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Colón-Emeric CS, McDermott CL, Lee DS, Berry SD. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review. JAMA 2024; 331:1397-1406. [PMID: 38536167 DOI: 10.1001/jama.2024.1416] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
Importance Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures. Observations Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions. Conclusions and Relevance More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.
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Affiliation(s)
- Cathleen S Colón-Emeric
- Division of Geriatrics, Duke University, Durham, North Carolina
- Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina
| | | | - Deborah S Lee
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Sarah D Berry
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Marcus Institute for Aging Research & Department of Medicine, Hebrew SeniorLife, Boston, Massachusetts
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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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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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Jarman MP, Jin G, Chen A, Losina E, Weissman JS, Berry SD, Salim A. Short-term outcomes of prehospital opioid pain management for older adults with fall-related injury. J Am Geriatr Soc 2024. [PMID: 38418369 DOI: 10.1111/jgs.18830] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Opioids are recommended for pain management in patients being cared for and transported by emergency medical services, but no specific guidelines exist for older adults with fall-related injury. Prior research suggests prehospital opioid administration can effectively manage pain in older adults, but less is known about safety in this population. We compared short-term safety outcomes, including delirium, disposition, and length of stay, among older adults with fall-related injury according to whether they received prehospital opioid analgesia. METHODS We linked Medicare claims data with prehospital patient care reports for older adults (≥65) with fall-related injury in Illinois between January 1, 2014 and December 31, 2015. We used weighted regression models (logistic, multinomial logistic, and Poisson) to assess the association between prehospital opioid analgesia and incidence of inpatient delirium, hospital disposition, and length of stay. RESULTS Of 28,150 included older adults, 3% received prehospital opioids. Patients receiving prehospital opioids (vs. no prehospital opioids) were less likely to be discharged home from the emergency department (adjusted probability = 0.30 [95% CI: 0.25, 0.34] vs. 0.47 [95% CI: 0.46, 0.48]), more likely to be discharged to a non-home setting after an inpatient admission (adjusted probability = 0.43 [95% CI: 0.39, 0.48] vs. 0.30 [95% CI: 0.30, 0.31]), had inpatient length of stay 0.4 days shorter (p < 0.001) and ICU length of stay 0.7 days shorter (p = 0.045). Incidence of delirium did not vary between treatment and control groups. CONCLUSIONS Few older adults receive opioid analgesia in the prehospital setting. Prehospital opioid analgesia may be associated with hospital disposition and length of stay for older adults with fall-related injury. However, our findings do not provide evidence of an association with inpatient delirium. These findings should be considered when developing guidelines for prehospital pain management specific to the older adult population.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Annie Chen
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elena Losina
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Salim
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
- Division of Trauma, Burn, and Surgical Critical Care, Brigham and Woemn's Hospital, Boston, Massachusetts, United States
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Chattaris T, Yang L, Johansson H, Sahni S, Samelson EJ, Kiel DP, Berry SD. Performance of FRAX in older adults with frailty: the Framingham Heart Study. Osteoporos Int 2024; 35:265-275. [PMID: 37872347 PMCID: PMC10872348 DOI: 10.1007/s00198-023-06950-0] [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: 02/15/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023]
Abstract
We compared the performance of FRAX according to frailty status in 3554 individuals from the Framingham Study. During 10-year follow-up, 6.9% and 3.0% of participants with and without frailty experienced MOF. Discrimination profiles were lower in participants with frailty compared to those without, but they improved when FRAX included BMD. INTRODUCTION Frailty increases fracture risk. FRAX was developed to predict fractures but never validated in individuals with frailty. We aimed to compare the predictive performance of FRAX (v4.3) in individuals with and without frailty. METHODS We conducted a cohort study using the Framingham Heart Study. Frailty was defined by the Fried phenotype. Major osteoporotic fractures (MOF) were ascertained from medical records during 10-year follow-up. To evaluate discrimination and calibration of FRAX, we calculated the area-under-the-receiver-operating characteristics curves (AUC) using logistic regression models and observed-to-predicted fracture probabilities. Analyses were stratified by frailty status. RESULTS Frailty was present in 550/3554 (15.5%) of participants. Participants with frailty were older (81.1 vs. 67.6 years), female (68.6% vs. 55.1%), and had greater mean FRAX scores (MOF: 15.9% vs. 10.1%) than participants without frailty. During follow-up, 38 participants with frailty (6.9%) and 91 without (3.0%) had MOFs. The AUC for FRAX (without BMD) was lower in participants with frailty (0.584; 95% CI 0.504-0.663) compared to those without (0.695; 95% CI 0.649-0.741); p value = 0.02. Among participants with frailty, the AUC improved when FRAX included BMD (AUC 0.658, p value < 0.01). FRAX overestimated MOF risk, with larger overestimations in individuals without frailty. Performance of FRAX for hip fracture was similar. CONCLUSION FRAX may have been less able to identify frail individuals at risk for fracture, as compared with individuals without frailty, unless information on BMD is available. This suggests that BMD captures features important for fracture prediction in frail persons. Future fracture prediction models should be developed among persons with frailty.
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Affiliation(s)
- Tanchanok Chattaris
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Nakhon Pathom, Thailand
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
| | - Laiji Yang
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
| | | | - Shivani Sahni
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Elizabeth J Samelson
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Douglas P Kiel
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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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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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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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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Berning MJ, Zhong Z, White EM, Niznik JD, Berry SD. Retention and Resilience of Nursing Home Staff During the COVID-19 Pandemic: Voices from the Frontline. J Am Med Dir Assoc 2023; 24:1606-1608. [PMID: 37582480 PMCID: PMC10543619 DOI: 10.1016/j.jamda.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023]
Affiliation(s)
- Michelle J Berning
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; University of Minnesota Medical School, Minneapolis, MN, USA
| | - Zada Zhong
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA; Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Elizabeth M White
- Brown University School of Public Health, Department of Health Services, Policy, & Practice, Providence, RI, USA
| | - Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA; Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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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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11
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Berry SD, Bakaev I, Chen H, Lipsitz LA. The balance of prescriptive and dynamic regulatory policies in nursing homes: Lessons learned from the COVID-19 pandemic. J Am Geriatr Soc 2023; 71:2672-2675. [PMID: 36959696 PMCID: PMC10517058 DOI: 10.1111/jgs.18339] [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: 12/20/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 03/25/2023]
Abstract
See related Brief report by Festa et al. in this issue.
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Affiliation(s)
- Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Medicine, Hebrew SeniorLife, Boston, MA
| | | | - Helen Chen
- San Francisco Veterans Affairs Hospital, University of California San Francisco, San Francisco, CA
| | - Lewis A. Lipsitz
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Medicine, Hebrew SeniorLife, Boston, MA
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12
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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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13
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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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14
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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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15
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Chattaris T, Chahal K, Berry SD. Factors besides frailty index affect length of stay in older patients with hip fractures. Osteoporos Int 2023:10.1007/s00198-023-06798-4. [PMID: 37246196 PMCID: PMC10225280 DOI: 10.1007/s00198-023-06798-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Tanchanok Chattaris
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Karen Chahal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sarah D Berry
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Boston, MA, USA.
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 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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Montoya A, Wen K, Travers JL, Rivera-Hernandez M, White E, Mor V, Berry SD. Resident Factors Associated With Breakthrough SARS-CoV-2 Infections. J Am Med Dir Assoc 2023:S1525-8610(23)00225-6. [PMID: 36965506 PMCID: PMC9977610 DOI: 10.1016/j.jamda.2023.02.102] [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: 12/22/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE To examine incidence of and resident characteristics associated with breakthrough infections (BTIs) and severe illness among residents with 2 messenger RNA (mRNA) vaccinations. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Nursing home (NH) residents who completed their primary series of mRNA COVID-19 vaccination by March 31, 2021. METHODS Electronic health records and Minimum Data Set assessments from a multistate NH data consortium were used to identify BTI and severe illness (a composite measure of hospitalization and/or death within 30 days of BTI) occurring prior to November 24, 2021. A t test for differences in means was used to compare covariates for residents with and without BTI. Finally, we estimated incidence rate ratios (IRRs) for BTI with 95% CIs using a modified Poisson regression approach, comparing residents with BTI vs residents without. We adjusted for facility fixed effects in our model. RESULTS Our sample included 23,172 residents from 984 NHs who were at least 14 days past their second mRNA vaccine dose. Of those, 1173 (5%) developed an incident COVID-19 BTI (mean follow-up time: 250 days). Among residents with BTI, 8.6% were hospitalized or died within 30 days of BTI diagnosis. Factors associated with severe illness included age ≥85 years (IRR 2.08, 95% CI 1.08-4.02, reference age <65 years), bowel incontinence (IRR 1.73, 95% CI 1.01-2.99), coronary artery disease (IRR 1.96, 95% CI 1.31-2.94), chronic kidney disease (IRR 1.65, 95% CI 1.07-2.54), and schizophrenia (IRR 2.38, 95% CI 1.19-4.75). CONCLUSIONS AND IMPLICATIONS Among vaccinated NH residents, BTIs and associated severe illness are rare. Residents aged ≥85 years and with certain comorbidities appear to be the most vulnerable. Given that the pandemic continues and testing policies have relaxed, these data provide prognostic information for NH facilities faced with continued outbreaks.
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Affiliation(s)
- Ana Montoya
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Katherine Wen
- Department of Medicine, Health, and Society, Vanderbilt University, Nashville, TN, USA
| | - Jasmine L Travers
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Elizabeth White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Department of Medicine & Harvard Medical Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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White EM, Travers JL, Gouskova N, Oh G, Syme M, Yang X, Montoya A, Feifer RA, Grabowski DC, Mor V, Berry SD. Differences In Nursing Home Staff COVID-19 Testing Rates And Odds Of Vaccination Across Work Shifts. Health Aff (Millwood) 2023; 42:217-226. [PMID: 36745839 PMCID: PMC9990769 DOI: 10.1377/hlthaff.2022.01011] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
COVID-19 vaccination and regular testing of nursing home staff have been critical interventions for mitigating COVID-19 outbreaks in US nursing homes. Although implementation of testing has largely been left to nursing home organizations to coordinate, vaccination occurred through a combination of state, federal, and organization efforts. Little research has focused on structural variation in these processes. We examined whether one structural factor, the primary shift worked by staff, was associated with differences in COVID-19 testing rates and odds of vaccination, using staff-level data from a multistate sample of 294 nursing homes. In facility fixed effects analyses, we found that night-shift staff had the lowest testing rates and lowest odds of vaccination, whereas day-shift staff had the highest testing rates and odds of vaccination. These findings highlight the need to coordinate resources and communication evenly across shifts when implementing large-scale processes in nursing homes and other organizations with shift-based workforces.
