Publications by authors named "Ellen P McCarthy"

115 Publications

Guilt as an Influencer in End-of-Life Care Decisions for Nursing Home Residents With Advanced Dementia.

J Gerontol Nurs 2022 Jan 1;48(1):22-27. Epub 2022 Jan 1.

The concept of guilt has been studied in the context of caregivers of older adults with advanced dementia, usually describing the feelings a person has of placing a loved one in a long-term care facility; however, little research has been done to understand how nursing home staff and proxies for older adults with dementia describe guilt as a decision-influencer in end-of-life care. For the current study, private, semi-structured interviews were conducted with 158 nursing home staff and 44 proxies in 13 nursing homes across four demographic regions in the United States. Interviews were reviewed and analyzed for how the concept of guilt was perceived as a decision-influencer. Nursing home staff described guilt as an important influencer in why proxies make decisions about end-of-life care. Staff noted that proxies who felt guilty about their relationship with their loved one or lack of time spent at end-of-life tended to be more aggressive in care decisions, whereas no proxies mentioned guilt as an influencer in care decisions. Rather, proxies used language of obligation and commitment to describe why they make decisions. Findings highlight the disconnect between nursing home staff and proxies in what motivates proxies to make end-of-life decisions for loved ones. Nursing home staff should be aware of misconceptions about proxies and work to understand proxies' true rationale and motivations for making care decisions. [(1), 22-27.].
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http://dx.doi.org/10.3928/00989134-20211206-03DOI Listing
January 2022

Social Isolation and Falls Risk: Lack of Social Contacts Decreases the Likelihood of Bathroom Modification Among Older Adults With Fear of Falling.

J Appl Gerontol 2021 Dec 29:7334648211062373. Epub 2021 Dec 29.

Department of Epidemiology, 1857Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Fall prevention strategies exist, but little is known about factors that influence whether they are used. We assessed whether social isolation modifies the association between fear of falling (FOF) and bathroom environmental modification. Data were included from 2858 Medicare beneficiaries in the National Health and Aging Trends Study. FOF and social isolation were assessed at baseline (2011); new bathroom modifications were assessed 1-year post-baseline. Social network size was dichotomized as any versus no social contacts. Logistic regression assessed associations between FOF and bathroom modification. Effect modification between FOF and social isolation was assessed with multiplicative interaction terms. FOF was associated with increased odds of bathroom modification. We observed a statistically significant interaction between FOF and social isolation ( = 0.03). Among those with no social contacts, FOF was associated with reduced odds bathroom modification that did not reach statistical significance (OR 0.5, 95% CI 0.2-1.3).
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http://dx.doi.org/10.1177/07334648211062373DOI Listing
December 2021

Validation of Claims Algorithms to Identify Alzheimer's Disease and Related Dementias.

J Gerontol A Biol Sci Med Sci 2021 Dec 17. Epub 2021 Dec 17.

Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI.

Background: Using billing data generated through healthcare delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.

Methods: We included 5,784 Medicare-enrolled, Health and Retirement Study participants aged >65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.

Results: Positive predictive value (PPV) of claims ranged from 53.8-70.3% and was highest using a revised algorithm and 1-year of observation. The trade-off of greater PPV was lower sensitivity; sensitivity could be maximized using 3-years of observation. All algorithms had low sensitivity (31.3-56.8%) and high specificity (92.3-98.0%). Algorithm test performance varied by participant characteristics, including age and race.

Conclusions: Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the trade-offs in accuracy among the approaches they consider.
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http://dx.doi.org/10.1093/gerona/glab373DOI Listing
December 2021

Frailty and Differences in Self-Reported Sexual Functioning Among Older Females and Males in National Social life, Health and Aging Project.

J Aging Health 2021 Dec 6:8982643211053772. Epub 2021 Dec 6.

The Marcus Institute for Aging Research, 51043Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA.

Objective: To understand the association of frailty with females' and males' self-reported sexual functioning.

Methods: Logistic regression on 5 domains of sexual function by frailty status (robust, pre-frail, frail) were analyzed from 2058 respondents to National Social Life, Health, and Aging Project (2010-2011).

Results: Females had similar frailty profiles to males, but more often reported low overall sexual functioning (12.9% v. 4.0%). Compared to robust, pre-frail and frail males had higher odds of sexual function-related: anxiety (pre-frail OR 1.91 95% CI [1.33, 2.74]; frail OR 2.13 95% CI [1.03, 4.41]), negative changes (pre-frail: OR 1.40, 95% CI [1.00, 1.96]; frail: OR 2.42, 95% CI [1.51, 3.89]), and erectile dysfunction (pre-frail: OR 1.81, 95% CI [1.23,2.68]; frail: 2.00, 95% CI [1.00,4.02]); frail females had 1.69 times higher odds (95% CI [1.16,2.48]) of negative changes.

Discussion: Frailty may be a clinical indicator of sexual functioning decline for males more than females.
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http://dx.doi.org/10.1177/08982643211053772DOI Listing
December 2021

Facility Characteristics Associated With Intensity of Care of Nursing Homes and Hospital Referral Regions.

J Am Med Dir Assoc 2021 Nov 23. Epub 2021 Nov 23.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Objectives: Intensity of care, such as hospital transfers and tube feeding of residents with advanced dementia varies by nursing home (NH) within and across regions. Little work has been done to understand how these 2 levels of influence relate. This study's objectives are to identify facility factors associated with NHs providing high-intensity care to residents with advanced dementia and determine whether these factors differ within and across hospital referral regions (HRRs).

Design: Cross-sectional analysis.

Setting And Participants: 1449 NHs.

Methods: Nationwide 2016-2017 Minimum Data Set was used to categorize NHs and HRRs into 4 levels of care intensity based on rates of hospital transfers and tube feeding among residents with advanced dementia: low-intensity NH in a low-intensity HRR, high-intensity NH in a low-intensity HRR, low-intensity NH in a high-intensity HRR, and a high-intensity NH in a high-intensity HRR.

Results: In high-intensity HRRs, high-vs low-intensity NHs were more likely to be urban, lack a dementia unit, have a nurse practitioner or physician (NP or PA) on staff, and have a higher proportion of residents who were male, aged <65 years, Black, had pressure ulcers, and shorter hospice stays. In low-intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high-intensity NH.

