riester MR, Bardenheier BH, Xu L, Puckrein G, van Aalst R, Loiacono MM, Zullo AR. Geographic Variation in Racial Disparities in Receipt of High-Dose Influenza Vaccine Among US Older Adults. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01628-z. [PMID: 37184814 PMCID: PMC10184628 DOI: 10.1007/s40615-023-01628-z] [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: 02/12/2023] [Revised: 04/29/2023] [Accepted: 04/30/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Racial disparities in receipt of high-dose influenza vaccine (HDV) have been documented nationally, but whether small-area geographic variation in such disparities exists remains unknown. We assessed the distribution of disparities in HDV receipt between Black and White traditional Medicare beneficiaries vaccinated against influenza within states and hospital referral regions (HRRs). METHODS We conducted a nationally representative retrospective cohort study of 11,768,724 community-dwelling traditional Medicare beneficiaries vaccinated against influenza during the 2015-2016 influenza season (94.3% White and 5.7% Black). Our comparison was marginalized versus privileged racial group measured as Black versus White race. Vaccination and type of vaccine were obtained from Medicare Carrier and Outpatient files. Differences in the proportions of individuals who received HDV between Black and White beneficiaries within states and HRRs were used to measure age- and sex-standardized disparities in HDV receipt. We restricted to states and HRRs with ≥ 100 beneficiaries per age-sex strata per racial group. RESULTS We detected a national disparity in HDV receipt of 12.8 percentage points (pps). At the state level, the median standardized HDV receipt disparity was 10.7 pps (minimum, maximum: 2.9, 25.6; n = 30 states). The median standardized HDV receipt disparity among HRRs was 11.6 pps (minimum, maximum: 0.4, 24.7; n = 54 HRRs). CONCLUSION Black beneficiaries were less likely to receive HDV compared to White beneficiaries in almost every state and HRR in our analysis. The magnitudes of disparities varied substantially across states and HRRs. Local interventions and policies are needed to target geographic areas with the largest disparities to address these inequities.
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Affiliation(s)
- Joe B B Silva
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Chanelle J Howe
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center for Epidemiologic Research, Brown University School of Public Health, Providence, RI, USA
| | - John W Jackson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Barbara H Bardenheier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Westat LLC, Rockville, MD, USA
| | - Liou Xu
- National Minority Quality Forum, Washington, DC, USA
| | - Gary Puckrein
- National Minority Quality Forum, Washington, DC, USA
| | - Robertus van Aalst
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI, USA
- Department of Modelling, Epidemiology, and Data Science, Sanofi, Lyon, France
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
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Zhang T, Thomas KS, Zullo AR, Coe AB, Gerlach LB, Daiello LA, Varma H, Lo D, Joshi R, Bynum JPW, Shireman TI. State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia. J Am Med Dir Assoc 2023; 24:555-558.e1. [PMID: 36841263 PMCID: PMC10089770 DOI: 10.1016/j.jamda.2023.01.014] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/19/2022] [Accepted: 01/18/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia. DESIGN This was an observational study using 20% sample of national Medicare data in 2017. SETTING AND PARTICIPANTS The study cohort included Medicare beneficiaries with dementia aged 65 years or older who resided in larger (≥25-bed) ALs in 2017. METHODS The study outcome was the percentage of eligible AL person-months in which antipsychotics were prescribed for each state. We used a random intercept linear regression model to shrink estimates toward the overall mean use of antipsychotics addressing unstable estimates due to small sample sizes in some states. RESULTS A total of 20,867 AL residents with dementia were included in the analysis, contributing to 194,718 person-months of observation. On average, AL residents with dementia were prescribed antipsychotics during 12.6% of their person-months. This rate varied significantly by state, with a low of 7.8% (95% CI 5.9%-10.3%) for Hawaii to a high of 20.5% (95% CI 16.4%-25.3%) for Wyoming. CONCLUSIONS AND IMPLICATIONS We observed significant state variation in the prescribing of antipsychotics among AL residents with dementia using national data. These variations may reflect differences in state regulations regarding the care for AL residents with dementia and suggest the need for further investigation to ensure high quality of care.
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Affiliation(s)
- Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Hiren Varma
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Richa Joshi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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Zullo AR, Riester MR, Hayes KN, Munshi MN, Berry SD. Comparative safety of sulfonylureas among U.S. nursing home residents. J Am Geriatr Soc 2023; 71:1047-1057. [PMID: 36495141 PMCID: PMC10089954 DOI: 10.1111/jgs.18160] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/23/2022] [Accepted: 10/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The comparative safety of sulfonylureas (SUs) in nursing home (NH) residents remains understudied despite widespread use. We compared the effects of three SU medications and initial SU doses on adverse glycemic and cardiovascular events among NH residents. METHODS This national retrospective cohort study linked Medicare claims with Minimum Data Set 2.0 assessments for long-stay NH residents aged ≥65 years between January 2008 and September 2010. Exposures were the SU medication initiated (glimepiride, glipizide, or glyburide) and doses (standard or reduced). One-year outcomes were hospitalizations or emergency department visits for severe hypoglycemia, heart failure (HF), stroke, and acute myocardial infarction (AMI). After the inverse probability of treatment and inverse probability of censoring by death weighting, we estimated hazard ratios (HR) using Cox regression models with robust 95% confidence intervals (CI). RESULTS The cohort (N = 6821) included 3698 new glipizide, 1754 glimepiride, and 1369 glyburide users. Overall, the mean (standard deviation) age was 81.4 (8.2) years, 4816 (70.6%) were female, and 5164 (75.7%) were White non-Hispanic residents. The rates of severe hypoglycemia were 30.3 (95% CI 22.3-40.1), 49.0 (95% CI 34.5-67.5), and 35.9 (95% CI 22.2-54.9) events per 1000 person-years among new glipizide, glimepiride, and glyburide users, respectively (glimepiride versus glipizide HR 1.6, 95% CI 1.0-2.4, p = 0.04; glyburide versus glipizide HR 1.2, 95% CI 0.7-1.9, p = 0.59). The rates of severe hypoglycemia were 27.1 (95% CI 18.6-38.0) and 42.8 (95% CI 33.6-53.8) events per 1000 person-years among new users of reduced and standard SU doses, respectively (HR 2.2, 95% CI 1.4-3.5, p < 0.01). Rates of HF, stroke, and AMI were similar between medications and doses. CONCLUSIONS Among long-stay NH residents, new use of glimepiride and standard SU doses resulted in higher rates of severe hypoglycemic events. Cardiovascular outcomes may not be affected by the choice of SU medication or dose.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI, USA