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Affiliation(s)
| | | | | | | | | | | | - Ana Montoya
- Ana Montoya, University of Michigan, Ann Arbor, Michigan
| | - Richard A Feifer
- Richard A. Feifer, RAF Healthcare Solutions, Simsbury, Connecticut
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Little MO, Hecker EJ, Colon-Emeric CS, Herndon L, McConnell ES, Xue TM, Berry SD. Perspectives on Deprescribing in long-term care: qualitative findings from nurses, aides, residents, and proxies. BMC Nurs 2023; 22:27. [PMID: 36721150 PMCID: PMC9890706 DOI: 10.1186/s12912-023-01179-y] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/12/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Deprescribing initiatives in the long-term care (LTC) setting are often unsuccessful or not sustained. Prior research has considered how physicians and pharmacists feel about deprescribing, yet little is known about the perspectives of frontline nursing staff and residents. Our aim was to elicit perspectives from LTC nursing staff, patients, and proxies regarding their experiences and preferences for deprescribing in order to inform future deprescribing efforts in LTC. METHODS This study was a qualitative analysis of interviews with nurses, nurse aides, a nurse practitioner, residents, and proxies (family member and/or responsible party) from three LTC facilities. The research team used semi-structured interviews. Guides were designed to inform an injury prevention intervention. Interviews were recorded and transcribed. A qualitative framework analysis was used to summarize themes related to deprescribing. The full study team reviewed the summary to identify actionable, clinical implications. RESULTS Twenty-six interviews with 28 participants were completed, including 11 nurse aides, three residents, seven proxies, one nurse practitioner, and six nurses. Three themes emerged that were consistent across facilities: 1) build trust with team members, including residents and proxies; 2) identify motivating factors that lead to resident, proxy, nurse practitioner, and staff acceptance of deprescribing; 3) standardize supportive processes to encourage deprescribing. These themes suggest several actionable steps to improve deprescribing initiatives including: 1) tell stories about successful deprescribing, 2) provide deprescribing education to frontline staff, 3) align medication risk/benefit discussions with what matters most to the resident, 4) standardize deprescribing monitoring protocols, 5) standardize interprofessional team huddles and care plan meetings to include deprescribing conversations, and 6) strengthen non-pharmacologic treatment programs. CONCLUSIONS By interviewing LTC stakeholders, we identified three important themes regarding successful deprescribing: Trust, Motivating Factors, and Supportive Processes. These themes may translate into actionable steps for clinicians and researchers to improve and sustain person-centered deprescribing initiatives. TRIAL REGISTRATION NCT04242186.
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Affiliation(s)
- Milta O. Little
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, NC Durham, USA
| | - Emily J. Hecker
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, NC Durham, USA
| | - Cathleen S. Colon-Emeric
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, NC Durham, USA ,grid.281208.10000 0004 0419 3073Durham VA Geriatric Research Education and Clinical Center, NC Durham, USA
| | - Laurie Herndon
- grid.497274.b0000 0004 0627 5136Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA USA
| | - Eleanor S. McConnell
- grid.281208.10000 0004 0419 3073Durham VA Geriatric Research Education and Clinical Center, NC Durham, USA ,grid.26009.3d0000 0004 1936 7961Duke University School of Nursing, NC Durham, USA
| | - Tingzhong Michelle Xue
- grid.281208.10000 0004 0419 3073Durham VA Geriatric Research Education and Clinical Center, NC Durham, USA ,grid.26009.3d0000 0004 1936 7961Duke University School of Nursing, NC Durham, USA
| | - Sarah D. Berry
- grid.497274.b0000 0004 0627 5136Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA USA ,grid.38142.3c000000041936754XBeth Israel Deaconess Medical Center, Department of Medicine & Harvard Medical School, Boston, MA USA
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20
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Niznik JD, Gilliam MA, Colón-Emeric C, Thorpe CT, Lund JL, Berry SD, Hanson LC. Controversies in Osteoporosis Treatment of Nursing Home Residents. J Am Med Dir Assoc 2022; 23:1928-1934. [PMID: 36335990 PMCID: PMC9885478 DOI: 10.1016/j.jamda.2022.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 06/13/2022] [Revised: 09/26/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
Osteoporotic fractures are a common and serious health problem for older adults living in nursing homes (NHs). Risk of fracture increases with age and dementia status, yet gaps in evidence result in controversies around when to start and stop treatment for osteoporosis in NH residents, particularly those who have high fracture risk but have limited life expectancy. In this article, we discuss these areas of controversy. We provide an overview of current guidelines that explicitly address osteoporosis treatment strategies for NH residents, review the evidence for osteoporosis medications in NH residents, and use these sources to suggest practical recommendations for clinical practice and for research. Three published guidelines (from the United States, Canada, and Australia) and several studies provide the current basis for clinical decisions about osteoporosis treatment for NH residents. Practical approaches may include broad use of vitamin D and selective use of osteoporosis medication based on risks, benefits, and goals of care. Clinicians still lack strong evidence to guide treatment of NH residents with advanced dementia, multimorbidity, or severe mobility impairment. Future priorities for research include identifying optimal approaches to risk stratification and prevention strategies for NH residents and evaluating the risk-benefit profile of pharmacologic treatments for osteoporosis NH residents across key clinical strata. In the absence of such evidence, decisions for initiating and continuing treatment should reflect a patient-centered approach that incorporates life expectancy, goals of care, and the potential burden of treatment.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Meredith A Gilliam
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
| | - Cathleen Colón-Emeric
- Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA; Durham VA Geriatric Research Education and Clinical Center, Durham, NC, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Boston, MA, USA; Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
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Chattaris T, Oh G, Gouskova NA, Kim DH, Kiel DP, Berry SD. Osteoporosis Medications Prevent Subsequent Fracture in Frail Older Adults. J Bone Miner Res 2022; 37:2103-2111. [PMID: 36168189 PMCID: PMC9712267 DOI: 10.1002/jbmr.4693] [Citation(s) in RCA: 2] [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: 06/09/2022] [Revised: 08/12/2022] [Accepted: 08/28/2022] [Indexed: 11/08/2022]
Abstract
Frailty is common in older adults with fractures. Osteoporosis medications reduce subsequent fracture, but limited data exist on medication efficacy in frail individuals. Our objective was to determine whether medications reduce the risk of subsequent fracture in frail, older adults. A retrospective cohort of Medicare fee-for-service beneficiaries was conducted (2014-2016). We included adults aged ≥65 years who were hospitalized with fractures without osteoporosis treatment. Pre-fracture frailty was defined using claims-based frailty index (≥0.2 = frail). Exposure to any osteoporosis treatment (oral or intravenous bisphosphonates, denosumab, and teriparatide) was ascertained using Part B and D claims and categorized according to the cumulative duration of exposure: none, 1-90 days, and >90 days. Subsequent fractures were ascertained from Part A or B claims. Cause-specific hazard models with time-varying exposure were fit to examine the association between treatment and fracture outcomes, controlling for relevant covariates. Among 29,904 patients hospitalized with fractures, 15,345 (51.3%) were frail, and 2148 (7.2%) received osteoporosis treatment (median treatment duration 183.0 days). Patients who received treatment were younger (80.2 versus 82.2 years), female (86.5% versus 73.0%), and less frail (0.20 versus 0.22) than patients without treatment. During follow-up, 5079 (17.0%) patients experienced a subsequent fracture. Treatment with osteoporosis medications for >90 days compared with no treatment reduced the risk of fracture (hazard ratio [HR] = 0.82; 95% confidence interval [CI] 0.68-1.00) overall. Results were similar in frail (HR = 0.85; 95% CI 0.65-1.12) and non-frail (HR = 0.80; 95% CI 0.61-1.04) patients but not significant. In conclusion, osteoporosis treatment >90 days was associated with similar trends in reduced risk of subsequent fracture in frail and non-frail persons. Treatment rates were very low, particularly among the frail. When weighing treatment options in frail older adults with hospitalized fractures, clinicians should be aware that drug therapy does not appear to lose its efficacy. © 2022 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Tanchanok Chattaris
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
| | - Gahee Oh
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
| | - Natalia A. Gouskova
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
| | - Dae Hyun Kim
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Douglas P. Kiel
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sarah D. Berry
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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22
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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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Recker A, White EM, Yang X, Feifer RA, Gravenstein S, Blackman C, Nanda A, Berry SD, Mor V. Factors Affecting SARS-CoV-2 Test Discordance in Skilled Nursing Facilities. J Am Med Dir Assoc 2022; 23:1279-1282. [PMID: 35809634 PMCID: PMC9212802 DOI: 10.1016/j.jamda.2022.06.006] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/09/2022] [Accepted: 06/12/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Reverse transcription polymerase chain reaction (PCR) and antigen tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are sometimes discordant. We evaluated the discordance between antigen and PCR tests sampled in skilled nursing facilities (SNFs) to assess the relationship of symptom presence, timing between tests, and the presence of a facility outbreak. DESIGN Observational study using electronic health record data. SETTING AND PARTICIPANTS Residents of 306 SNFs in 23 states, operated by 1 company. METHODS We identified all rapid antigen and PCR tests conducted in study SNFs as of January 10, 2021, and classified whether symptoms were present and whether the facility was in outbreak at time of testing. We calculated the proportions of antigen tests with discordant follow-up PCR results conducted no more than 2 days after the antigen test. RESULTS Of the 171,280 antigen tests in 34,437 SNF residents, 20,991 (12.3%) were followed by a PCR test within 2 days. A total of 1324 negative antigen tests were followed by a positive PCR result, representing 0.8% of all antigen tests and 6.3% of repeated antigen tests; while 337 positive antigen tests were followed by a negative PCR result, representing 0.2% of all antigen tests and 1.6% of repeated antigen tests. Discordance more often occurred when residents were symptomatic at time of antigen testing, during known facility outbreaks, and when the antigen test was compared with a PCR test done within 2 days vs 1 day. CONCLUSIONS AND IMPLICATIONS Overall, discordance between SARS-CoV-2 antigen and PCR tests was low. Discordance was more common when the individual was symptomatic at time of antigen testing and during facility outbreaks. This suggests that a testing strategy which couples widespread use of antigen tests with clinical thresholds to conduct follow-up confirmatory PCR testing appears to perform well in SNFs, where timely and accurate SARS-CoV-2 case identification are critical.