Conclusions And Implications: These findings suggest that within high-intensity HRRs, there are potentially modifiable factors that could be targeted to reduce burdensome care in advanced dementia, including having a dementia unit, palliative care training for NPs and PAs, and increased use of hospice care.
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http://dx.doi.org/10.1016/j.jamda.2021.10.015DOI Listing
November 2021

Initiation of Long-Acting Opioids Following Hospital Discharge Among Medicare Beneficiaries.

J Hosp Med 2021 Dec;16(12):724-726

Harvard Medical School, Boston, Massachusetts.

Guidelines recommend against initiating long-acting opioids during acute hospitalization, owing to higher risk of overdose and morbidity compared to short-acting opioid initiation. We investigated the incidence of long-acting opioid initiation following hospitalization in a retrospective cohort of Medicare beneficiaries with an acute care hospitalization in 2016 who were ≥65 years old, did not have cancer or hospice care, and had not filled an opioid prescription within the preceding 90 days. Among 258,193 hospitalizations, 47,945 (18.6%) were associated with a claim for a new opioid prescription in the week after hospital discharge: 817 (0.3%) with both short- and long-acting opioids, 125 (0.1%) with long-acting opioids only, and 47,003 (18.2%) with short-acting opioids only. Most long-acting opioid claims occurred in surgical patients (770 out of 942; 81.7%). Compared with beneficiaries prescribed short-acting opioids only, beneficiaries prescribed long-acting opioids were younger, had a higher prevalence of diseases of the musculoskeletal system and connective tissue, and had more known risk factors for opioid-related adverse events, including anxiety disorders, opioid use disorder, prior long-term high-dose opioid use, and benzodiazepine co-prescription. These findings may help target quality-improvement initiatives.
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http://dx.doi.org/10.12788/jhm.3721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8626058PMC
December 2021

Barriers to identifying residents with dementia for embedded pragmatic trials: A call to action.

J Am Geriatr Soc 2021 Nov 2. Epub 2021 Nov 2.

Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA.

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http://dx.doi.org/10.1111/jgs.17539DOI Listing
November 2021

Relative risks of adverse events among older adults receiving opioids versus NSAIDs after hospital discharge: A nationwide cohort study.

PLoS Med 2021 09 27;18(9):e1003804. Epub 2021 Sep 27.

Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America.

Background: Although analgesics are initiated on hospital discharge in millions of adults each year, studies quantifying the risks of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) among older adults during this transition are limited. We sought to determine the incidence and risk of post-discharge adverse events among older adults with an opioid claim in the week after hospital discharge, compared to those with NSAID claims only.

Methods And Findings: We performed a retrospective cohort study using a national sample of Medicare beneficiaries age 65 and older, hospitalized in United States hospitals in 2016. We excluded beneficiaries admitted from or discharged to a facility. We derived a propensity score that included over 100 factors potentially related to the choice of analgesic, including demographics, diagnoses, surgeries, and medication coadministrations. Using 3:1 propensity matching, beneficiaries with an opioid claim in the week after hospital discharge (with or without NSAID claims) were matched to beneficiaries with an NSAID claim only. Primary outcomes included death, healthcare utilization (emergency department [ED] visits and rehospitalization), and a composite of known adverse effects of opioids or NSAIDs (fall/fracture, delirium, nausea/vomiting, complications of slowed colonic motility, acute renal failure, and gastritis/duodenitis) within 30 days of discharge. After propensity matching, there were 13,385 beneficiaries in the opioid cohort and 4,677 in the NSAID cohort (mean age: 74 years, 57% female). Beneficiaries receiving opioids had a higher incidence of death (1.8% versus 1.1%; relative risk [RR] 1.7 [1.3 to 2.3], p < 0.001, number needed to harm [NNH] 125), healthcare utilization (19.0% versus 17.4%; RR 1.1 [1.02 to 1.2], p = 0.02, NNH 59), and any potential adverse effect (25.2% versus 21.3%; RR 1.2 [1.1 to 1.3], p < 0.001, NNH 26), compared to those with an NSAID claim only. Specifically, they had higher relative risk of fall/fracture (4.5% versus 3.4%; RR 1.3 [1.1 to 1.6], p = 0.002), nausea/vomiting (9.2% versus 7.3%; RR 1.3 [1.1 to 1.4], p < 0.001), and slowed colonic motility (8.0% versus 6.2%; RR 1.3 [1.1 to 1.4], p < 0.001). Risks of delirium, acute renal failure, and gastritis/duodenitis did not differ between groups. The main limitation of our study is the observational nature of the data and possibility of residual confounding.

Conclusions: Older adults filling an opioid prescription in the week after hospital discharge were at higher risk for mortality and other post-discharge adverse outcomes compared to those filling an NSAID prescription only.
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http://dx.doi.org/10.1371/journal.pmed.1003804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8504723PMC
September 2021

Risk factors for opioid-related adverse drug events among older adults after hospital discharge.

J Am Geriatr Soc 2022 Jan 15;70(1):228-234. Epub 2021 Sep 15.

Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Background: Although opioids are initiated on hospital discharge in millions of older adults each year, there are no studies examining patient- and prescribing-related risk factors for opioid-related adverse drug events (ADEs) after hospital discharge among medical patients.

Methods: A retrospective cohort study of a national sample of Medicare beneficiaries aged 65 years and older, hospitalized for a medical reason, with at least one claim for an opioid within 2 days of hospital discharge. We excluded patients receiving hospice care and patients admitted from or discharged to a facility. We used administrative billing codes and medication claims to define potential opioid-related ADEs within 30 days of hospital discharge, and competing risks regression to identify risk factors for these events.