| | - Melissa R. Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Graduate Department of Pharmaceutical Sciences, University of Toronto Leslie Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Medha N. Munshi
- Joslin Diabetes Center, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah D. Berry
- Beth Israel Deaconess Medical Center, Boston, MA, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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Goyal P, Zullo AR, Gladders B, Onyebeke C, Kwak MJ, Allen LA, Levitan EB, Safford MM, Gilstrap L. Real-world safety of neurohormonal antagonist initiation among older adults following a heart failure hospitalization. ESC Heart Fail 2023; 10:1623-1634. [PMID: 36807850 DOI: 10.1002/ehf2.14317] [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: 08/08/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023] Open
Abstract
AIMS To optimize guideline-directed medical therapy for heart failure, patients may require the initiation of multiple neurohormonal antagonists (NHAs) during and following hospitalization. The safety of this approach for older adults is not well established. METHODS AND RESULTS We conducted an observational cohort study of 207 223 Medicare beneficiaries discharged home following a hospitalization for heart failure with reduced ejection fraction (HFrEF) (2008-2015). We performed Cox proportional hazards regression to examine the association between the count of NHAs initiated within 90 days of hospital discharge (as a time-varying exposure) and all-cause mortality, all-cause rehospitalization, and fall-related adverse events over the 90 day period following hospitalization. We calculated inverse probability-weighted hazard ratios (IPW-HRs) with 95% confidence intervals (CIs) comparing initiation of 1, 2, or 3 NHAs vs. 0. The IPW-HRs for mortality were 0.80 [95% CI (0.78-0.83)] for 1 NHA, 0.70 [95% CI (0.66-0.75)] for 2, and 0.94 [95% CI (0.83-1.06)] for 3. The IPW-HRs for readmission were 0.95 [95% CI (0.93-0.96)] for 1 NHA, 0.89 [95% CI (0.86-0.91)] for 2, and 0.96 [95% CI (0.90-1.02)] for 3. The IPW-HRs for fall-related adverse events were 1.13 [95% CI (1.10-1.15)] for 1 NHA, 1.25 [95% CI (1.21-1.30)] for 2, and 1.64 [95% CI (1.54-1.76)] for 3. CONCLUSIONS Initiating 1-2 NHAs among older adults within 90 days of HFrEF hospitalization was associated with lower mortality and lower readmission. However, initiating 3 NHAs was not associated with reduced mortality or readmission and was associated with a significant risk for fall-related adverse events.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, RI, USA
| | - Barbara Gladders
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Chukwuma Onyebeke
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Min Ji Kwak
- Department of Internal Medicine, McGovern Medical School, Houston, TX, USA
| | - Larry A Allen
- Division of Cardiology, University of Colorado Schools of Medicine, Aurora, CO, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY, 10063, USA
| | - Lauren Gilstrap
- The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH, USA
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Riester MR, Zullo AR. Prediction tool Development and Implementation in pharmacy praCTice (PreDICT) proposed guidance. Am J Health Syst Pharm 2023; 80:111-123. [PMID: 36242567 DOI: 10.1093/ajhp/zxac298] [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: 10/13/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Proposed guidance is presented for Prediction tool Development and Implementation in pharmacy praCTice (PreDICT). This guidance aims to assist pharmacists and their collaborators with planning, developing, and implementing custom risk prediction tools for use by pharmacists in their own health systems or practice settings. We aimed to describe general considerations that would be relevant to most prediction tools designed for use in health systems or other pharmacy practice settings. SUMMARY The PreDICT proposed guidance is organized into 3 sequential phases: (1) planning, (2) development and validation, and (3) testing and refining prediction tools for real-world use. Each phase is accompanied by a checklist of considerations designed to be used by pharmacists or their trainees (eg, residents) during the planning or conduct of a prediction tool project. Commentary and a worked example are also provided to highlight some of the most relevant and impactful considerations for each phase. CONCLUSION The proposed guidance for PreDICT is a pharmacist-focused set of checklists for planning, developing, and implementing prediction tools in pharmacy practice. The list of considerations and accompanying commentary can be used as a reference by pharmacists or their trainees before or during the completion of a prediction tool project.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Departments of Health Services, Policy, and Practice and Epidemiology, Brown University School of Public Health, Providence, RI.,Department of Pharmacy, Rhode Island Hospital, Providence, RI, USA
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Margraf AM, Davoodi NM, Chen K, Shield RR, McAuliffe LM, Collins CM, Zullo AR. Provider beliefs about the ideal design of an opioid deprescribing and substitution intervention for older adults. Am J Health Syst Pharm 2023; 80:53-60. [PMID: 36205419 DOI: 10.1093/ajhp/zxac282] [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: 10/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Opportunities exist to meaningfully reduce suboptimal prescription opioid use among older adults. Deprescribing is one possible approach to reducing suboptimal use. Appropriate interventions should outline how to carefully taper opioids, closely monitor adverse events, substitute viable alternative and affordable nonopioid pain treatments, and initiate medications for opioid use disorder to properly manage use disorders, as needed. We sought to document and understand provider perceptions to begin developing effective and safe opioid deprescribing interventions. METHODS We conducted 3 semistructured focus groups that covered topics such as participant perspectives on opioid deprescribing in older adults, how to design an ideal intervention, and how to identify potential barriers or facilitators in implementing an intervention. Focus group transcripts were double coded and qualitatively analyzed to identify overarching themes. RESULTS Healthcare providers (n = 17), including physicians, pharmacists, nurses, social workers, and administrative staff, participated in 3 focus groups. We identified 4 key themes: (1) involve pharmacists in deprescribing and empower them as leaders of an opioid deprescribing service; (2) ensure tight integration and close collaboration throughout the deprescribing process from the inpatient to outpatient settings; (3) more expansive inclusion criteria than age alone; and (4) provision of access to alternative pharmacological and nonpharmacological pain management modalities to patients. CONCLUSION Our findings, which highlight various healthcare provider beliefs about opioid deprescribing interventions, are expected to serve as a framework for other organizations to develop and implement interventions. Future studies should incorporate patients' and family caregivers' perspectives.