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Affiliation(s)
- Amy Recker
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Elizabeth M White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Xiaofei Yang
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | | | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Division of Geriatrics and Palliative Medicine, Brown University Alpert Medical School, Providence, RI, USA; Providence Veterans Administration Medical Center Research Service, Providence, RI, USA
| | | | - Aman Nanda
- Division of Geriatrics and Palliative Medicine, Brown University Alpert Medical School, Providence, RI, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Department of Medicine, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Providence Veterans Administration Medical Center Research Service, Providence, RI, USA
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McGarry BE, Gandhi AD, Syme M, Berry SD, White EM, Grabowski DC. Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes. JAMA Health Forum 2022; 3:e222363. [PMID: 35983581 PMCID: PMC9338409 DOI: 10.1001/jamahealthforum.2022.2363] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/08/2022] [Indexed: 11/14/2022] Open
Abstract
Question Are state COVID-19 vaccine mandates for US nursing home employees associated with staff vaccination coverage and reported staff shortages? Findings This cohort study of nursing homes in 38 states found that states with a vaccine mandate experienced an increase in staff vaccination coverage compared with facilities in states with no mandate and no worsening of reported staffing shortages following the mandates. Meaning These findings suggest that given the waning vaccine-induced immunity and low booster dose coverage among nursing home staff in many parts of the US, state mandates for booster doses may be warranted to improve and sustain vaccination coverage in nursing homes. Importance Several states implemented COVID-19 vaccine mandates for nursing home employees, which may have improved vaccine coverage but may have had the unintended consequence of staff departures. Objective To assess whether state vaccine mandates for US nursing home employees are associated with staff vaccination rates and reported staff shortages. Design, Setting, and Participants This cohort study performed event study analyses using National Healthcare Safety Network data from June 6, 2021, through November 14, 2021. Changes in weekly staff vaccination rates and reported staffing shortages were evaluated for nursing homes in states with mandates after the mandate announcement compared with changes in facilities in nonmandate states. An interaction between the mandates and county political leaning was considered. Data analysis was performed from February to March 2022. Exposures Weeks after announcement of a state’s COVID-19 vaccine mandate. Main Outcomes and Measures Weekly percentage of all health care staff at a nursing home who received at least 1 COVID-19 vaccine dose, and a weekly indicator of whether a nursing home reported a staffing shortage. Results Among 38 study-eligible states, 26 had no COVID-19 vaccine mandate for nursing home employees, 4 had a mandate with a test-out option, and 8 had a mandate with no test-out option. Ten weeks or more after mandate announcement, nursing homes in states with a mandate and no test-out option experienced a 6.9 percentage point (pp) increase in staff vaccination coverage (95% CI, −0.1 to 13.9); nursing homes in mandate states with a test-out option experienced a 3.1 pp increase (95% CI, 0.5 to 5.7) compared with facilities in nonmandate states. No significant increases were detected in the frequency of reported staffing shortages after a mandate announcement in mandate states with or without test-out options. Increases in vaccination rates in states with mandates were larger in Republican-leaning counties (14.3 pp if no test-out option; 4.3 pp with option), and there was no evidence of increased staffing shortages. Conclusions and Relevance The findings of this cohort study suggest that state-level vaccine mandates were associated with increased staff vaccination coverage without increases in reported staffing shortages. Vaccination increases were largest when mandates had no test-out option and were also larger in Republican-leaning counties, which had lower mean baseline vaccination rates. These findings support the use of state mandates for booster doses for nursing home employees because they may improve vaccine coverage, even in areas with greater vaccine hesitancy.
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Affiliation(s)
- Brian E. McGarry
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Ashvin D. Gandhi
- Anderson School of Management, University of California Los Angeles
| | - Maggie Syme
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth M. White
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
| | - David C. Grabowski
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Mintz J, Duprey MS, Zullo AR, Lee Y, Kiel DP, Daiello LA, Rodriguez KE, Venkatesh AK, Berry SD. Identification of Fall-Related Injuries in Nursing Home Residents Using Administrative Claims Data. J Gerontol A Biol Sci Med Sci 2022; 77:1421-1429. [PMID: 34558615 PMCID: PMC9255678 DOI: 10.1093/gerona/glab274] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Fall-related injuries (FRIs) are a leading cause of morbidity, mortality, and costs among nursing home (NH) residents. Carefully defining FRIs in administrative data is essential for improving injury-reduction efforts. We developed a series of novel claims-based algorithms for identifying FRIs in long-stay NH residents. METHODS This is a retrospective cohort of residents of NH residing there for at least 100 days who were continuously enrolled in Medicare Parts A and B in 2016. FRIs were identified using 4 claims-based case-qualifying (CQ) definitions (Inpatient [CQ1], Outpatient and Provider with Procedure [CQ2], Outpatient and Provider with Fall [CQ3], or Inpatient or Outpatient and Provider with Fall [CQ4]). Correlation was calculated using phi correlation coefficients. RESULTS Of 153 220 residents (mean [SD] age 81.2 [12.1], 68.0% female), we identified 10 104 with at least one FRI according to one or more CQ definition. Among 2 950 residents with hip fractures, 1 852 (62.8%) were identified by all algorithms. Algorithm CQ4 (n = 326-2 775) identified more FRIs across all injuries while CQ1 identified less (n = 21-2 320). CQ2 identified more intracranial bleeds (1 028 vs 448) than CQ1. For nonfracture categories, few FRIs were identified using CQ1 (n = 20-488). Of the 2 320 residents with hip fractures identified by CQ1, 2 145 (92.5%) had external cause of injury codes. All algorithms were strongly correlated, with phi coefficients ranging from 0.82 to 0.99. CONCLUSIONS Claims-based algorithms applied to outpatient and provider claims identify more nonfracture FRIs. When identifying risk factors, stakeholders should select the algorithm(s) suitable for the FRI and study purpose.
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Affiliation(s)
- Joel Mintz
- Nova Southeastern University College of Allopathic Medicine, Davie, Florida, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, Massachusetts, USA
| | - Matthew S Duprey
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island, USA
| | - 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 and 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 and Harvard Medical School, Boston, Massachusetts, USA
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Canaday DH, Oyebanji OA, White E, Keresztesy D, Payne M, Wilk D, Carias L, Aung H, St Denis K, Sheehan ML, Berry SD, Cameron CM, Cameron MJ, Wilson BM, Balazs AB, King CL, Gravenstein S. COVID-19 vaccine booster dose needed to achieve Omicron-specific neutralisation in nursing home residents. EBioMedicine 2022; 80:104066. [PMID: 35605428 PMCID: PMC9122310 DOI: 10.1016/j.ebiom.2022.104066] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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] [Received: 02/01/2022] [Revised: 04/26/2022] [Accepted: 05/02/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nursing home (NH) residents have borne a disproportionate share of SARS-CoV-2 morbidity and mortality. Vaccines have limited hospitalisation and death from earlier variants in this vulnerable population. With the rise of Omicron and future variants, it is vital to sustain and broaden vaccine-induced protection. We examined the effect of boosting with BNT162b2 mRNA vaccine on humoral immunity and Omicron-specific neutralising activity among NH residents and healthcare workers (HCWs). METHODS We longitudinally enrolled 85 NH residents (median age 77) and 48 HCWs (median age 51), and sampled them after the initial vaccination series; and just before and 2 weeks after booster vaccination. Anti-spike, anti-receptor binding domain (RBD) and neutralisation titres to the original Wuhan strain and neutralisation to the Omicron strain were obtained. FINDINGS Booster vaccination significantly increased vaccine-specific anti-spike, anti-RBD, and neutralisation levels above the pre-booster levels in NH residents and HCWs, both in those with and without prior SARS-CoV-2 infection. Omicron-specific neutralisation activity was low after the initial 2 dose series with only 28% of NH residents' and 28% HCWs' titres above the assay's lower limit of detection. Omicron neutralising activity following the booster lifted 86% of NH residents and 93% of HCWs to the detectable range. INTERPRETATION With boosting, the vast majority of HCWs and NH residents developed detectable Omicron-specific neutralising activity. These data provide immunologic evidence that strongly supports booster vaccination to broaden neutralising activity and counter waning immunity in the hope it will better protect this vulnerable, high-risk population against the Omicron variant. FUNDING NIH AI129709-03S1, U01 CA260539-01, CDC 200-2016-91773, and VA BX005507-01.
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Affiliation(s)
- David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH; Geriatric Research, Education and Clinical Center, Cleveland VA.
| | | | - Elizabeth White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | | | - Michael Payne
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Dennis Wilk
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lenore Carias
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Htin Aung
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Cheryl M Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mark J Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | | | | | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI; Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI; Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI
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Syme ML, Gouskova N, Berry SD. COVID-19 Vaccine Uptake Among Nursing Home Staff via Statewide Policy: The Mississippi Vaccinate or Test Out Policy. Am J Public Health 2022; 112:762-765. [PMID: 35324261 PMCID: PMC9010915 DOI: 10.2105/ajph.2022.306800] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/04/2022]
Abstract
Objectives. To examine whether COVID-19 vaccine mandates that allow a test-out exemption for nursing home staff are associated with increased staff vaccination rates in nursing homes. Methods. Using the National Healthcare Safety Network data, we conducted analyses to test trends over time in statewide staff vaccination rates between June 1, 2021, and August 29, 2021, in Mississippi, 4 adjacent states, and the United States overall. Results. COVID-19 staff vaccination rates increased slowly following Mississippi enacting a vaccinate-or-test-out policy, achieving small, but statistically greater gains than most comparator states. Yet, staff vaccination rates in Mississippi remained well below the national average and similar numerically to surrounding states without mandates. Conclusions. Mississippi's COVID-19 vaccinate-or-test policy was ineffective in meaningfully increasing staff vaccination rates. For COVID-19 nursing home mandates to be effective while still balancing the staff turnover risks, facilities might consider a more stringent or hybrid approach (e.g., test-out option not offered to new staff). Public Health Implications. Statewide COVID-19 vaccine mandates, when given a test-out option, do not appear to be an effective strategy to meaningfully increase nursing home staff COVID-19 vaccination. (Am J Public Health. 2022;112(5):762-765. https://doi.org/10.2105/AJPH.2022.306800).