Results: Among 22,879 medical hospitalizations (median age 74, 36.9% female) with an opioid claim within 2 days of hospital discharge, a potential opioid-related ADE occurred in 1604 (7.0%). Independent risk factors included age of 80 years and older (HR 1.18, 95% CI 1.05-1.33); clinical conditions, including kidney disease (HR 1.22, 95% CI 1.08-1.37), dementia/delirium (HR 1.38, 95% CI 1.22-1.56), anxiety disorder (HR 1.20, 95% CI 1.06-1.36), opioid use disorder (HR 1.20, 95% CI 1.03-1.39), intestinal disorders (HR 1.31, 95% CI 1.15-1.49), pancreaticobiliary disorders (HR 1.32, 95% CI 1.09-1.61), and musculoskeletal and nervous system injuries (HR 1.35, 95% CI 1.17-1.54); red flags for opioid misuse (HR 1.37, 95% CI 1.04-1.80); opioid use in the 30 days before hospitalization (HR 1.20, 95% CI 1.08-1.34); and prescription of long-acting opioids (HR 1.34, 95% CI 1.06-1.70).

Conclusions: Potential opioid-related ADEs occurred within 30 days of hospital discharge in 7.0% of older adults discharged from a medical hospitalization with an opioid prescription. Identified risk factors can be used to inform physician decision-making, conversations with older adults about risk, and development and targeting of harm reduction strategies.
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http://dx.doi.org/10.1111/jgs.17453DOI Listing
January 2022

Overall survival with warfarin vs. low-molecular-weight heparin in cancer-associated thrombosis.

J Thromb Haemost 2021 11 21;19(11):2825-2834. Epub 2021 Sep 21.

Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Background: When compared with warfarin, low-molecular-weight heparin (LMWH) reduces the incidence of recurrent venous thromboembolism (VTE) in cancer. However, a survival benefit of LMWH over warfarin for the treatment of cancer-associated VTE has not been established.

Methods: Using the Surveillance, Epidemiology and End Results and Medicare linked database from 2007 through 2016, we identified Medicare beneficiaries (aged ≥66 years) who were: (1) diagnosed with primary gastric, colorectal, pancreatic, lung, ovarian, or brain cancer; (2) diagnosed with cancer-associated VTE; and (3) prescribed LMWH or warfarin within 30 days. The primary outcome was overall survival (OS). Patients were matched 1:1 using exact matching for cancer stage and propensity score matching for cancer diagnosis, age, year of VTE, and time from cancer diagnosis to index VTE. Cox proportional-hazards regression was performed to estimate hazard ratios (HR) and 95% confidence intervals (95% CI).

Results: A total of 9706 patients were included. Warfarin was associated with a significant improvement in OS compared with LMWH (median OS, 9.8 months [95% CI, 9.1-10.4] vs. 7.2 months [95% CI, 6.8-7.8]; HR, 0.86; 95% CI 0.83-0.90; p < .001). The survival advantage was most pronounced in pancreatic (HR 0.82 [95% CI, 0.74-0.90], p < .001) and gastric cancers (HR 0.82 [95% CI, 0.68-0.98], p = .03). The observed differences in survival were consistent across subgroups including cancer stage, age, comorbidity burden, and year of VTE.

Conclusions: In this population-based study, warfarin was associated with improved OS compared with LMWH for the treatment of cancer-associated VTE.
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http://dx.doi.org/10.1111/jth.15519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8530982PMC
November 2021

ADVANCE: Methodology of a qualitative study.

J Am Geriatr Soc 2021 08 10;69(8):2132-2142. Epub 2021 May 10.

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.

Background/objectives: Quantitative studies have documented persistent regional, facility, and racial differences in the intensity of care provided to nursing home (NH) residents with advanced dementia including, greater intensity in the Southeastern United States, among black residents, and wide variation among NHs in the same hospital referral region (HRR). The reasons for these differences are poorly understood, and the appropriate way to study them is poorly described.

Design: Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) is a large qualitative study to elucidate factors related to NH organizational culture and proxy perspectives contributing to differences in the intensity of advanced dementia care. Using nationwide 2016-2017 Minimum DataSet information, four HRRs were identified in which the relative intensity of advanced dementia care was high (N = 2 HRRs) and low (N = 2 HRRs) based on hospital transfer and tube-feeding rates among residents with this condition. Within those HRRs, we identified facilities providing high (N = 2 NHs) and low (N = 2 NHs) intensity care relative to all NHs in that HRR (N = 16 total facilities; 4 facilities/HRR).

Results/conclusions: To date, the research team conducted 275 h of observation in 13 NHs and interviewed 158 NH providers from varied disciplines to assess physical environment, care processes, decision-making processes, and values. We interviewed 44 proxies (black, N = 19; white, N = 25) about their perceptions of advance care planning, decision-making, values, communication, support, trust, literacy, beliefs about death, and spirituality. This report describes ADVANCE study design and the facilitators and challenges of its implementation, providing a template for the successful application of large qualitative studies focused on quality care in NHs.
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http://dx.doi.org/10.1111/jgs.17217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373706PMC
August 2021

Changes in a Frailty Index and Association with Mortality.

J Am Geriatr Soc 2021 04 29;69(4):1057-1062. Epub 2020 Dec 29.

Hinda and Arthur Marcus Institute for Aging, Hebrew Senior Life, Boston, Massachusetts, USA.

Background: Although frailty status is dynamic, whether improvements in frailty predict mortality is unknown.

Objective: Describe 1-year changes in a frailty index (FI) and association with 48-month mortality.

Design: Secondary analysis of the National Health in Aging Trends Study.

Setting: Community.

Participants: Five thousand six hundred and seventy two Medicare beneficiaries 65 and older (3,267 (55.8%) females).

Measurements: A 40-item deficit accumulation FI was measured in 2011 and 2012, based on multidomain assessment including comorbidities, activities of daily living, physical tasks, cognition, and performance testing. We categorized 2011 FI into robust (FI < 0.15), pre-frail (FI = 0.15-0.24), mild frailty (FI = 0.25-0.34), and moderate to severe frailty (FI ≥ 0.35). Change in frailty was calculated as the FI change from 2011 to 2012, categorized as either absolute (>0.045 decrease, 0.015-0.045 decrease, ±0.015 change, 0.015-0.045 increase, >0.045 increase) or proportional change (>20% decrease, 5-20% decrease, ±5% change, 5-20% increase, 20% increase). We measured the association of FI change with 4-year mortality using Cox regression.