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Affiliation(s)
- Alissa M Margraf
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | | | - Kevin Chen
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Renee R Shield
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Laura M McAuliffe
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Christine M Collins
- Department of Pharmacy, Rhode Island Hospital and Lifespan Corporation, Providence, RI, USA
| | - Andrew R Zullo
- Department of Pharmacy, Rhode Island Hospital, Providence, RI.,Departments of Epidemiology, Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
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Bayer TA, Jiang L, Erqou S, Kunicki ZJ, Singh M, Duprey M, Bozzay M, McGeary JE, Zullo AR, Wu WC, Gravenstein S, Rudolph JL. Incidence of New Dementia Diagnosis in Veterans Admitted to Nursing Homes After Heart Failure Hospitalization. J Alzheimers Dis 2023; 94:1397-1404. [PMID: 37424463 PMCID: PMC11016306 DOI: 10.3233/jad-221300] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Hospitalization with heart failure (HF) may signal an increased risk of Alzheimer's disease and related dementias (ADRD). Nursing homes routinely assess cognition but the association of these results with new ADRD diagnosis in a population at high risk of ADRD is not known. OBJECTIVE To determine the association between nursing home cognitive assessment results and new diagnosis of dementia after heart failure hospitalization. METHODS This retrospective cohort study included Veterans hospitalized for HF and discharged to nursing homes, from 2010 to 2015, without a prior diagnosis of ADRD. We determined mild, moderate, or severe cognitive impairment using multiple items of the nursing home admission assessment. We used Cox regression to determine the association of cognitive impairment with new ADRD diagnosis during 365 days of follow-up. RESULTS The cohort included 7,472 residents, new diagnosis of ADRD occurred in 4,182 (56%). The adjusted hazard ratio of ADRD diagnosis was 4.5 (95% CI 4.2, 4.8) for the mild impairment group, 5.4 (95% CI 4.8, 5.9) for moderate impairment, and 4.0 (95% CI 3.2, 5.0) for severe impairment compared to the cognitively intact group. CONCLUSION New ADRD diagnoses occurred in more than half of Veterans with HF admitted to nursing homes for post-acute care.
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Affiliation(s)
- Thomas A. Bayer
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Division of Geriatrics and Palliative Medicine, Providence, RI, USA
| | - Lan Jiang
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
| | - Sebhat Erqou
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
| | - Zachary J. Kunicki
- Warren Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
| | - Mriganka Singh
- Warren Alpert Medical School of Brown University, Division of Geriatrics and Palliative Medicine, Providence, RI, USA
| | - Matthew Duprey
- Brown University School of Public Health, Department of Health Services Policy and Practice, Providence, RI, USA
| | - Melanie Bozzay
- Warren Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
- Providence VA Medical Center, Center for Neurorestoration and Neurotechnology, Providence, RI, USA
| | - John E. McGeary
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Providence, RI, USA
| | - Andrew R. Zullo
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
- Brown University School of Public Health, Department of Health Services Policy and Practice, Providence, RI, USA
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA
| | - Wen-Chih Wu
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
- Brown University School of Public Health, Department of Epidemiology, Providence, RI, USA
- Providence VA Medical Center, Department of Medicine, Providence, RI, USA
| | - Stefan Gravenstein
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Division of Geriatrics and Palliative Medicine, Providence, RI, USA
- Brown University School of Public Health, Department of Health Services Policy and Practice, Providence, RI, USA
| | - James L. Rudolph
- Providence VA Medical Center, Long-Term Services and Supports Center of Innovation, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Division of Geriatrics and Palliative Medicine, Providence, RI, USA
- Brown University School of Public Health, Department of Health Services Policy and Practice, Providence, RI, USA
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Kunicki ZJ, Madrigal C, Quach LT, Riester MR, Jiang L, Duprey MS, Bozzay M, Zullo AR, Singh M, McGeary J, Wu WC, Rudolph JL. Comparing Resident, Proxy, and Staff Respondents for Nursing Home Residents' Preferences for Everyday Living. J Appl Gerontol 2023; 42:28-36. [PMID: 36029016 DOI: 10.1177/07334648221123059] [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] [Indexed: 12/14/2022] Open
Abstract
To encourage person-centered care, the Centers for Medicare and Medicaid require nursing homes to measure resident preferences using the Preferences Assessment Tool (PAT). No known research has examined the implications of respondent type (i.e., resident, proxy, staff) on preference importance; therefore, the purpose of this study was to compare the importance of preferences depending on which respondent completed the PAT. Participants included 16,111 Veterans discharged to community-based skilled nursing facilities after hospitalization for heart failure. A majority (95%) of residents completed the PAT compared to proxy (3%) and staff (2%). Proxy responders were both more and less likely to indicate individual preferences as important compared to residents. Staff members were consistently less likely to indicate all preferences as important compared to residents. Findings from this study emphasize the need for proxy and staff to find methods to better understand residents' preferences when residents are not able to participate in assessments.