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Affiliation(s)
- Maggie L Syme
- All authors are with Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA. Sarah Berry is also with Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston
| | - Natalia Gouskova
- All authors are with Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA. Sarah Berry is also with Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston
| | - Sarah D Berry
- All authors are with Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA. Sarah Berry is also with Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston
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Niznik JD, Berry SD, Syme M, Kelley CJ, Hanson LC, Harrison J. Addressing hesitancy to COVID-19 vaccines in healthcare assistants. Geriatr Nurs 2022; 45:169-173. [PMID: 35490606 PMCID: PMC9035372 DOI: 10.1016/j.gerinurse.2022.04.011] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
Abstract
COVID-19 vaccination rates have been suboptimal in frontline healthcare assistants (HCAs). We sought to characterize contributors to COVID-19 vaccine hesitancy among HCAs. We conducted an analysis of online survey responses from members of the National Association of Health Care Assistants from December 2020-January 2021. Respondents were asked what it would take for them to be vaccinated against COVID-19. Responses from 309 HCAs were coded to characterize respondents' willingness to be vaccinated and identify contributors to vaccine hesitancy. Approximately 60% (n = 185) of HCAs expressed hesitancy but would consider getting vaccinated under certain circumstances. We identified 8 overarching themes for contributors to COVID-19 vaccine hesitancy, the most common being safety concerns (70% of respondents). Others included efficacy (11.4%), workplace requirements (9.7%), societal influence (9.2%), and compensation (8.1%). Interventions to increase vaccine uptake among HCAs may be most effective by addressing concerns regarding the short-term and long-term safety implications of COVID-19 vaccines.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC 27599, USA; Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA; Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Department of Medicine, and Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Maggie Syme
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Casey J Kelley
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC 27599, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC 27599, USA
| | - Jill Harrison
- Department of Health Services, Policy, and Practice, Brown University, School of Public Health, Providence, RI, USA
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Davis SR, Ward HE, Kelly V, Palmer D, Ankersmit-Udy AE, Lopdell TJ, Berry SD, Littlejohn MD, Tiplady K, Adams LF, Carnie K, Burrett A, Thomas N, Snell RG, Spelman RJ, Lehnert K. Screening for phenotypic outliers identifies an unusually low concentration of a β-lactoglobulin B protein isoform in bovine milk caused by a synonymous SNP. Genet Sel Evol 2022; 54:22. [PMID: 35296234 PMCID: PMC8925192 DOI: 10.1186/s12711-022-00711-z] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 02/28/2022] [Indexed: 12/12/2022] Open
Abstract
Background Milk samples from 10,641 dairy cattle were screened by a mass spectrometry method for extreme concentrations of the A or B isoforms of the whey protein, β-lactoglobulin (BLG), to identify causative genetic variation driving changes in BLG concentration. Results A cohort of cows, from a single sire family, was identified that produced milk containing a low concentration of the BLG B protein isoform. A genome-wide association study (GWAS) of BLG B protein isoform concentration in milk from AB heterozygous cows, detected a group of highly significant single nucleotide polymorphisms (SNPs) within or close to the BLG gene. Among these was a synonymous G/A variation at position + 78 bp in exon 1 of the BLG gene (chr11:103256256G > A). The effect of the A allele of this SNP (which we named B’) on BLG expression was evaluated in a luciferase reporter assay in transfected CHO-K1 and MCF-7 cells. In both cell types, the presence of the B’ allele in a plasmid containing the bovine BLG gene from -922 to + 898 bp (relative to the transcription initiation site) resulted in a 60% relative reduction in mRNA expression, compared to the plasmid containing the wild-type B sequence allele. Examination of a mammary RNAseq dataset (n = 391) identified 14 heterozygous carriers of the B’ allele which were homozygous for the BLG B protein isoform (BB’). The level of expression of the BLG B’ allele was 41.9 ± 1.0% of that of the wild-type BLG B allele. Milk samples from three cows, homozygous for the A allele at chr11:103,256,256 (B’B’), were analysed (HPLC) and showed BLG concentrations of 1.04, 1.26 and 1.83 g/L relative to a mean of 4.84 g/L in milk from 16 herd contemporaries of mixed (A and B) BLG genotypes. The mechanism by which B’ downregulates milk BLG concentration remains to be determined. Conclusions High-throughput screening and identification of outliers, enabled the discovery of a synonymous G > A mutation in exon 1 of the B allele of the BLG gene (B’), which reduced the milk concentration of β-lactoglobulin B protein isoform, by more than 50%. Milk from cows carrying the B’ allele is expected to have improved processing characteristics, particularly for cheese-making. Supplementary Information The online version contains supplementary material available at 10.1186/s12711-022-00711-z.
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Affiliation(s)
- Stephen R Davis
- Research & Development, Livestock Improvement Corporation, Ruakura Road, Hamilton, New Zealand. .,ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand.
| | - Hamish E Ward
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand
| | - Van Kelly
- School of Biological Sciences, University of Auckland, Symonds Street, Auckland, New Zealand
| | - David Palmer
- School of Biological Sciences, University of Auckland, Symonds Street, Auckland, New Zealand
| | - Alexandra E Ankersmit-Udy
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand
| | - Thomas J Lopdell
- Research & Development, Livestock Improvement Corporation, Ruakura Road, Hamilton, New Zealand
| | - Sarah D Berry
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand
| | - Mathew D Littlejohn
- Research & Development, Livestock Improvement Corporation, Ruakura Road, Hamilton, New Zealand
| | - Kathryn Tiplady
- Research & Development, Livestock Improvement Corporation, Ruakura Road, Hamilton, New Zealand
| | - Linda F Adams
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand
| | - Katie Carnie
- Research & Development, Livestock Improvement Corporation, Ruakura Road, Hamilton, New Zealand
| | - Alayna Burrett
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand
| | - Natalie Thomas
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand
| | - Russell G Snell
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand.,School of Biological Sciences, University of Auckland, Symonds Street, Auckland, New Zealand
| | - Richard J Spelman
- Research & Development, Livestock Improvement Corporation, Ruakura Road, Hamilton, New Zealand
| | - Klaus Lehnert
- ViaLactia Biosciences Ltd., a subsidiary (now closed) of Fonterra Co-Operative Ltd., Fanshawe Street, Auckland, New Zealand
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Zhang T, Wilson IB, Zullo AR, Meyers DJ, Lee Y, Daiello LA, Kim DH, Kiel DP, Shireman TI, Berry SD. Hip Fracture Rates in Nursing Home Residents With and Without HIV. J Am Med Dir Assoc 2022; 23:517-518. [PMID: 34582781 PMCID: PMC8938961 DOI: 10.1016/j.jamda.2021.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/21/2022]
Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David J Meyers
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Lori A Daiello
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Dae Hyun Kim
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research & Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, 1200 Centre Street, Boston, MA, USA
| | - Douglas P Kiel
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research & Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, 1200 Centre Street, Boston, MA, USA
| | - Theresa I Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Sarah D Berry
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research & Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, 1200 Centre Street, Boston, MA, USA
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Berry SD, Goldfeld KS, McConeghy K, Gifford D, Davidson HE, Han L, Syme M, Gandhi A, Mitchell SL, Harrison J, Recker A, Johnson KS, Gravenstein S, Mor V. Evaluating the Findings of the IMPACT-C Randomized Clinical Trial to Improve COVID-19 Vaccine Coverage in Skilled Nursing Facilities. JAMA Intern Med 2022; 182:324-331. [PMID: 35099523 PMCID: PMC8804975 DOI: 10.1001/jamainternmed.2021.8067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Identifying successful strategies to increase COVID-19 vaccination among skilled nursing facility (SNF) residents and staff is integral to preventing future outbreaks in a continually overwhelmed system. OBJECTIVE To determine whether a multicomponent vaccine campaign would increase vaccine rates among SNF residents and staff. DESIGN, SETTING, AND PARTICIPANTS This was a cluster randomized trial with a rapid timeline (December 2020-March 2021) coinciding with the Pharmacy Partnership Program (PPP). It included 133 SNFs in 4 health care systems across 16 states: 63 and 70 facilities in the intervention and control arms, respectively, and participants included 7496 long-stay residents (>100 days) and 17 963 staff. INTERVENTIONS Multicomponent interventions were introduced at the facility level that included: (1) educational material and electronic messaging for staff; (2) town hall meetings with frontline staff (nurses, nurse aides, dietary, housekeeping); (3) messaging from community leaders; (4) gifts (eg, T-shirts) with socially concerned messaging; (5) use of a specialist to facilitate consent with residents' proxies; and (6) funds for additional COVID-19 testing of staff/residents. MAIN OUTCOMES AND MEASURES The primary outcomes of this study were the proportion of residents (from electronic medical records) and staff (from facility logs) who received a COVID-19 vaccine (any), examined as 2 separate outcomes. Mixed-effects generalized linear models with a binomial distribution were used to compare outcomes between arms, using intent-to-treat approach. Race was examined as an effect modifier in the resident outcome model. RESULTS Most facilities were for-profit (95; 71.4%), and 1973 (26.3%) of residents were Black. Among residents, 82.5% (95% CI, 81.2%-83.7%) were vaccinated in the intervention arm, compared with 79.8% (95% CI, 78.5%-81.0%) in the usual care arm (marginal difference 0.8%; 95% CI, -1.9% to 3.7%). Among staff, 49.5% (95% CI, 48.4%-50.6%) were vaccinated in the intervention arm, compared with 47.9% (95% CI, 46.9%-48.9%) in usual care arm (marginal difference: -0.4%; 95% CI, -4.2% to 3.1%). There was no association of race with the outcome among residents. CONCLUSIONS AND RELEVANCE A multicomponent vaccine campaign did not have a significant effect on vaccination rates among SNF residents or staff. Among residents, vaccination rates were high. However, half the staff remained unvaccinated despite these efforts. Vaccination campaigns to target SNF staff will likely need to use additional approaches. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04732819.