Results: From 2011 to 2012, mean FI increased by 0.02 (standard deviation 0.07), with 58.6% having an increase. Over 4 years, 1,039 participants (13.6%) died. After adjusting for age and sex, compared to stable frailty (±0.015), both absolute (>0.045) and proportional (>20%) increases in frailty were associated with higher mortality among pre-frail participants (hazard ratio (HR) = 2.35, 95% confidence interval (CI) = (1.45-3.79) and HR (95% CI) = 3.32 (1.76-6.26), respectively), participants with mild frailty (HR (95% CI) = 1.96 (1.35-2.85) and 2.03 (1.37-3.02)) and moderate or severe frailty (HR (95% CI) = 1.99 (1.48-2.67) and 1.94 (1.43-2.63)) but not robust participants (HR (95% CI)= 1.48 (0.86-2.54), HR (95% CI) = 1.62 (0.80-3.28)). However, decreases in FI were not significantly associated with decreased risk of mortality.

Conclusions: Increasing deficit accumulation FI over 1 year is associated with increased mortality risk. While decreasing FI occurs, we did not find evidence to support reduced mortality risk.
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http://dx.doi.org/10.1111/jgs.17002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071066PMC
April 2021

Beyond the Health Deficit Count: Examining Deficit Patterns in a Deficit-Accumulation Frailty Index.

J Am Geriatr Soc 2021 03 25;69(3):792-797. Epub 2020 Nov 25.

The Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA.

Background/objectives: Exploring deficit patterns among frail people may reveal subgroups of different prognostic importance.

Design: Analysis of National Health and Aging Trends Study.

Setting: Community.

Participants: Community dwelling older adults with mild to moderate frailty (deficit-accumulation frailty index (FI) of 0.25-0.40) (n = 1821).

Measurements: Latent class analysis identified distinct clinical subgroups based on comorbidity (range: 0-10), National Health and Aging Trends Study dementia classification, and short physical performance battery (SPPB) (range: 0-12). Survival analyses compared 5-year mortality by subgroups.

Results: Three latent classes existed: Class 1 (n = 831, mean FI = 0.30) had 2.7% probable dementia, high comorbidities (mean = 3.6), and low physical impairment (SPPB mean = 9.9); Class 2 (n = 734, mean FI = 0.32) had 6.9% probable dementia, low comorbidities (mean = 2.8), and moderate physical impairment (SPPB mean = 6.2); Class 3 (n = 256, mean FI = 0.34) had 20.7% probable dementia, low comorbidities (mean = 2.4), and high physical impairment (SPPB mean = 2.0). Compared to Class 1, Classes 2 and 3 experienced higher 5-year mortality (C2: 1.28 (95% confidence intervals (CI) = 1.00-1.62); C3: 1.87 (95% CI = 1.29-2.73)).

Conclusion: Deficit patterns among the mild-to-moderately frail provide additional prognostic information and highlight opportunities for preventive interventions.
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http://dx.doi.org/10.1111/jgs.16955DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8049510PMC
March 2021

Reflections on the IJHPR's article collection on dementia.

Isr J Health Policy Res 2020 10 6;9(1):50. Epub 2020 Oct 6.

Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA, USA.

Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) constitute a worldwide public health crisis. In light of the AD/ADRD epidemic now existing within the global COVID-19 pandemic, the need for global action to improve dementia care is greater than ever. The article collection "Dementia- an Interdisciplinary Approach," in the Israeli Journal of Health Policy and Research (IJHPR) highlights the need for interprofessional approaches to improving outcomes for people living with dementia and their care partners, as well as the complexities of conducting dementia care research.
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http://dx.doi.org/10.1186/s13584-020-00411-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537951PMC
October 2020

National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia.

J Am Geriatr Soc 2020 10 23;68(10):2240-2248. Epub 2020 Jul 23.

Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

Background/objectives: Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking.

Design: Retrospective cohort study using the National Inpatient Sample from 2012 to 2016.

Setting: U.S. acute care hospitals.

Participants: A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia.

Measurements: Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs.

Results: The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community.

Conclusion: The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.
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http://dx.doi.org/10.1111/jgs.16636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811187PMC
October 2020

Diagnosed prevalence of Alzheimer's disease and related dementias in Medicare Advantage plans.

Alzheimers Dement (Amst) 2020 5;12(1):e12048. Epub 2020 Jul 5.

Hebrew Senior Life Hinda and Arthur Marcus Institute for Aging Research Boston Massachusetts USA.

Introduction: One-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA). Yet, little is known about MA beneficiaries diagnosed with Alzheimer's disease (AD) and AD-related dementias (AD/ADRD).

Methods: We calculated the prevalence of AD/ADRD diagnoses in 2014 and 2016 in three MA plans. We determined the demographic characteristics of beneficiaries diagnosed with AD/ADRD, and whether they disenrolled from the MA plan for any reason within 364 days from the index date.

Results: In 2014 and 2016, the overall prevalence of AD/ADRD diagnoses was 5.6% and 6.5%, respectively. In 2016, AD/ADRD beneficiaries were on average 82.4 (SD = 7.4) years of age, 61.8% female, and had multiple comorbidities. By 364 days post-index date, 32% of beneficiaries with AD/ADRD had disenrolled from their plan. The demographic characteristics of 2014 beneficiaries with diagnosed AD/ADRD were similar to their 2016 counterparts.

Discussion: The prevalence of AD/ADRD diagnosis in MA is lower than rates reported in Medicare fee-for-service.
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http://dx.doi.org/10.1002/dad2.12048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335904PMC
July 2020

Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care.

J Am Geriatr Soc 2020 07;68 Suppl 2:S14-S20

Center for Aging Research, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.
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http://dx.doi.org/10.1111/jgs.16618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393801PMC
July 2020

Achieving Health Equity in Embedded Pragmatic Trials for People Living with Dementia and Their Family Caregivers.

J Am Geriatr Soc 2020 07;68 Suppl 2:S8-S13

Department of Psychiatry and Behavioral Sciences, University of California Davis, Davis, California, USA.