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Affiliation(s)
- Zachary J Kunicki
- Department of Psychiatry and Human Behavior, 12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Caroline Madrigal
- VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA.,Department of Health Services, Policy, and Practice, 174610Brown University School of Public Health, Providence, RI, USA
| | - Lien T Quach
- VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA.,Department of Gerontology, The University of Massachusetts Boston, Boston, MA, USA.,Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA
| | - Melissa R Riester
- Department of Psychiatry and Human Behavior, 12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Lan Jiang
- VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA
| | - Matthew S Duprey
- Department of Health Services, Policy, and Practice, 174610Brown University School of Public Health, Providence, RI, USA
| | - Melanie Bozzay
- Department of Psychiatry and Human Behavior, 12321Alpert Medical School of Brown University, Providence, RI, USA.,VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA
| | - Andrew R Zullo
- VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA.,Department of Health Services, Policy, and Practice, 174610Brown University School of Public Health, Providence, RI, USA
| | - Mriganka Singh
- VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA.,Department of Medicine, 12321Alpert Medical School of Brown University, Providence, RI 02912, USA
| | - John McGeary
- Department of Psychiatry and Human Behavior, 12321Alpert Medical School of Brown University, Providence, RI, USA
| | - Wen-Chih Wu
- VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA.,Department of Medicine, 12321Alpert Medical School of Brown University, Providence, RI 02912, USA
| | - James L Rudolph
- VA Center of Innovation in Long Term Services, 20100Providence VA Medical Center, Providence, RI, USA.,Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA, USA
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Kunicki ZJ, Bayer T, Jiang L, Bozzay ML, Quinn MJ, De Vito AN, Emrani S, Erqou S, McGeary JE, Zullo AR, Duprey MS, Singh M, Primack JM, Kelso CM, Wu WC, Rudolph JL. Comparing Lookback Periods to Ascertain Alzheimer's Disease and Related Dementias. Am J Alzheimers Dis Other Demen 2023; 38:15333175231199566. [PMID: 37650437 PMCID: PMC10623942 DOI: 10.1177/15333175231199566] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Claims data are a valuable resource for studying Alzheimer's disease and related dementias (ADRD). Alzheimer's disease and related dementias is often identified using a list of claims codes and a fixed lookback period of 3 years of data. However, a 1-year lookback or an approach using all-available lookback data could be beneficial based on different research questions. Thus, the purpose of this study was to compare 1-year and all-available lookback approaches to ascertaining ADRD compared to the standard 3-year approach. Using a cohort of Veterans hospitalized for heart failure (N = 373, 897), our results suggested high agreement (93% or greater) between the lookback periods. The 1-year lookback period had lower sensitivity (60%) and underestimated the prevalence of ADRD. These results suggest that 1-year and all-available lookback periods are viable approaches when using claims data.
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Affiliation(s)
- Zachary J. Kunicki
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
| | - Thomas Bayer
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Lan Jiang
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
| | | | - McKenzie J. Quinn
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
| | - Alyssa N. De Vito
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sheina Emrani
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sebhat Erqou
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
| | - John E. McGeary
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
| | - Andrew R. Zullo
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | | | - Mriganka Singh
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Jennifer M. Primack
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
| | - Catherine M. Kelso
- VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
- Office of Patient Care Services, Geriatrics and Extended Care, Veterans Health Administration, Washington, DC, USA
| | - Wen-Chih Wu
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - James L. Rudolph
- VA Center of Innovation in Long Term Services, Providence VA Medical Center, Providence, RI, USA
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
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Gantenberg J, van Aalst R, Diakun DR, Limone BL, Nelson CB, Savitz DA, Zullo AR. 2198. Healthcare Utilization During Acute Medically Attended Respiratory Syncytial Virus (RSV) Episodes among Infants in the United States. Open Forum Infect Dis 2022. [PMCID: PMC9752774 DOI: 10.1093/ofid/ofac492.1817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Healthcare utilization during acute medically attended (MA) RSV-associated lower respiratory tract infection (LRTI) episodes remains poorly characterized, particularly among term infants without comorbidities. Describing the care incurred during these episodes may provide important information regarding the impact of MA RSV LRTI. Objective: Estimate the occurrence and average number of outpatient, emergency department (ED), and inpatient visits during infants' first RSV season. Methods Using deidentified insurance claims data (MarketScan Commercial ®, MSC; MarketScan Medicaid ®, MSM; Optum Clinformatics ®, OC), we assembled a cohort of infants born in the United States between April 1, 2016 and February 29, 2020 and identified their first MA RSV LRTI episode during their first RSV season. We defined an RSV episode as the 7 days following an index RSV diagnosis (inclusive of the diagnosis date), allowing for two alternative definitions of the index diagnosis—a specific definition, based on ICD-10 codes explicitly indicating RSV, and a sensitive definition, including codes for unspecified bronchiolitis. We calculated the average number of outpatient, ED, and inpatient visits during this episode, stratifying estimates by gestational age and the presence/absence of comorbidities. We also calculated the proportion of episodes involving a given place of service. Results Using the specific (sensitive) definitions, infants averaged 1.11 (1.19), 0.90 (0.89), and 1.56 (1.39) outpatient visits during their first acute RSV episode, in the MSC, MSM, and OC datasets, respectively (Table). They averaged 0.35 (0.23), 0.51 (0.47), and 0.39 (0.23) visits to the ED and 0.28 (0.14), 0.25 (0.14), and 0.23 (0.11) inpatient stays. While MA RSV LRTI episodes among infants who were preterm and/or had other comorbidities (comorbidity groups B and C) were more likely to involve an ED or inpatient visit, up to 21% (10%) of episodes among otherwise healthy term infants involved an inpatient stay.