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Affiliation(s)
- Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Keith S Goldfeld
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Kevin McConeghy
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Providence Veteran's Administration Medical Center, Providence, Rhode Island
| | - David Gifford
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC
| | | | - Lisa Han
- Insight Therapeutics, Norfolk, Virginia
| | - Maggie Syme
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Ashvin Gandhi
- University of California, Los Angeles Anderson School of Management, Los Angeles
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jill Harrison
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Amy Recker
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island
| | - Kimberly S Johnson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Stefan Gravenstein
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Vincent Mor
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island.,Providence Veteran's Administration Medical Center, Providence, Rhode Island
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Zullo AR, Duprey MS, Smith RJ, Gutman R, Berry SD, Munshi MN, Dore DD. Effects of dipeptidyl peptidase-4 inhibitors and sulphonylureas on cognitive and physical function in nursing home residents. Diabetes Obes Metab 2022; 24:247-256. [PMID: 34647409 PMCID: PMC8741644 DOI: 10.1111/dom.14573] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/26/2021] [Accepted: 10/08/2021] [Indexed: 02/03/2023]
Abstract
AIMS Dipeptidyl peptidase-4 inhibitors (DPP4Is) may mitigate hypoglycaemia-mediated declines in cognitive and physical functioning compared with sulphonylureas (SUs), yet comparative studies are unavailable among older adults, particularly nursing home (NH) residents. We evaluated the effects of DPP4Is versus SUs on cognitive and physical functioning among NH residents. MATERIALS AND METHODS This new-user cohort study included long-stay NH residents aged ≥65 years from the 2007-2010 national US Minimum Data Set (MDS) clinical assessments and linked Medicare claims. We measured cognitive decline from the validated 6-point MDS Cognitive Performance Scale, functional decline from the validated 28-point MDS Activities of Daily Living scale, and hospitalizations or emergency department visits for altered mental status from Medicare claims. We compared 180-day outcomes in residents who initiated a DPP4I versus SU after 1:1 propensity score matching using Cox regression models. RESULTS The matched cohort (N = 1784) had a mean ± SD age of 80 ± 8 years and 73% were women. Approximately 46% had no or mild cognitive impairment and 35% had no or mild functional impairment before treatment initiation. Compared with SU users, DPP4I users had lower 180-day rates of cognitive decline [hazard ratio (HR) = 0.61, 95% confidence interval (CI) 0.31-1.19], altered mental status events (HR = 0.71, 95% CI 0.39-1.27), and functional decline (HR = 0.89, 95% CI 0.51-1.56), but estimates were imprecise. CONCLUSIONS Rates of cognitive and functional decline may be reduced among older NH residents using DPP4Is compared with SUs, but larger studies with greater statistical power should resolve the remaining uncertainty by providing more precise effect estimates.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI
- Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI
| | - Matthew S. Duprey
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Robert J. Smith
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Warren Alpert Medical School, Brown University
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health
| | - Sarah D. Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Medha N. Munshi
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Joslin Diabetes Center, Boston, MA
| | - David D. Dore
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Exponent, Natick, MA
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Seligman BJ, Berry SD, Lipsitz LA, Travison TG, Kiel DP. Epigenetic Age Acceleration and Change in Frailty in MOBILIZE Boston. J Gerontol A Biol Sci Med Sci 2022; 77:1760-1765. [PMID: 35037036 PMCID: PMC9434439 DOI: 10.1093/gerona/glac019] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 08/30/2021] [Indexed: 01/19/2023] Open
Abstract
Age-associated changes in DNA methylation have been implicated as 1 mechanism to explain the development of frailty; however, previous cross-sectional studies of epigenetic age acceleration (eAA) and frailty have had inconsistent findings. Few longitudinal studies have considered the association of eAA with change in frailty. We sought to determine the association between eAA and change in frailty in the MOBILIZE Boston cohort. Participants were assessed at 2 visits 12-18 months apart. Intrinsic, extrinsic, GrimAge, and PhenoAge eAA were assessed from whole-blood DNA methylation at baseline using the Infinium 450k array. Frailty was assessed by a continuous frailty score based on the frailty phenotype and by frailty index (FI). Analysis was by correlation and linear regression with adjustment for age, sex, smoking status, and body mass index. Three hundred and ninety-five participants with a frailty score and 431 with an FI had epigenetic and follow-up frailty measures. Mean (standard deviation) ages were 77.8 (5.49) and 77.9 (5.47) for the frailty score and the FI cohorts respectively, and 232 (58.7%) and 257 (59.6%) were female. All participants with epigenetic data identified as White. Baseline frailty score was not correlated with intrinsic or extrinsic eAA, but was correlated with PhenoAge and, even after adjustment for covariates, GrimAge. Baseline FI was correlated with extrinsic, GrimAge, and PhenoAge eAA with and without adjustment. No eAA measure was associated with change in frailty, with or without adjustment. Our results suggest that no eAA measure was associated with change in frailty. Further studies should consider longer periods of follow-up and repeated eAA measurement.
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Affiliation(s)
- Benjamin J Seligman
- Address correspondence to: Benjamin J. Seligman, MD, PhD, Division of Geriatric Medicine, Department of Medicine, David Geffen School of Medicine, 1100 Glendon Avenue, 710–714, Los Angeles, CA 90024, USA. E-mail:
| | - Sarah D Berry
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Lewis A Lipsitz
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas G Travison
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Douglas P Kiel
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA,Broad Institute of MIT & Harvard, Cambridge, Massachusetts, USA
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Lee DS, Zullo AR, Lee Y, Daiello LA, Kim DH, Kiel DP, Berry SD. Discontinuation of beta-blockers among nursing home residents at end of life. J Am Geriatr Soc 2022; 70:200-207. [PMID: 34669190 PMCID: PMC8742763 DOI: 10.1111/jgs.17493] [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: 06/09/2021] [Revised: 09/01/2021] [Accepted: 09/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Given limited life expectancy of nursing home (NH) residents, harms of continuing beta-blockers (BBs) may outweigh clinical benefits. Our objective was to describe beta-blocker discontinuation for NH residents during the last year of life, and identify characteristics associated with earlier discontinuation. METHODS This was a retrospective cohort study that included all long-stay residents in fee-for-service Medicare who died in 2016 and were prescribed oral BBs 1 year before death. Beta-blocker discontinuation was defined as a gap in medication on hand for ≥45 days per Medicare Part D claims, measured from the last date drug was on hand. Comorbidities were obtained from Chronic Condition Warehouse, and other characteristics from the Minimum Data Set. Kaplan-Meier curves were used to describe time to first discontinuation. Findings were stratified by cardiac diagnoses, perceived life expectancy of <6 months, or elevated mortality index. RESULTS Eighty-eight thousand two hundred and eighty-four residents were prescribed ≥1 daily BB 12 months before death. Mean age was 84.1 years and 69.2% were female. Of these, 60,573 residents (68.6%) remained on a BB in the last 45 days of life, and 57,880 residents (65.6%) had ≥1 cardiac diagnosis. Only 5239 residents (5.9%) had elevated mortality index, whereas 16,798 residents (19.0%) had perceived poor prognosis. In the last year of life, there was no difference in beta-blocker discontinuation pattern between residents with and without cardiac diagnoses. Residents with perceived poor prognosis and elevated mortality index discontinued BBs earlier. For example, mean time until discontinuation among residents with poor perceived prognosis was 245 versus 279 days in residents without such prognosis (p < 0.0001). CONCLUSIONS BBs are commonly prescribed to NH residents in the final year of life. Overall, discontinuation occurs earlier in residents for whom clinicians perceive limited life expectancy, suggesting that improved prognostication may offer an important opportunity to reduce polypharmacy toward end of life.
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Affiliation(s)
| | | | - Yoojin Lee
- Brown University School of Public Health
| | | | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife,Beth Israel Deaconess Medical Center & Harvard Medical School
| | - Douglas P. Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife,Beth Israel Deaconess Medical Center & Harvard Medical School
| | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife,Beth Israel Deaconess Medical Center & Harvard Medical School
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Xue T(M, Colón-Emeric CS, Herndon L, Hecker EJ, Berry SD, Little MO, McConnell ES. Strengthening Resident, Proxy, and Staff Engagement in Injury Prevention in Skilled Nursing Facilities. Gerontologist 2021; 62:1112-1123. [PMID: 34971374 PMCID: PMC9451018 DOI: 10.1093/geront/gnab193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/30/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Engaging residents, their proxies, and skilled nursing facility (SNF) staff through effective communication has potential for improving fall-related injury prevention. The purpose of this study was to understand how multiple stakeholders develop and communicate fall-related injury prevention plans to enhance sustained implementation. RESEARCH DESIGN AND METHODS Descriptive qualitative study using framework analysis applied to open-ended semistructured interviews (n = 28) regarding experiences of communication regarding fall-related injury prevention, guided by the Patient and Family Engaged Care framework. Participants included residents at high risk of injury and their proxies, nursing assistants, nurses, and a nurse practitioner from 3 SNFs in the Eastern United States (Massachusetts and North Carolina). RESULTS Interdisciplinary teams were viewed as essential for injury prevention. However, the roles of the interdisciplinary team members were sometimes unclear. Communication structures were often hierarchical, which reduced engagement of nursing assistants and frustrated proxies. Practices that enhanced engagement included knowing the residents, active listening skills, and use of strategies for respecting autonomy. Engagement was inhibited by time constraints, lack of proactive communication among staff, and by challenges eliciting the perspectives of residents with dementia. Resident barriers included desire for autonomy, strong preferences, and language differences. DISCUSSION AND IMPLICATIONS Strengthening team meeting processes and cultivating open communication and collaboration could facilitate staff, resident, and proxy engagement in injury prevention planning and implementation. Skill building and targeting resources to improve communication can address barriers related to staff practices, resident characteristics, and time constraints.