Embedded pragmatic clinical trials (ePCTs) advance research on Alzheimer's disease/Alzheimer's disease and related dementias (AD/ADRD) in real-world contexts; however, health equity issues have not yet been fully considered, assessed, or integrated into ePCT designs. Health disparity populations may not be well represented in ePCTs without special efforts to identify and successfully recruit sites of care that serve larger numbers of these populations. The National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory's Health Equity Team will contribute to the overall mission of the collaboratory by developing and implementing strategies to address health equity in the conduct of ePCTs and ensure the collaboratory is a national resource for all Americans with dementia. As a first step toward meeting these goals, this article reviews what is currently known about the inclusion of health disparities populations of people living with dementia (PLWD) and their caregivers in ePCTs, highlights unique challenges related to health equity in the conduct of ePCTs, and suggests priority areas in the design and implementation of ePCTs to increase the awareness and avoidance of pitfalls that may perpetuate and magnify healthcare disparities. J Am Geriatr Soc 68:S8-S13, 2020.
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http://dx.doi.org/10.1111/jgs.16614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7422698PMC
July 2020

Embedded Pragmatic Trials in Dementia Care: Realizing the Vision of the NIA IMPACT Collaboratory.

J Am Geriatr Soc 2020 07;68 Suppl 2:S1-S7

Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.

Close to 6 million Americans have Alzheimer's disease (AD) or Alzheimer's disease and related dementia (AD/ADRD). These high-need, high-cost patients are vulnerable to receiving poor quality uncoordinated care, ultimately leading to adverse health outcomes, poor quality of life, and misuse of resources. Improving the care of persons living with dementia (PLWD) and their caregivers is an urgent public health challenge that must be informed by high-quality evidence. Although prior research has elucidated opportunities to improve AD/ADRD care, the adoption of promising interventions has been stymied by the lack of research evaluating their effectiveness when implemented under real-world conditions. Embedded pragmatic clinical trials (ePCTs) in healthcare systems have the potential to accelerate the translation of evidence-based interventions into clinical practice. Building from the foundation of the National Institutes of Healthcare Systems Collaboratory, in September 2019 the National Institute on Aging Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory was launched. Its mission is to build the nation's capacity to conduct ePCTs within healthcare systems for PLWD and their caregivers by (1) developing and disseminating best practice research methods, (2) supporting the design and conduct of ePCTs including pilot studies, (3) building investigator capacity through training and knowledge generation, (4) catalyzing collaboration among stakeholders, and (5) ensuring the research includes culturally tailored interventions for people from diverse backgrounds. This report presents the rationale, structure, key activities, and markers of success for the overall NIA IMPACT Collaboratory. The articles that follow in this special Issue describe the specific work of its 10 core working groups and teams. J Am Geriatr Soc 68:S1-S7, 2020.
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http://dx.doi.org/10.1111/jgs.16621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020214PMC
July 2020

Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art.

J Am Geriatr Soc 2020 07;68 Suppl 2:S49-S54

Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA.

Embedded pragmatic clinical trials (ePCTs) are embedded in healthcare systems as well as their data environments. For people living with dementia (PLWD), settings of care can be different from the general population and involve additional people whose information is also important. The ePCT designs have the opportunity to leverage data that becomes available through the normal delivery of care. They may be particularly valuable in Alzheimer's disease and Alzheimer's disease-related dementia (AD/ADRD), given the complexity of case identification and the diversity of care settings. Grounded in the objectives of the Data and Technical Core of the newly established National Institute on Aging Imbedded Pragmatic Alzheimer's Disease and AD-Related Dementias Clinical Trials Collaboratory (IMPACT Collaboratory), this article summarizes the state of the art in using existing data sources (eg, Medicare claims, electronic health records) in AD/ADRD ePCTs and approaches to integrating them in real-world settings. J Am Geriatr Soc 68:S49-S54, 2020.
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http://dx.doi.org/10.1111/jgs.16617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924260PMC
July 2020

Changes in Predictive Performance of a Frailty Index with Availability of Clinical Domains.

J Am Geriatr Soc 2020 08 10;68(8):1771-1777. Epub 2020 Apr 10.

Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.

Objectives: Determine the effects of missing data in frailty identification and risk prediction.

Design: Analysis of the National Health in Aging Trends Study.

Setting: Community.

Participants: About 6206 older adults.

Measurements: A 41-variable frailty index (FI) was constructed with the following domains: comorbidities, activities of daily living (ADLs), instrumental activities of daily living, self-reported physical limitations, physical performance, and neuropsychiatric tests. We evaluated discrimination after removing single and multiple domains, comparing C-statistics for predicting 5-year risk of mortality and 1-year risks of disability and falls.

Results: The full FI yielded a mean of .18 and C-statistics of .72 (95% confidence interval, .70-.74) for mortality, .80 (.77-.82) for disability, and .66 (.64-.68) for falls. Removal of any single domain shifted the FI distribution, resulting in a mean FI ranging from .13 (removing comorbidities) to .20 (removing ADLs) and frailty prevalence (FI ≥ .25) from 16.0% to 28.7%. Among robust participants models missing ADLs misclassified most often, (19% as pre-frail). Among pre-frail and frail participants missing comorbidities misclassified most often(69.2% from pre-frail to robust, 24% from frail to pre-frail, and 4.9% from frail to robust). Removal of any single domain minimally changed C-statistics: mortality, .71-.73; disability, .79-.80; and falls, .64-.66. Removing neuropsychiatric testing and physical performance yielded comparable C-statistics of .70, .78, and .66 for mortality, ADLs, and falls, respectively. However, removal of three or four domains based on likely availability decreased C-statistics for mortality (.69, .66),disability (.75, .70), and falls (.64, .63), respectively.

Conclusion: While FI discrimination is robust to missing information in any single domain, risk prediction is affected by absence of multiple domains. This work informs the application of FI as a clinical and research tool. J Am Geriatr Soc 68:1771-1777, 2020.
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http://dx.doi.org/10.1111/jgs.16436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872739PMC
August 2020

Changes in Predictive Performance of a Frailty Index with Availability of Clinical Domains.

J Am Geriatr Soc 2020 08 10;68(8):1771-1777. Epub 2020 Apr 10.

Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.

Objectives: Determine the effects of missing data in frailty identification and risk prediction.

Design: Analysis of the National Health in Aging Trends Study.

Setting: Community.

Participants: About 6206 older adults.

Measurements: A 41-variable frailty index (FI) was constructed with the following domains: comorbidities, activities of daily living (ADLs), instrumental activities of daily living, self-reported physical limitations, physical performance, and neuropsychiatric tests. We evaluated discrimination after removing single and multiple domains, comparing C-statistics for predicting 5-year risk of mortality and 1-year risks of disability and falls.