![]() Conclusion Up to 1 in 5 infants experiencing an MA RSV LRTI episode during their first RSV season visited an inpatient setting, including between 9% and 21% of otherwise healthy term infants. This study was funded by Sanofi and AstraZeneca. Disclosures Jason Gantenberg, PhD, MPH, Sanofi: Grant/Research Support Robertus van Aalst, PhD, MSc, Sanofi: Stocks/Bonds David R. Diakun, BS, Sanofi: Employed by IBM Watson Health which was contracted by Sanofi to perfom outcomes research|Sobi: Employed by IBM Watson Health which was contracted by Sobi to conduct the study Christopher B. Nelson, PhD MPH, Sanofi: employee|Sanofi: Stocks/Bonds David A. Savitz, PhD, Sanofi-Pasteur: Grant/Research Support|Sanofi-Pasteur: Honoraria Andrew R. Zullo, PharmD, PhD, Sanofi: Grant/Research Support.
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Affiliation(s)
- Jason Gantenberg
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | | | | | | | | | - David A Savitz
- Brown University School of Public Health, Providence, Rhode Island
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Joyce NR, Khan MA, Zullo AR, Pfeiffer MR, Metzger KB, Margolis SA, Ott BR, Curry AE. Distance From Home to Motor Vehicle Crash Location: Implications for License Restrictions Among Medically-At-Risk Older Drivers. J Aging Soc Policy 2022:1-15. [PMID: 36463560 PMCID: PMC10239525 DOI: 10.1080/08959420.2022.2145791] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 05/11/2022] [Indexed: 12/07/2022]
Abstract
In 30 states, licensing agencies can restrict the distance from home that "medically-at-risk" drivers are permitted to drive. However, where older drivers crash relative to their home or how distance to crash varies by medical condition is unknown. Using geocoded crash locations and residential addresses linked to Medicare claims, we describe how the relationship between distance from home to crash varies by driver characteristics. We find that a majority of crashes occur within a few miles from home with little variation across driver demographics or medical conditions. Thus, distance restrictions may not reduce crash rates among older adults, and the tradeoff between safety and mobility warrants consideration.
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Affiliation(s)
- Nina R. Joyce
- Department of Epidemiology, Brown University School of Public Health
- Center for Gerontology and Health Care Research, Brown University School of Public Health
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia
| | - Marzan A. Khan
- Center for Gerontology and Health Care Research, Brown University School of Public Health
| | - Andrew R. Zullo
- Department of Epidemiology, Brown University School of Public Health
- Center for Gerontology and Health Care Research, Brown University School of Public Health
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia
- Department of Health Services Policy and Practice, Brown University School of Public Health
- Center of Innovation in Longterm Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Melissa R. Pfeiffer
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia
| | - Kristina B. Metzger
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia
| | - Seth A. Margolis
- Department of Neurology, Warren Alpert Medical School of Brown University
- Department of Psychiatry & Human Behavior, Brown University, Providence, Rhode Island
| | - Brian R. Ott
- Department of Neurology, Warren Alpert Medical School of Brown University
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Allison E. Curry
- Center for Injury Research and Prevention, Children’s Hospital of Philadelphia
- Division of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
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Riester MR, Roberts AI, Silva JBB, Howe CJ, Bardenheier BH, van Aalst R, Loiacono MM, Zullo AR. Geographic Variation in Influenza Vaccination Disparities Between Hispanic and Non-Hispanic White US Nursing Home Residents. Open Forum Infect Dis 2022; 9:ofac634. [PMID: 36540392 PMCID: PMC9757686 DOI: 10.1093/ofid/ofac634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/22/2022] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Disparities in influenza vaccination exist between Hispanic and non-Hispanic White US nursing home (NH) residents, but the geographic areas with the largest disparities remain unknown. We examined how these racial/ethnic disparities differ across states and hospital referral regions (HRRs). METHODS This retrospective cohort study included >14 million short-stay and long-stay US NH resident-seasons over 7 influenza seasons from October 1, 2011, to March 31, 2018, where residents could contribute to 1 or more seasons. Residents were aged ≥65 years and enrolled in Medicare fee-for-service. We used the Medicare Beneficiary Summary File to ascertain race/ethnicity and Minimum Data Set assessments for influenza vaccination. We calculated age- and sex-standardized percentage point (pp) differences in the proportions vaccinated between non-Hispanic White and Hispanic (any race) resident-seasons. Positive pp differences were considered disparities, where the proportion of non-Hispanic White residents vaccinated was greater than the proportion of Hispanic residents vaccinated. States and HRRs with ≥100 resident-seasons per age-sex stratum per racial/ethnic group were included in analyses. RESULTS Among 7 442 241 short-stay resident-seasons (94.1% non-Hispanic White, 5.9% Hispanic), the median standardized disparities in influenza vaccination were 4.3 pp (minimum, maximum: 0.3, 19.2; n = 22 states) and 2.8 pp (minimum, maximum: -3.6, 10.3; n = 49 HRRs). Among 6 758 616 long-stay resident-seasons (93.7% non-Hispanic White, 6.5% Hispanic), the median standardized differences were -0.1 pp (minimum, maximum: -4.1, 11.4; n = 18 states) and -1.8 pp (minimum, maximum: -6.5, 7.6; n = 34 HRRs). CONCLUSIONS Wide geographic variation in influenza vaccination disparities existed across US states and HRRs. Localized interventions targeted toward areas with high disparities may be a more effective strategy to promote health equity than one-size-fits-all national interventions.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Anthony I Roberts
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Joe B B Silva
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Chanelle J Howe
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Epidemiologic Research, Brown University, Providence, Rhode Island, USA
| | - Barbara H Bardenheier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Westat LLC, Rockville, Maryland, USA
| | - Robertus van Aalst
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Modelling, Epidemiology, and Data Science, Global Medical Affairs, Sanofi, Lyon, France
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Matthew M Loiacono
- Global Medical Evidence Generation, Sanofi, Swiftwater, Pennsylvania, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
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McConeghy KW, Bardenheier B, Huang AW, White EM, Feifer RA, Blackman C, Santostefano CM, Lee Y, DeVone F, Halladay CW, Rudolph JL, Zullo AR, Mor V, Gravenstein S. Infections, Hospitalizations, and Deaths Among US Nursing Home Residents With vs Without a SARS-CoV-2 Vaccine Booster. JAMA Netw Open 2022; 5:e2245417. [PMID: 36477482 PMCID: PMC9856563 DOI: 10.1001/jamanetworkopen.2022.45417] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/21/2022] [Indexed: 12/12/2022] Open