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Affiliation(s)
- Tingzhong (Michelle) Xue
- Address correspondence to: Tingzhong (Michelle) Xue, MS, RN, Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710, USA. E-mail:
| | - Cathleen S Colón-Emeric
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA,Division of Geriatrics in the Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laurie Herndon
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Emily J Hecker
- Division of Geriatrics in the Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Milta O Little
- Division of Geriatrics in the Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eleanor S McConnell
- Duke University School of Nursing, Durham, North Carolina, USA,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
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36
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Canaday DH, Oyebanji OA, White E, Keresztesy D, Payne M, Wilk D, Carias L, Aung H, St Denis K, Sheehan ML, Berry SD, Cameron CM, Cameron MJ, Wilson BM, Balazs AB, King CL, Gravenstein S. Significantly elevated antibody levels and neutralization titers in nursing home residents after SARS-CoV-2 BNT162b2 mRNA booster vaccination. medRxiv 2021:2021.12.07.21267179. [PMID: 34909792 PMCID: PMC8669859 DOI: 10.1101/2021.12.07.21267179] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Nursing home (NH) residents have experienced significant morbidity and mortality to SARS-CoV-2 throughout the pandemic. Vaccines initially curbed NH resident morbidity and mortality, but antibody levels and protection have declined with time since vaccination, prompting introduction of booster vaccination. This study assesses humoral immune response to booster vaccination in 85 NH residents and 44 health care workers (HCW) that we have followed longitudinally since initial SARS-CoV-2 BNT162b2 mRNA vaccination. The findings reveal that booster vaccination significantly increased anti-spike, anti-receptor binding domain, and neutralization titers above the pre-booster levels in almost all NH residents and HCW to significantly higher levels than shortly after the completion of the initial vaccine series. These data support the CDC recommendation to offer vaccine boosters to HCWs and NH residents on an immunological basis. Notably, even the older, more frail and more multi-morbid NH residents have sizable antibody increases with boosting.
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Affiliation(s)
- David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | | | - Elizabeth White
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | | | - Michael Payne
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Dennis Wilk
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Lenore Carias
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Htin Aung
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Cheryl M Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mark J Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | | | | | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI
- Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, RI
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37
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Canaday DH, Carias L, Oyebanji OA, Keresztesy D, Wilk D, Payne M, Aung H, St. Denis K, Lam EC, Rowley CF, Berry SD, Cameron CM, Cameron MJ, Wilson B, Balazs AB, Gravenstein S, King CL. Reduced BNT162b2 Messenger RNA Vaccine Response in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)-Naive Nursing Home Residents. Clin Infect Dis 2021; 73:2112-2115. [PMID: 33993265 PMCID: PMC8240817 DOI: 10.1093/cid/ciab447] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [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] [Received: 04/04/2021] [Indexed: 11/14/2022] Open
Abstract
After BNT162b2 messenger RNA vaccination, antibody levels to spike, receptor-binding domain, and virus neutralization were examined in 149 nursing home residents and 110 healthcare worker controls. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-naive nursing home residents' median post-second vaccine dose antibody neutralization titers are one-quarter that of SARS-CoV-2-naive healthcare workers.
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Affiliation(s)
- David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Geriatric Research, Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Lenore Carias
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Oladayo A Oyebanji
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Debbie Keresztesy
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Dennis Wilk
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael Payne
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Htin Aung
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kerri St. Denis
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts, USA
| | - Evan C Lam
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts, USA
| | - Christopher F Rowley
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Cheryl M Cameron
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mark J Cameron
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brigid Wilson
- Geriatric Research, Education and Clinical Center, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Alejandro B Balazs
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts, USA
| | - Stefan Gravenstein
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center on Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Christopher L King
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Division of Infectious Diseases, Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
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38
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Canaday DH, Oyebanji OA, Keresztesy D, Payne M, Wilk D, Carias L, Aung H, St. Denis K, Lam EC, Rowley CF, Berry SD, Cameron CM, Cameron MJ, Wilson BM, Balazs AB, King CL, Gravenstein S. Significant Reduction in Vaccine-Induced Antibody Levels and Neutralization Activity Among Healthcare Workers and Nursing Home Residents 6 Months Following Coronavirus Disease 2019 BNT162b2 mRNA Vaccination. Clin Infect Dis 2021; 75:e884-e887. [PMID: 35174389 PMCID: PMC9402619 DOI: 10.1093/cid/ciab963] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 09/29/2021] [Indexed: 01/19/2023] Open
Abstract
Antibody decline occurred from 2 weeks to 6 months post-BNT162b2 mRNA vaccination in nursing home (NH) residents and healthcare workers. Antispike, receptor-binding domain, and neutralization levels dropped >81% irrespective of prior infection. Notably, 69% of infection-naive NH residents had neutralizing antibodies at or below the assay's limit of detection.
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Affiliation(s)
- David H Canaday
- Correspondence: D. H. Canaday, Case Western Reserve University School of Medicine, 10900 Euclid Ave, BRB 1022, Cleveland, OH 44106-4984 ()
| | - Oladayo A Oyebanji
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Debbie Keresztesy
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael Payne
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Dennis Wilk
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Lenore Carias
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Htin Aung
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Kerri St. Denis
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, USA
| | - Evan C Lam
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, USA
| | - Christopher F Rowley
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Cheryl M Cameron
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mark J Cameron
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Brigid M Wilson
- Geriatric Research, Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | | | - Christopher L King
- Division of Infectious Disease, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Stefan Gravenstein
- Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA,Center on Innovation in Long-Term Services and Supports, Providence Veterans Administration Medical Center, Providence, Rhode Island, USA
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Berry SD, Baier RR, Syme M, Gouskova N, Bishnoi C, Patel U, Leitson M, Gharpure R, Stone ND, Link-Gelles R, Gifford DR. Strategies associated with COVID-19 vaccine coverage among nursing home staff. J Am Geriatr Soc 2021; 70:19-28. [PMID: 34741529 PMCID: PMC8657529 DOI: 10.1111/jgs.17559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/01/2021] [Revised: 10/08/2021] [Accepted: 10/24/2021] [Indexed: 11/29/2022]
Abstract
Background After the first of three COVID‐19 vaccination clinics in U.S. nursing homes (NHs), the median vaccination coverage of staff was 37.5%, indicating the need to identify strategies to increase staff coverage. We aimed at comparing the facility‐level activities, policies, incentives, and communication methods associated with higher staff COVID‐19 vaccination coverage. Methods Design. Case–control analysis. Setting. Nationally stratified random sample of 1338 U.S. NHs participating in the Pharmacy Partnership for Long‐Term Care Program. Participants. Nursing home leadership. Measurement. During February 4–March 2, 2021, we surveyed NHs with low (<35%), medium (40%–60%), and high (>75%) staff vaccination coverage, to collect information on facility strategies used to encourage staff vaccination. Cases were respondents with medium and high vaccination coverage, whereas controls were respondents with low coverage. We used logistic regression modeling, adjusted for county and NH characteristics, to identify strategies associated with facility‐level vaccination coverage. Results We obtained responses from 413 of 1338 NHs (30.9%). Compared with facilities with lower staff vaccination coverage, facilities with medium or high coverage were more likely to have designated frontline staff champions (medium: adjusted odds ratio [aOR] 3.6, 95% CI 1.3–10.3; high: aOR 2.9, 95% CI 1.1–7.7) and set vaccination goals (medium: aOR 2.4, 95% 1.0–5.5; high: aOR 3.7, 95% CI 1.6–8.3). NHs with high vaccination coverage were more likely to have given vaccinated staff rewards such as T‐shirts compared with NHs with low coverage (aOR 3.8, 95% CI 1.3–11.0). Use of multiple strategies was associated with greater likelihood of facilities having medium or high vaccination coverage: For example, facilities that used ≥9 strategies were three times more likely to have high staff vaccination coverage than facilities using <6 strategies (aOR 3.3, 95% CI 1.2–8.9). Conclusions Use of designated champions, setting targets, and use of non‐monetary awards were associated with high NH staff COVID‐19 vaccination coverage.
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Affiliation(s)
- Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, and Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rosa R Baier
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Maggie Syme
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Natalia Gouskova
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Courtney Bishnoi
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Urvi Patel
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Michael Leitson
- Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Radhika Gharpure
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nimalie D Stone
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ruth Link-Gelles
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,US Public Health Service Commissioned Corps, Rockville, Maryland, USA
| | - David R Gifford
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Health Policy and Evaluation in Long-Term Care, American Health Care Association/National Center for Assisted Living, Washington, DC, USA
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Abey-Nesbit R, Schluter PJ, Wilkinson TJ, Thwaites JH, Berry SD, Allore H, Jamieson HA. Risk factors for injuries in New Zealand older adults with complex needs: a national population retrospective study. BMC Geriatr 2021; 21:630. [PMID: 34736406 PMCID: PMC8567659 DOI: 10.1186/s12877-021-02576-1] [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: 10/12/2020] [Accepted: 10/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls and falls-related injuries are common among older adults. Injuries in older adults lead to poor outcomes and lower quality of life. The objective of our study was to identify factors associated with fall-related injuries among home care clients in New Zealand. METHODS The study cohort consisted of 75,484 community-dwelling people aged 65 years or older who underwent an interRAI home care assessment between June 2012 and June 2018 in New Zealand. The injuries included for analysis were fracture of the distal radius, hip fracture, pelvic fracture, proximal humerus fracture, subarachnoid haemorrhage, traumatic subdural haematoma, and vertebral fracture. Unadjusted and adjusted competing risk regression models were used to identify factors associated with fall-related injuries. RESULTS A total of 7414 (9.8%) people sustained a falls-related injury over the 6-year period, and most injuries sustained were hip fractures (4735 63.9%). The rate of injurious falls was 47 per 1000 person-years. The factors associated with injury were female sex, older age, living alone, Parkinson's disease, stroke/CVA, falls, unsteady gait, tobacco use, and being underweight. Cancer, dyspnoea, high BMI, and a decrease in the amount of food or fluid usually consumed, were associated with a reduced risk of sustaining an injury. After censoring hip fractures the risks associated with other types of injury were sex, age, previous falls, dyspnoea, tobacco use, and BMI. CONCLUSIONS While it is important to reduce the risk of falls, it is especially important to reduce the risk of falls-related injuries. Knowledge of risk factors associated with these types of injuries can help to develop focused intervention programmes and development of a predictive model to identify those who would benefit from intervention programmes.