Results: The full FI yielded a mean of .18 and C-statistics of .72 (95% confidence interval, .70-.74) for mortality, .80 (.77-.82) for disability, and .66 (.64-.68) for falls. Removal of any single domain shifted the FI distribution, resulting in a mean FI ranging from .13 (removing comorbidities) to .20 (removing ADLs) and frailty prevalence (FI ≥ .25) from 16.0% to 28.7%. Among robust participants models missing ADLs misclassified most often, (19% as pre-frail). Among pre-frail and frail participants missing comorbidities misclassified most often(69.2% from pre-frail to robust, 24% from frail to pre-frail, and 4.9% from frail to robust). Removal of any single domain minimally changed C-statistics: mortality, .71-.73; disability, .79-.80; and falls, .64-.66. Removing neuropsychiatric testing and physical performance yielded comparable C-statistics of .70, .78, and .66 for mortality, ADLs, and falls, respectively. However, removal of three or four domains based on likely availability decreased C-statistics for mortality (.69, .66),disability (.75, .70), and falls (.64, .63), respectively.

Conclusion: While FI discrimination is robust to missing information in any single domain, risk prediction is affected by absence of multiple domains. This work informs the application of FI as a clinical and research tool. J Am Geriatr Soc 68:1771-1777, 2020.
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http://dx.doi.org/10.1111/jgs.16436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872739PMC
August 2020

Predicting Mortality and Adverse Outcomes: Comparing the Frailty Index to General Prognostic Indices.

J Gen Intern Med 2020 05 18;35(5):1516-1522. Epub 2020 Feb 18.

Hinda and Arthur Marcus Institute for Aging, Hebrew Senior Life, Boston, MA, USA.

Background: Mortality prediction models are useful to guide clinical decision-making based on prognosis. The frailty index, which allows prognostication and personalized care planning, has not been directly compared with validated prognostic models.

Objective: To compare the discrimination of mortality, disability, falls, and hospitalization between a frailty index and validated prognostic indices.

Design: Secondary Analysis of the National Health and Aging Trends Study.

Participants: Seven thousand thirty-three Medicare beneficiaries 65 years or older.

Measurements: We measured a deficit-accumulation frailty index, Schonberg index, and Lee index at the 2011 baseline assessment. Primary outcome was mortality at 5 years. Secondary outcomes were decline in activities of daily living (ADL), decline in instrumental activities of daily living (IADL), fall, and hospitalization at 1 year. We used C-statistics to compare discrimination between indices, adjusting for age and sex.

Results: The study population included 4146 (44.8%) with age ≥ 75 years, with a median frailty index of 0.15 (interquartile range 0.09-0.25). A total of 1385 participants died (14.7%) and 2386 (35.2%) were lost to follow-up. Frailty, Schonberg, and Lee indices predicted mortality similarly: C-statistics (95% confidence interval) were 0.78 (0.77-0.80) for frailty index; 0.79 (0.78-0.81) for Schonberg index; and 0.78 (0.77-0.80) for Lee index. The frailty index had higher C-statistics for decline in ADL function (frailty index, 0.80 [0.78-0.83]; Schonberg, 0.74 [0.72-0.76]; Lee, 0.74 [0.71-0.77]) and falls (frailty index, 0.66 [0.65-0.68]; Schonberg, 0.61 [0.58-0.63]; Lee, 0.61 [0.59-0.63]). C-statistics were similar for decline in IADL function (frailty index, 0.61 [0.59-0.63]; Schonberg, 0.60 [0.59-0.62]; Lee, 0.60 [0.58-0.62]) and hospitalizations (frailty index, 0.68 [0.66-0.70]; Schonberg, 0.68 [0.66-0.69]; Lee, 0.65 [0.63-0.67]).

Conclusions: A deficit-accumulation frailty index performs as well as prognostic indices for mortality prediction, and better predicts ADL disability and falls in community-dwelling older adults. Frailty assessment offers a unifying approach to risk stratification for key health outcomes relevant to older adults.
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http://dx.doi.org/10.1007/s11606-020-05700-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210351PMC
May 2020

Hospital Transfer Rates Among US Nursing Home Residents With Advanced Illness Before and After Initiatives to Reduce Hospitalizations.

JAMA Intern Med 2020 03;180(3):385-394

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.

Importance: Hospital transfers among nursing home residents in the United States who have been diagnosed with advanced illnesses and have limited life expectancy are often burdensome, costly, and of little clinical benefit. National initiatives, introduced since 2012, have focused on reducing such hospitalizations, but little is known about the consequences of these initiatives in this population.

Objective: To investigate the change in hospital transfer rates among nursing home residents with advanced illnesses, such as dementia, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD), from 2011 to 2017-before and after the introduction of national initiatives to reduce hospitalizations.

Design, Setting, And Participants: In this cross-sectional study, nationwide Minimum Data Set (MDS) assessments from January 1, 2011, to December 31, 2016 (with the follow-up for transfer rates until December 31, 2017), were used to identify annual inception cohorts of long-stay (>100 days) nursing home residents who had recently progressed to the advanced stages of dementia, CHF, or COPD. The data were analyzed from October 24, 2018, to October 3, 2019.

Main Outcomes And Measures: The number of hospital transfers (hospitalizations, observation stays, and emergency department visits) per person-year alive was calculated from the MDS assessment from the date when residents first met the criteria for advanced illness up to 12 months afterward using Medicare claims from 2011 to 2017. Transfer rates for all causes, potentially avoidable conditions (sepsis, pneumonia, dehydration, urinary tract infections, CHF, and COPD), and serious bone fractures (pelvis, hip, wrist, ankle, and long bones of arms or legs) were investigated. Hospice enrollment and mortality were also ascertained.