Abstract
Importance A SARS-CoV-2 vaccine booster dose has been recommended for all nursing home residents. However, data on the effectiveness of an mRNA vaccine booster in preventing infection, hospitalization, and death in this vulnerable population are lacking. Objective To evaluate the association between receipt of a SARS-CoV-2 mRNA vaccine booster and prevention of infection, hospitalization, or death among nursing home residents. Design, Setting, and Participants This cohort study emulated sequentially nested target trials for vaccination using data from 2 large multistate US nursing home systems: Genesis HealthCare, a community nursing home operator (system 1) and Veterans Health Administration community living centers (VHA CLCs; system 2). The cohort included long-term (≥100 days) nursing home residents (10 949 residents from 202 community nursing homes and 4321 residents from 128 VHA CLCs) who completed a 2-dose series of an mRNA vaccine (either BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna]) and were eligible for a booster dose between September 22 and November 30, 2021. Residents were followed up until March 8, 2022. Exposures Receipt of a third mRNA vaccine dose, defined as a booster dose (boosted group), or nonreceipt of a booster dose (unboosted group) on an eligible target trial date. If participants in the unboosted group received a booster dose on a later target trial date, they were included in the booster group for that target trial; thus, participants could be included in both the boosted and unboosted groups. Main Outcomes and Measures Test-confirmed SARS-CoV-2 infection, hospitalization, or death was followed up to 12 weeks after booster vaccination. The primary measure of estimated vaccine effectiveness was the ratio of cumulative incidences in the boosted group vs the unboosted group at week 12, adjusted with inverse probability weights for treatment and censoring. Results System 1 included 202 community nursing homes; among 8332 boosted residents (5325 [63.9%] female; 6685 [80.2%] White) vs 10 886 unboosted residents (6865 [63.1%] female; 8651 [79.5%] White), the median age was 78 (IQR, 68-87) years vs 78 (IQR, 68-86) years. System 2 included 128 VHA CLCs; among 3289 boosted residents (3157 [96.0%] male; 1950 [59.3%] White) vs 4317 unboosted residents (4151 [96.2%] male; 2434 [56.4%] White), the median age was 74 (IQR, 70-80) vs 74 (IQR, 69-80) years. Booster vaccination was associated with reductions in SARS-CoV-2 infections of 37.7% (95% CI, 25.4%-44.2%) in system 1 and 57.7% (95% CI, 43.5%-67.8%) in system 2. For hospitalization, reductions of 74.4% (95% CI, 44.6%-86.2%) in system 1 and 64.1% (95% CI, 41.3%-76.0%) in system 2 were observed. Estimated vaccine effectiveness for death associated with SARS-CoV-2 was 87.9% (95% CI, 75.9%-93.9%) in system 1; however, although a reduction in death was observed in system 2 (46.6%; 95% CI, -34.6% to 94.8%), this reduction was not statistically significant. A total of 45 SARS-CoV-2-associated deaths occurred in system 1 and 18 deaths occurred in system 2. For the combined end point of SARS-CoV-2-associated hospitalization or death, boosted residents in system 1 had an 80.3% (95% CI, 65.7%-88.5%) reduction, and boosted residents in system 2 had a 63.8% (95% CI, 41.4%-76.1%) reduction. Conclusions and Relevance In this study, during a period in which both the Delta and Omicron variants were circulating, SARS-CoV-2 booster vaccination was associated with significant reductions in SARS-CoV-2 infections, hospitalizations, and the combined end point of hospitalization or death among residents of 2 US nursing home systems. These findings suggest that administration of vaccine boosters to nursing home residents may have an important role in preventing COVID-19-associated morbidity and mortality.
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Affiliation(s)
- Kevin W. McConeghy
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Barbara Bardenheier
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Andrew W. Huang
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Elizabeth M. White
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | | | | | - Christopher M. Santostefano
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Frank DeVone
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island
| | - Christopher W. Halladay
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island
| | - James L. Rudolph
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Andrew R. Zullo
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Vincent Mor
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Stefan Gravenstein
- Center of Innovation in Long-Term Services and Supports, Veterans Administration Medical Center, Providence, Rhode Island
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island
- Division of Geriatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Coe AB, Zhang T, Zullo AR, Gerlach LB, Thomas KS, Daiello LA, Varma H, Lo D, Joshi R, Shireman TI, Bynum JP. Psychotropic medication prescribing in assisted living and nursing home residents with dementia after the National Partnership. J Am Geriatr Soc 2022; 70:3513-3525. [PMID: 35984088 PMCID: PMC9771901 DOI: 10.1111/jgs.18004] [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: 04/24/2022] [Revised: 06/30/2022] [Accepted: 07/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay NH (LSNH) residents after the Partnership. METHODS Using a 20% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study including AL and LSNH residents with dementia. The monthly prevalence of psychotropic medication prescribing (antipsychotics, antidepressants, anxiolytics/sedative-hypnotics, anticonvulsants/mood stabilizers, benzodiazepines, and antidementia medications) was examined. We used an interrupted time-series analysis to compare medication prescribing before (July 1, 2010-March 31, 2012) and after (April 1, 2012-December 31, 2017) the Partnership in both settings. RESULTS We identified 107,931 beneficiaries with ≥1 month as an AL resident and 323,766 beneficiaries with ≥1 month as a LSNH resident with dementia, including 1,923,867 person-months and 4,984,405 person-months, respectively. Antipsychotic prescribing declined over the study period in both settings. After the launch of the Partnership, the rate of decline in antipsychotic prescribing slowed in AL residents with dementia (slope change = 0.03 [95% CLs: 0.02, 0.04]) while the rate of decline in antipsychotic prescribing increased in LSNH residents with dementia (slope change = -0.12 [95% CLs: -0.16, -0.08]). Antidepressants were the most prevalent medication prescribed, anticonvulsant/mood stabilizer prescribing increased, and anxiolytic/sedative-hypnotic and antidementia medication prescribing declined. CONCLUSIONS The federal Partnership to reduce antipsychotic prescribing in NH residents did not appear to affect antipsychotic prescribing in AL residents with dementia. Given the increase in the prescribing of mood stabilizers/anticonvulsants that occurred after the launch of the Partnership, monitoring may be warranted for all psychotropic medications in AL and NH settings.