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Affiliation(s)
- Rebecca Abey-Nesbit
- Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand.
| | - Philip J Schluter
- School of Health Sciences, University of Canterbury-Te Whare Wānanga o Waitaha, Christchurch, New Zealand.,School of Clinical Medicine - Primary Care Clinical Unit, The University of Queensland, Brisbane, Australia
| | - Tim J Wilkinson
- Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand.,Canterbury District Health Board, Christchurch, New Zealand
| | | | - Sarah D Berry
- Harvard Medical School, Boston, MA, USA.,Division of Geriatric Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Hebrew Senior Life, Boston, MA, USA
| | - Heather Allore
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA.,Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Hamish A Jamieson
- Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand.,Canterbury District Health Board, Christchurch, New Zealand
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Niznik JD, Harrison J, White EM, Syme M, Hanson LC, Kelley CJ, Porter L, Berry SD. Perceptions of COVID-19 vaccines among healthcare assistants: A national survey. J Am Geriatr Soc 2021; 70:8-18. [PMID: 34449885 PMCID: PMC8657352 DOI: 10.1111/jgs.17437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 06/21/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
Background Limited COVID‐19 vaccination acceptance among healthcare assistants (HCAs) may adversely impact older adults, who are at increased risk for severe COVID‐19 infections. Our study objective was to evaluate the perceptions of COVID‐19 vaccine safety and efficacy in a sample of frontline HCAs, overall and by race and ethnicity. Methods An online survey was conducted from December 2020 to January 2021 through national e‐mail listserv and private Facebook page for the National Association of Health Care Assistants. Responses from 155 HCAs, including certified nursing assistants, home health aides, certified medical assistants, and certified medication technicians, were included. A 27‐item survey asked questions about experiences and perceptions of COVID‐19 vaccines, including how confident they were that COVID‐19 vaccines are safe, effective, and adequately tested in people of color. Multivariable regression was used to identify associations with confidence in COVID‐19 vaccines. Results We analyzed data from 155 completed responses. Among respondents, 23.9% were black and 8.4% Latino/a. Most respondents worked in the nursing home setting (53.5%), followed by hospitals (12.9%), assisted living (11.6%), and home care (10.3%). Respondents expressed low levels of confidence in COVID‐19 vaccines, with fewer than 40% expressing at least moderate confidence in safety (38.1%), effectiveness (31.0%), or adequate testing in people of color (27.1%). Non‐white respondents reported lower levels of confidence in adequate testing of vaccines compared to white respondents. In bivariate and adjusted models, respondents who gave more favorable scores of organizational leadership at their workplace expressed greater confidence in COVID‐19 vaccines. Conclusion Frontline HCAs reported low confidence in COVID‐19 vaccines. Stronger organizational leadership in the workplace appears to be an important factor in influencing HCA's willingness to be vaccinated. Action is needed to enhance COVID‐19 vaccine uptake in this important population with employers playing an important role to build vaccine confidence and trust among employees.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA.,Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Jill Harrison
- Department of Health Services, Policy, and Practice, Brown University, School of Public Health, Providence, Rhode Island, USA
| | - Elizabeth M White
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Maggie Syme
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Laura C Hanson
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
| | - Casey J Kelley
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
| | - Lori Porter
- National Association of Health Care Assistants (NAHCA), Carl Junction, Missouri, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, and Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Whitney SA, Berry SD. Rethinking Positive Coronavirus Results: Interpreting RT-PCR Testing in Nursing Home Residents. J Am Med Dir Assoc 2021; 22:2034-2035. [PMID: 34416149 PMCID: PMC8324419 DOI: 10.1016/j.jamda.2021.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Scott A Whitney
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Zullo AR, Smith RJ, Gutman R, Kohler B, Duprey MS, Berry SD, Munshi MN, Dore DD. Comparative safety of dipeptidyl peptidase-4 inhibitors and sulfonylureas among frail older adults. J Am Geriatr Soc 2021; 69:2923-2930. [PMID: 34291453 DOI: 10.1111/jgs.17371] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 05/03/2021] [Revised: 06/22/2021] [Accepted: 06/26/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Studies comparing dipeptidyl peptidase-4 inhibitors (DPP4Is) to sulfonylureas (SUs) are unavailable for frail older adults, especially nursing home (NH) residents. We examined the effects of DPP4Is versus SUs on severe adverse glycemic events, cardiovascular events, and death among NH residents. METHODS We conducted a national retrospective cohort study of long-stay NH residents aged ≥65 years using 2008-2010 national US Minimum Data Set clinical assessment data and linked Medicare claims. Exposure was new DPP4I versus new SU use assessed via Medicare Part D drug claims. One-year outcomes were severe hypoglycemia, severe hyperglycemia, acute myocardial infarction (AMI), heart failure (HF), major adverse cardiovascular events plus HF (MACE+HF), and death. We compared outcomes after propensity score matching using Cox proportional hazards regression models. RESULTS The cohort (N = 2016) had a mean (SD) age of 81 (8.1) years and was 72% female. Compared with SU users, DPP4I users had a lower 1-year rate of severe hypoglycemic events (HR = 0.57, 95% CI 0.34-0.94), but statistically similar rates of severe hyperglycemic events (HR = 0.94, 95% CI 0.52-1.72), AMI (HR = 0.76, 95% CI 0.44-1.30), HF (HR = 1.01, 95% CI 0.79-1.30), MACE+HF (HR = 0.90, 95% CI 0.72-1.12), and death (HR = 0.97, 95% CI 0.86-1.10). CONCLUSIONS DPP4Is should be a preferred treatment option over SUs for NH residents and other frail older adults given the importance of avoiding hypoglycemia.
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Affiliation(s)
- 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.,Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, Rhode Island, USA
| | - Robert J Smith
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Bianca Kohler
- Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, Rhode Island, USA
| | - Matthew S Duprey
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Medha N Munshi
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Joslin Diabetes Center, Boston, Massachusetts, USA
| | - David D Dore
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Health Sciences, Exponent, Inc., Natick, Massachusetts, USA
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44
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Binder EF, Christensen JC, Stevens-Lapsley J, Bartley J, Berry SD, Dobs AS, Fortinsky RH, Hildreth KL, Kiel DP, Kuchel GA, Marcus RL, McDonough CM, Orwig D, Sinacore DR, Schwartz RS, Volpi E, Magaziner J, Schechtman KB. A multi-center trial of exercise and testosterone therapy in women after hip fracture: Design, methods and impact of the COVID-19 pandemic. Contemp Clin Trials 2021; 104:106356. [PMID: 33716173 PMCID: PMC9119796 DOI: 10.1016/j.cct.2021.106356] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 11/25/2020] [Revised: 03/04/2021] [Accepted: 03/08/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Up to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown. METHODS The Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density. RESULTS Enrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology. CONCLUSIONS Results from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients.
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Affiliation(s)
- Ellen F Binder
- Division of Geriatrics and Nutritional Science, Washington University School of Medicine in St. Louis, St. Louis, MO, United States of America.
| | - Jesse C Christensen
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, United States of America
| | - Jennifer Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Denver, CO, United States of America
| | - Jenna Bartley
- UConn Center on Aging, University of Connecticut, Farmington, CT, United States of America
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Department of Medicine, Beth Isreal Deasconess Medical Center and Harvard Medical School, Boston, MA, United States of America
| | - Adrian S Dobs
- Department of Medicine, Johns Hopkins Medicine, Baltimore, MD, United States of America
| | - Richard H Fortinsky
- UConn Center on Aging, University of Connecticut, Farmington, CT, United States of America
| | - Kerry L Hildreth
- Division of Geriatrics, University of Colorado Anschutz Medical Campus, Denver, CO, United States of America
| | - Douglas P Kiel
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Department of Medicine, Beth Isreal Deasconess Medical Center and Harvard Medical School, Boston, MA, United States of America
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut, Farmington, CT, United States of America
| | - Robin L Marcus
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, United States of America
| | - Christine M McDonough
- School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Denise Orwig
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - David R Sinacore
- Department of Physical Therapy, High Point University, High Point, NC, United States of America
| | - Robert S Schwartz
- Division of Geriatrics, University of Colorado Anschutz Medical Campus, Denver, CO, United States of America
| | - Elena Volpi
- Sealy Center on Aging, University of Texas Medical Branch at Galveston, Galveston, TX, United States of America
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Kenneth B Schechtman
- Division of Biostatistics, Washington University School of Medicine in St. Louis, St. Louis, MO, United States of America
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45
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Mintz J, Lee A, Gold M, Hecker EJ, Colón-Emeric C, Berry SD. Validation of the Minimum Data Set Items on Falls and Injury in Two Long-Stay Facilities. J Am Geriatr Soc 2021; 69:1099-1100. [PMID: 33615432 PMCID: PMC8136143 DOI: 10.1111/jgs.16974] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/12/2020] [Accepted: 11/19/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Joel Mintz
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida, USA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, Massachusetts, USA
| | - Alexandra Lee
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Meryl Gold
- Albany Medical Center, Albany, New York, USA
| | - Emily J. Hecker
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Roslindale, Massachusetts, USA
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46
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Berry SD, Johnson KS, Myles L, Herndon L, Montoya A, Fashaw S, Gifford D. Lessons learned from frontline skilled nursing facility staff regarding COVID-19 vaccine hesitancy. J Am Geriatr Soc 2021; 69:1140-1146. [PMID: 33764497 PMCID: PMC8183564 DOI: 10.1111/jgs.17136] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
Background Presently a median of 37.5% of the U.S. skilled nursing facility (SNF) workforce has been vaccinated for COVID‐19. It is essential to understand vaccine hesitancy among SNF workers to inform vaccine campaigns going forward. Objective To describe the concerns raised among healthcare workers and staff from SNFs during town hall meetings. Design Sixty‐three SNFs from four corporations were invited to send Opinion Leaders, outspoken staff from nursing, nurse aid, dietary, housekeeping or recreational therapy, to attend a 1‐h virtual town hall meeting. Meetings used a similar format where the moderator solicited concerns that the attendees themselves had or had heard from others in the facility about the COVID‐19 vaccine. Physicians and moderators used personal stories to address concerns and reaffirmed positive emotions. Setting Twenty‐six video town hall meetings with SNF staff. Participants Healthcare workers and staff, with physicians serving as content experts. Measurement Questions and comments about the COVID‐19 vaccines noted by physicians. Results One hundred and ninety three staff from 50 facilities participated in 26 meetings between December 30, 2020 and January 15, 2021. Most staff reported getting information about the vaccine from friends or social media. Concerns about how rapidly the vaccines were developed and side effects, including infertility or pregnancy related concerns, were frequently raised. There were no differences in concerns raised by discipline. Questions about returning to prior activities after being vaccinated were common and offered the opportunity to build on positive emotions to reduce vaccine hesitancy. Conclusions Misinformation about the COVID‐19 vaccine was widespread among SNF staff. Sharing positive emotions and stories may be more effective than sharing data when attempting to reduce vaccine hesitancy in SNF staff.