Results: The proportions of residents in the 2011 and 2016 cohorts who underwent any hospital transfer were 56.1% and 45.4% of those with advanced dementia, 77.6% and 69.5% of those with CHF, and 76.2% and 67.2% of those with COPD. The mean (SD) number of transfers per person-year alive for potentially avoidable conditions was higher in the 2011 cohort vs 2016 cohort: advanced dementia, 2.4 (14.0) vs 1.6 (11.2) (adjusted risk ratio [aRR], 0.73; 95% CI, 0.65-0.81); CHF, 8.5 (32.0) vs 6.7 (26.8) (aRR, 0.72; 95% CI, 0.65-0.81); and COPD, 7.8 (30.9) vs 5.5 (24.8) (aRR, 0.64; 95% CI, 0.57-0.72). Transfers for bone fractures remained unchanged, and mortality did not increase. Hospice enrollment was low across all illness groups and years (range, 23%-30%).

Conclusions And Relevance: The findings of this study suggest that concurrent with new initiatives aimed at reducing hospitalizations, hospital transfers declined between 2011 and 2017 among nursing home residents with advanced illnesses without increased mortality rates. Opportunities remain to further reduce unnecessary hospital transfers in this population and improve goal-directed care for those residents who opt to forgo hospitalization.
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http://dx.doi.org/10.1001/jamainternmed.2019.6130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990757PMC
March 2020

Effects of Social Disparities on Management and Surgical Outcomes for Patients with Secondary Hyperparathyroidism.

World J Surg 2020 02;44(2):537-543

Division of General Surgery, Department of Surgery, University Health Network, Toronto General Hospital, 10 En 214, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.

Introduction: Nearly 80% of chronic renal failure patients have secondary hyperparathyroidism. Cinacalcet is used to lower parathyroid hormone; however, it is expensive and has side effects. When secondary hyperparathyroidism is resistant to medication or medications are inaccessible, parathyroidectomy is performed. Race and socioeconomic status influence access to care and surgical outcomes. We sought to evaluate the effect of race and socioeconomic status on parathyroidectomy rate as well as surgical outcomes of patients with secondary hyperparathyroidism.

Methods: We undertook cross-sectional analysis of adults diagnosed with secondary hyperparathyroidism in the USA between 2012 and 2014, using the National Inpatient Sample. Univariate and multivariate analyses were used to determine associations between social disparities, likelihood to undergo parathyroidectomy, and surgical outcomes.

Results: Between 2012 and 2014, a national estimate of 724,170 hospitalizations were identified where patients had a diagnosis of secondary hyperparathyroidism. Operative rate was 0.67%. By socioeconomic status, differences in rates of surgery in the poorest compared to the richest were not significant (0.74% vs. 0.55%, OR 1.08, p = 0.5). African-American patients had higher rates of parathyroidectomy compared to Caucasians (1 vs. 0.74%, OR 1.49, p < 0.001). African-American patients also had a trend toward more complications and greater length of stay.

Conclusions: According to a large administrative dataset, parathyroidectomy for secondary hyperparathyroidism is seldom used in the USA. African-American patients have higher rates of surgical management. Surgical outcomes may be affected by race. Clinicians treating secondary hyperparathyroidism should be aware of existing disparities within their health system.
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http://dx.doi.org/10.1007/s00268-019-05207-4DOI Listing
February 2020

Developing a patient decision aid for women aged 70 and older with early stage, estrogen receptor positive, HER2 negative, breast cancer.

J Geriatr Oncol 2019 11 24;10(6):980-986. Epub 2019 May 24.

Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States of America.

Objectives: Since women ≥70 years with early stage, estrogen receptor positive (ER+), HER2 negative breast cancer face several preference-sensitive treatment decisions, the investigative team aimed to develop a pamphlet decision aid (DA) for such women.

Materials And Methods: The content of the DA was informed by literature review, international criteria, and expert feedback, and includes information on benefits and risks of lumpectomy versus mastectomy, lymph node surgery, radiotherapy after lumpectomy, and endocrine therapy. It considers women's overall health and was written using low literacy principles. Women from two Boston-based hospitals who were diagnosed in the past 6-24 months were recruited to provide feedback on the DA and its acceptability. The DA was iteratively revised based on their qualitative input.

Results: Of 48 eligible women contacted, 35 (73%) agreed to participate. Their mean age was 74.3 years; 33 (94%) were non-Hispanic white; and 24 (67%) were college graduates. Overall, 26 (74%) thought the length of the DA was just right, 29 (83%) thought all or most of the information was clear, 32 (91%) found the DA helpful, and 33 (94%) would recommend it. In open ended comments, participants noted that the DA was clear, well-organized, and would help women prepare for and participate in treatment decision-making.

Conclusions: The investigative team developed a novel breast cancer treatment DA that is acceptable to women ≥70 years with a history of ER+, HER2-, early stage breast cancer. Next, the DA's efficacy needs to be tested with diverse older women newly diagnosed with breast cancer.
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http://dx.doi.org/10.1016/j.jgo.2019.05.004DOI Listing
November 2019

Meeting the World Health Organization Maternal Antenatal Care Guidelines Is Associated with Improved Early and Middle Childhood Cognition in Ethiopia.

J Pediatr 2019 06 5;209:33-38.e1. Epub 2019 Apr 5.

Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA.

Objective: To assess the association between meeting the World Health Organization (WHO) maternal antenatal care attendance guidelines and early and middle childhood cognition among impoverished Ethiopian children.

Study Design: A total of 1914 impoverished Ethiopian children from the Young Lives longitudinal cohort study were included. Childhood cognition was assessed via the Cognitive Development Assessment (CDA) and Peabody Picture Vocabulary Test (PPVT) at ages 4-5 years; PPVT, Early Grade Reading Assessment (EGRA), and Math Test at ages 7-8 years; and PPVT, Math Test, and Reading Test at ages 11-12 years. Linear regression models were used to examine the association between maternal antenatal care attendance and childhood academic achievement test scores.

Results: In the univariable analysis, children of mothers who received the WHO recommended 4+ antenatal care visits or received the WHO recommended first antenatal care visit during the first trimester scored higher on all academic achievement tests. In the multivariable analysis, children of mothers who received 4+ antenatal care visits scored significantly higher on the CDA at ages 4-5 years and Math Test at ages 7-8 years. Children of mothers who received antenatal care in the first trimester scored higher on the CDA at ages 4-5 years and Math Test scores at ages 11-12 years. Children of mothers who received both antenatal care in the first trimester and 4+ antenatal care visits scored significantly higher on the CDA at ages 4-5 years and Math Test at both ages 7-8 and 11-12 years.