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Affiliation(s)
- Antoinette B. Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA., Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Andrew R. Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA., Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lauren B. Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA., Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lori A. Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hiren Varma
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Richa Joshi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Theresa I. Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie P.W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA., Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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O’Neill ET, Bosco E, Persico E, Silva JB, Riester MR, Moyo P, van Aalst R, Loiacono MM, Chit A, Gravenstein S, Zullo AR. Correlation of long-term care facility vaccination practices between seasons and resident types. BMC Geriatr 2022; 22:835. [PMID: 36333667 PMCID: PMC9635204 DOI: 10.1186/s12877-022-03540-3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Background Influenza vaccination varies widely across long-term care facilities (LTCFs) due to staff behaviors, LTCF practices, and patient factors. It is unclear how seasonal LTCF vaccination varies between cohabitating but distinct short-stay and long-stay residents. Thus, we assessed the correlation of LTCF vaccination between these populations and across seasons. Methods The study design is a national retrospective cohort using Medicare and Minimum Data Set (MDS) data. Participants include U.S. LTCFs. Short-stay and long-stay Medicare-enrolled residents age ≥ 65 in U.S. LTCFs from a source population of residents during October 1st-March 31st in 2013–2014 (3,042,881 residents; 15,683 LTCFs) and 2014–2015 (3,143,174, residents; 15,667 LTCFs). MDS-assessed influenza vaccination was the outcome. Pearson correlation coefficients were estimated to assess seasonal correlations between short-stay and long-stay resident vaccination within LTCFs. Results The median proportion of short-stay residents vaccinated across LTCFs was 70.4% (IQR, 50.0–82.7%) in 2013–2014 and 69.6% (IQR, 50.0–81.6%) in 2014–2015. The median proportion of long-stay residents vaccinated across LTCFs was 85.5% (IQR, 78.0–90.9%) in 2013–2014 and 84.6% (IQR, 76.6–90.3%) in 2014–2015. Within LTCFs, there was a moderate correlation between short-stay and long-stay vaccination in 2013–2014 (r = 0.50, 95%CI: 0.49–0.51) and 2014–2015 (r = 0.53, 95%CI: 0.51–0.54). Across seasons, there was a moderate correlation for LTCFs with short-stay residents (r = 0.54, 95%CI: 0.53–0.55) and a strong correlation for those with long-stay residents (r = 0.68, 95%CI: 0.67–0.69). Conclusions In LTCFs with inconsistent influenza vaccination across seasons or between populations, targeted vaccination protocols for all residents, regardless of stay type, may improve successful vaccination in this vulnerable patient population. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03540-3.
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Affiliation(s)
- Emily T. O’Neill
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Elliott Bosco
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Erin Persico
- grid.20431.340000 0004 0416 2242University of Rhode Island College of Pharmacy, Kingston, RI USA
| | - Joe B. Silva
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Melissa R. Riester
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Patience Moyo
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA
| | - Robertus van Aalst
- grid.417555.70000 0000 8814 392XSanofi, Swiftwater, PA USA ,grid.4494.d0000 0000 9558 4598Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Ayman Chit
- grid.417555.70000 0000 8814 392XSanofi, Swiftwater, PA USA ,grid.17063.330000 0001 2157 2938Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
| | - Stefan Gravenstein
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA ,grid.413904.b0000 0004 0420 4094Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI USA ,grid.40263.330000 0004 1936 9094Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI USA
| | - Andrew R. Zullo
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-3, Providence, RI 02912 USA ,grid.40263.330000 0004 1936 9094Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI USA ,grid.413904.b0000 0004 0420 4094Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI USA ,grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, Providence, RI USA
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Sarri G, Bennett D, Debray T, Deruaz‐Luyet A, Soriano Gabarró M, Largent JA, Li X, Liu W, Lund JL, Moga DC, Gokhale M, Rentsch CT, Wen X, Yanover C, Ye Y, Yun H, Zullo AR, Lin KJ. ISPE-Endorsed Guidance in Using Electronic Health Records for Comparative Effectiveness Research in COVID-19: Opportunities and Trade-Offs. Clin Pharmacol Ther 2022; 112:990-999. [PMID: 35170021 PMCID: PMC9087010 DOI: 10.1002/cpt.2560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/02/2022] [Indexed: 11/08/2022]
Abstract
As the scientific research community along with healthcare professionals and decision makers around the world fight tirelessly against the coronavirus disease 2019 (COVID-19) pandemic, the need for comparative effectiveness research (CER) on preventive and therapeutic interventions for COVID-19 is immense. Randomized controlled trials markedly under-represent the frail and complex patients seen in routine care, and they do not typically have data on long-term treatment effects. The increasing availability of electronic health records (EHRs) for clinical research offers the opportunity to generate timely real-world evidence reflective of routine care for optimal management of COVID-19. However, there are many potential threats to the validity of CER based on EHR data that are not originally generated for research purposes. To ensure unbiased and robust results, we need high-quality healthcare databases, rigorous study designs, and proper implementation of appropriate statistical methods. We aimed to describe opportunities and challenges in EHR-based CER for COVID-19-related questions and to introduce best practices in pharmacoepidemiology to minimize potential biases. We structured our discussion into the following topics: (1) study population identification based on exposure status; (2) ascertainment of outcomes; (3) common biases and potential solutions; and (iv) data operational challenges specific to COVID-19 CER using EHRs. We provide structured guidance for the proper conduct and appraisal of drug and vaccine effectiveness and safety research using EHR data for the pandemic. This paper is endorsed by the International Society for Pharmacoepidemiology (ISPE).