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Affiliation(s)
- Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life & Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly S Johnson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lonnita Myles
- Center for Health Policy and Evaluation in LTC, American Health Care Association, Washington, District of Columbia, USA
| | - Laurie Herndon
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life & Harvard Medical School, Boston, Massachusetts, USA
| | - Ana Montoya
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Shekinah Fashaw
- Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - David Gifford
- Center for Health Policy and Evaluation in LTC, American Health Care Association, Washington, District of Columbia, USA.,Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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47
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Canaday DH, Carias L, Oyebanji OA, Keresztesy D, Wilk D, Payne M, Aung H, St Denis K, Lam EC, Wilson B, Rowley CF, Berry SD, Cameron CM, Cameron MJ, Balazs AB, Gravenstein S, King CL. Reduced BNT162b2 mRNA vaccine response in SARS-CoV-2-naive nursing home residents. medRxiv 2021:2021.03.19.21253920. [PMID: 33791727 PMCID: PMC8010759 DOI: 10.1101/2021.03.19.21253920] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The SARS-CoV-2 pandemic impact on nursing home (NH) residents prompted their prioritization for early vaccination. To fill the data gap for vaccine immunogenicity in NH residents, we examined antibody levels after BNT162b2 mRNA vaccine to spike, receptor binding domain (RBD) and for virus neutralization in 149 NH residents and 111 health care worker controls. SARS-CoV-2-naive NH residents mount antibody responses with nearly 4-fold lower median neutralization titers and half the anti-spike level compared to SARS-CoV-2-naive healthcare workers. By contrast, SARS-CoV-2-recovered vaccinated NH residents had neutralization, anti-spike and anti-RBD titers similar to SARS-CoV-2-recovered vaccinated healthcare workers. NH residents' blunted antibody responses have important implications regarding the quality and durability of protection afforded by neoantigen vaccines. We urgently need better longitudinal evidence on vaccine effectiveness specific to NH resident populations to inform best practices for NH infection control measures, outbreak prevention and potential indication for a vaccine boost.
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Affiliation(s)
- David H Canaday
- Case Western Reserve University School of Medicine, Cleveland, OH
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | - Lenore Carias
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | | | - Dennis Wilk
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Michael Payne
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Htin Aung
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Evan C Lam
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA
| | - Brigid Wilson
- Geriatric Research, Education and Clinical Center, Cleveland VA
| | - Christopher F Rowley
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah D Berry
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Cheryl M Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Mark J Cameron
- Case Western Reserve University School of Medicine, Cleveland, OH
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48
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Berning MJ, Palmer E, Tsai T, Mitchell SL, Berry SD. An advance care planning long-term care initiative in response to COVID-19. J Am Geriatr Soc 2021; 69:861-867. [PMID: 33577704 PMCID: PMC8013602 DOI: 10.1111/jgs.17051] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 10/29/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/03/2022]
Abstract
Objective Describe a systematic approach to address advance care planning (ACP) during a COVID‐19 outbreak and its impact on the incidence of new do‐not‐hospitalize (DNH) directives among long‐term care (LTC) residents. Design Prospective quality improvement initiative. Setting Two long‐term chronic care campuses within a large academic healthcare organization. Participants LTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020. Intervention Using a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID‐19 focused ACP discussions. Residents without DNH directives with COVID‐19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly. Measurements Residents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020. Results At baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID‐19 from April 2, 2020 to May 21, 2020. During follow‐up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID‐19, and 29/124 (23%) died. Conclusions There was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID‐19 pandemic through a systematic ACP initiative which utilized real‐time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.
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Affiliation(s)
| | - Emily Palmer
- Department of Medicine, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Timothy Tsai
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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49
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Zullo AR, Lee Y, Lary C, Daiello LA, Kiel DP, Berry SD. Comparative effectiveness of denosumab, teriparatide, and zoledronic acid among frail older adults: a retrospective cohort study. Osteoporos Int 2021; 32:565-573. [PMID: 33411003 PMCID: PMC7933063 DOI: 10.1007/s00198-020-05732-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 07/07/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
UNLABELLED The comparative effects of zoledronic acid, denosumab, and teriparatide for preventing hip fractures in frail older adults, especially those in nursing homes, were unknown. We found that denosumab and zoledronic acid may be as effective as teriparatide for hip fracture prevention in nursing home residents. INTRODUCTION Several non-oral drugs exist for osteoporosis treatment, including zoledronic acid (ZA), denosumab, and teriparatide. Little data exist on the comparative effectiveness of these drugs for hip fracture prevention in frail older adults. We examined their comparative effectiveness in one of the frailest segments of the US population-nursing home (NH) residents. METHODS We conducted a national retrospective cohort study of NH residents aged ≥ 65 years using 2012 to 2016 national US Minimum Data Set clinical assessment data and linked Medicare claims. New parenteral ZA, denosumab, and teriparatide use was assessed via Medicare Parts B and D; hip fracture outcomes via Part A; and 125 covariates for confounding adjustment via several datasets. We used inverse probability weighted (IPW) competing risk regression models to compare hip fracture risk between groups with teriparatide as the reference. RESULTS The study cohort (N = 2019) included 1046 denosumab, 578 teriparatide, and 395 ZA initiators. Mean age was 85 years, 90% were female, and 68% had at least moderate functional impairment. Seventy-two residents (3.6%) had a hip fracture and 1100 (54.5%) died over a mean follow-up of 1.5 years. Compared to teriparatide use, denosumab use was associated with a 46% lower risk of hip fracture (HR 0.54, 95% CI 0.29-1.00) and no difference was observed for ZA (HR 0.70, 95% CI 0.26-1.85). CONCLUSIONS Denosumab and ZA may be as effective as teriparatide for hip fracture prevention in frail older adults. Given their lower cost and easier administration, denosumab and ZA are likely preferable non-oral treatments for most frail, older adults.
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Affiliation(s)
- A R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, 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.
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, USA.
| | - Y Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
| | - C Lary
- Center for Outcomes Research, Maine Medical Center, Portland, ME, USA
| | - L A Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, 121 South Main Street, Box G-S121-8, Providence, RI, 02912, USA
- Alzheimer's Disease and Memory Disorders Center, Rhode Island Hospital, RI, Providence, USA
| | - D P Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - S D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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50
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Shi SM, Bakaev I, Chen H, Travison TG, Berry SD. Risk Factors, Presentation, and Course of Coronavirus Disease 2019 in a Large, Academic Long-Term Care Facility. J Am Med Dir Assoc 2020; 21:1378-1383.e1. [PMID: 32981664 PMCID: PMC7447263 DOI: 10.1016/j.jamda.2020.08.027] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/06/2020] [Accepted: 08/09/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To describe clinical characteristics and risk factors associated with coronavirus disease 2019 (COVID-19) in long-stay nursing home residents. DESIGN AND PARTICIPANTS Retrospective cohort study (March 16, 2020 to May 8, 2020). SETTING Academic long-term chronic care facility (Boston, MA). PARTICIPANTS Long-term care residents. METHODS Patient characteristics and clinical symptoms were obtained via electronic medical records and Minimum Data Set. Staff residence was inferred by zip codes. COVID-19 infection was confirmed by polymerase chain reaction testing using nasopharyngeal swabs. Residents were followed until discharge from facility, death, or up to 21 days. Risks of COVID-19 infection were modeled by generalized estimating equation to estimate the relative risk (RR) and 95% confidence intervals (CI) of patient characteristics and staff community of residence. RESULTS Overall 146 of 389 (37.5%) long-stay residents tested positive for COVID-19. At the time of positive test, 66 of 146 (45.5%) residents were asymptomatic. In the subsequent illness course, the most common symptom was anorexia (70.8%), followed by delirium (57.6%). During follow-up, 44 (30.1%) of residents with COVID-19 died. Mortality increased with frailty (16.7% in pre-frail, 22.2% in moderately frail, and 50.0% in frail; P < .001). The proportion of residents infected with COVID-19 varied across the long-term care units (range: 0%‒90.5%). In adjusted models, male sex (RR 1.80, 95% CI 1.07, 3.05), bowel incontinence (RR 1.97, 95% CI 1.10, 3.52), and staff residence remained significant predictors of COVID-19. For every 10% increase in the proportion of staff living in a high prevalence community, the risk of testing positive increased by 6% (95% CI 1.04, 1.08). CONCLUSIONS AND IMPLICATIONS Among long-term care residents diagnosed with COVID-19, nearly one-half were asymptomatic at the time of diagnosis. Predictors of COVID-19 infection included male sex, bowel incontinence, and staff residence in a community with a high burden of COVID-19. Universal testing of patients and staff in communities with high COVID-19 rates is essential to mitigate outbreaks.
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Affiliation(s)
- Sandra M Shi
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA; Hebrew SeniorLife, Department of Medicine, Boston, MA
| | - Innokentiy Bakaev
- Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA; Hebrew SeniorLife, Department of Medicine, Boston, MA
| | - Helen Chen
- Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA; Hebrew SeniorLife, Department of Medicine, Boston, MA
| | - Thomas G Travison
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA
| | - Sarah D Berry
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Beth Israel Deaconess Medical Center, Department of Medicine, and Harvard Medical School, Boston, MA; Hebrew SeniorLife, Department of Medicine, Boston, MA.
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