Conclusions: Children of mothers who received the WHO recommended number and timing of antenatal care visits had significantly higher academic achievement scores across multiple domains during early and middle childhood. Promotion of antenatal care visit attendance may improve cognition through middle childhood.
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http://dx.doi.org/10.1016/j.jpeds.2019.02.032DOI Listing
June 2019

Self-Reported Physical and Mental Health of Gender Nonconforming Transgender Adults in the United States.

LGBT Health 2018 10 5;5(7):443-448. Epub 2018 Sep 5.

1 Division of General Internal Medicine and Primary Care, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital , Boston, Massachusetts.

Purpose: This study compares the health status of gender nonconforming transgender adults with gender-binary transgender peers (i.e., transgender men and transgender women).

Methods: We performed a retrospective analysis of the 2014-2016 Behavioral Risk Factor Surveillance System.

Results: After adjustment for sociodemographic characteristics, proxies for healthcare access, health conditions, and health behaviors, gender nonconforming transgender adults were at increased odds, compared with gender-binary transgender peers, of self-reported poor or fair health and self-reported limitation in any way in any activities because of physical, mental, or emotional problems.

Conclusions: Gender nonconforming transgender adults experienced worse self-reported health disparities than gender-binary transgender peers.
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http://dx.doi.org/10.1089/lgbt.2017.0275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207157PMC
October 2018

Relationship between Race/Ethnicity and Hysterectomy Outcomes for Benign Gynecologic Conditions.

J Minim Invasive Gynecol 2019 Mar - Apr;26(3):456-462. Epub 2018 May 25.

Division of General Medicine and Primary Care, Department of Medicine, Harvard Medical School, Boston, Massachusetts; Harvard Medical School, Beth Israel Deaconess Medical Center and Office for Diversity Inclusion and Community Partnership, Harvard Medical School, Boston, Massachusetts.

Study Objective: To examine the association between race/ethnicity, route of hysterectomy, and risk of inpatient surgical complications.

Design: Cross-sectional analysis (Canadian Task Force classification III).

Setting: Inpatient hospitals in the United States.

Patients And Interventions: There were 114 719 women aged 18 and older from the Nationwide Inpatient Sample who underwent an elective hysterectomy for benign indications using International Classification of Diseases codes.

Measurements And Main Results: Multivariable logistic regression was performed to examine the association between race/ethnicity and route of hysterectomy and surgical complications, after adjusting for patient characteristics, clinical factors, and hospital characteristics. Analyses were weighted to provide national estimates of prevalence. The rate of minimally invasive hysterectomy was 55.0% in white women, 28.6% in black women, 50.1% in Hispanic women, and 45.6% in other race/ethnic categories. Compared with white women, black women had a .55 odds (95% confidence interval, .52-.59) of undergoing minimally invasive hysterectomy, after adjusting for patient, clinical, and hospital characteristics. This finding remained consistent across quartiles of median household income of residence, primary payer, and diagnosis of myomas. Among women who had an elective hysterectomy, 6091 experienced a complication, representing an estimated 30 455 women nationwide. The rate of surgical complications was 5.3% in white women, 5.9% in black women, 4.6% in Hispanic women, and 5.1% in women of other racial/ethnic groups. There was no difference in odds of experiencing a surgical complication between white and black women (odds ratio, 1.03; 95% confidence interval, .93-1.13) after adjusting for patient, clinical, and hospital characteristics. This finding remained consistent across quartiles of median household income of residence, primary payer, and route of hysterectomy.

Conclusion: Among women undergoing an elective hysterectomy, black women were less likely to receive minimally invasive hysterectomy compared with white women. However, the rate of inpatient surgical complications did not vary significantly by race/ethnicity. Further research is encouraged to identify and address the influential factors behind the disparity in minimally invasive hysterectomy use among black women in the United States.
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http://dx.doi.org/10.1016/j.jmig.2018.05.017DOI Listing
July 2019

Use of Surveillance Mammography Among Older Breast Cancer Survivors by Life Expectancy.

J Clin Oncol 2017 Sep 27;35(27):3123-3130. Epub 2017 Jul 27.

Rachel A. Freedman, Dana-Farber Cancer Institute; Nancy L. Keating and Ellen P. McCarthy, Harvard Medical School; Nancy L. Keating, Lydia E. Pace, and Joyce Lii, Brigham and Women's Hospital; and Ellen P. McCarthy and Mara A. Schonberg, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

Purpose The benefits of annual surveillance mammography in older breast cancer survivors with limited life expectancy are not known, and there are important risks; however, little is known about mammography use among these women. Materials and Methods We used National Health Interview Study data from 2000, 2005, 2008, 2010, 2013, and 2015 to examine surveillance mammography use among women age ≥ 65 years who reported a history of breast cancer. Using multivariable logistic regression, we assessed the probability of mammography within the last 12 months by 5- and 10-year life expectancy (using the validated Schonberg index), adjusting for survey year, region, age, marital status, insurance, educational attainment, and indicators of access to care. Results Of 1,040 respondents, 33.7% were age ≥ 80 years and 88.6% were white. Approximately 8.6% and 35.1% had an estimated life expectancy of ≤ 5 and ≤ 10 years, respectively. Overall, 78.9% reported having routine surveillance mammography in the last 12 months. Receipt of mammography decreased with decreasing life expectancy ( P < .001), although 56.7% and 65.9% of those with estimated ≤ 5-year and ≤ 10-year life expectancy, respectively, reported mammography in the last year. Conversely, 14.1% of those with life expectancy > 10 years did not report mammography. In adjusted analyses, lower ( v higher) life expectancy was significantly associated with lower odds of mammography (odds ratio, 0.4; 95% CI, 0.3 to 0.8 for ≤ 5-year life expectancy and OR, 0.4; 95% CI, 0.3 to 0.6 for ≤ 10-year life expectancy). Conclusion Many (57%) older breast cancer survivors with an estimated short life expectancy (< 5 years) receive annual surveillance mammography despite unknown benefits, whereas 14% with estimated life expectancy > 10 years did not report mammography. Practice guidelines are needed to optimize and tailor follow-up care for older patients.
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http://dx.doi.org/10.1200/JCO.2016.72.1209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597254PMC
September 2017
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