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Affiliation(s)
| | - Dimitri Bennett
- Takeda Global Evidence and OutcomesTakeda Pharmaceuticals USA, IncCambridgeMassachusettsUSA
- Center for Clinical Epidemiology and BiostatisticsPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Thomas Debray
- Julius Center for Health Sciences and Primary CareUniversity Medical Centre UtrechtUtrechtThe Netherlands
- Smart Data Analysis and StatisticsUtrechtThe Netherlands
| | - Anouk Deruaz‐Luyet
- Global Epidemiology and Real‐World Evidence CoECorporate Medical AffairsBoehringer Ingelheim International GmbHIngelheim‐am‐RheinGermany
| | - Montse Soriano Gabarró
- Bayer Partnerships and Integrated Evidence Generation OfficeIntegrated Evidence Generation & Business InnovationMedical Affairs & PharmacovigilanceBayer AGBerlinGermany
| | | | - Xiaojuan Li
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMassachusettsUSA
| | - Wei Liu
- Division of EpidemiologyOffice of Surveillance and EpidemiologyCenter for Drug Evaluation and Research, Food and Drug AdministrationSilver SpringMarylandUSA
| | - Jennifer L. Lund
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Daniela C. Moga
- Department of Pharmacy Practice and ScienceCollege of PharmacyUniversity of KentuckyLexingtonKentuckyUSA
| | - Mugdha Gokhale
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Department of EpidemiologyMerckWest PointPennsylvaniaUSA
| | - Christopher T. Rentsch
- Faculty of Epidemiology and Population HealthDepartment of Non‐communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUK
- Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Xuerong Wen
- Health OutcomesPharmacy PracticeCollege of PharmacyUniversity of Rhode IslandKinstonRhode IslandUSA
| | | | - Yizhou Ye
- Global Epidemiology, Pharmacovigilance and Patient SafetyAbbVie IncNorth ChicagoIllinoisUSA
| | - Huifeng Yun
- Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Andrew R. Zullo
- Department of Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
- Department of EpidemiologyBrown University School of Public HealthProvidenceRhode IslandUSA
- Center of Innovation in Long‐Term Services and SupportsProvidence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
- Department of PharmacyLifespan‐Rhode Island HospitalProvidenceRhode IslandUSA
| | - Kueiyu Joshua Lin
- Brigham and Women’s Hospital and Harvard Medical SchoolBostonMassachusettsUSA
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47
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Mintz J, Duprey MS, Zullo AR, Lee Y, Kiel DP, Daiello LA, Rodriguez KE, Venkatesh AK, Berry SD. Correction to: Identification of Fall-Related Injuries in Nursing Home Residents Using Administrative Claims Data. J Gerontol A Biol Sci Med Sci 2022; 77:2147. [PMID: 35532361 PMCID: PMC9536433 DOI: 10.1093/gerona/glac098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Matthew S Duprey
- Address correspondence to: Matthew S. Duprey, PharmD, PhD, Department of Health Services, Policy, and Practice, Brown University, 121 Second Main St, Box G-S121-6, Providence, RI 02903, USA. E-mail:
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island, USA
| | - Douglas P Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Lori A Daiello
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island, USA
| | - Kenneth E Rodriguez
- Department of Orthopedic Trauma Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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48
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Riester MR, Goyal P, Jiang L, Erqou S, Rudolph JL, McGeary JE, Rogus-Pulia NM, Madrigal C, Quach L, Wu WC, Zullo AR. New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:3368-3379. [PMID: 34981366 PMCID: PMC9550891 DOI: 10.1007/s11606-021-07233-2] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge. OBJECTIVE Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge. DESIGN Retrospective cohort. PARTICIPANTS Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF. MAIN MEASURES Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge. KEY RESULTS Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge. CONCLUSIONS Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Sebhat Erqou
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - James L Rudolph
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - John E McGeary
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Nicole M Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Caroline Madrigal
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lien Quach
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Wen-Chih Wu
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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49
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McConeghy KW, White EM, Blackman C, Santostefano CM, Lee Y, Rudolph JL, Canaday D, Zullo AR, Jernigan JA, Pilishvili T, Mor V, Gravenstein S. Effectiveness of a Second COVID-19 Vaccine Booster Dose Against Infection, Hospitalization, or Death Among Nursing Home Residents — 19 States, March 29–July 25, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1235-1238. [PMID: 36173757 PMCID: PMC9533729 DOI: 10.15585/mmwr.mm7139a2] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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50
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Meehan A, Uth R, Gadbois EA, Baier RR, Gravenstein S, Zullo AR, Kabler H, Loiacono MM, Bardenheier BH. Impact of COVID-19 on influenza and infection control practices in nursing homes. J Am Geriatr Soc 2022; 71:661-665. [PMID: 36146903 PMCID: PMC9538598 DOI: 10.1111/jgs.18061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Amy Meehan
- Brown University School of Public HealthProvidenceRhode IslandUSA
| | - Rebecca Uth
- Brown University School of Public HealthProvidenceRhode IslandUSA
| | - Emily A. Gadbois
- Brown University School of Public HealthProvidenceRhode IslandUSA
| | - Rosa R. Baier
- Brown University School of Public HealthProvidenceRhode IslandUSA
| | - Stefan Gravenstein
- Brown University School of Public HealthProvidenceRhode IslandUSA,Warren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA,Providence Veterans Affairs Medical CenterProvidenceRhode IslandUSA
| | - Andrew R. Zullo
- Brown University School of Public HealthProvidenceRhode IslandUSA,Providence Veterans Affairs Medical CenterProvidenceRhode IslandUSA,Rhode Island HospitalProvidenceRhode IslandUSA
| | | | | | - Barbara H. Bardenheier
- Brown University School of Public HealthProvidenceRhode IslandUSA,Westat, Inc.RockvilleMarylandUSA
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