Publications by authors named "Jennifer Tjia"

118 Publications

Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care.

J Palliat Med 2021 Nov 24. Epub 2021 Nov 24.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Cross-sectional study. Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.
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http://dx.doi.org/10.1089/jpm.2021.0062DOI Listing
November 2021

Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life.

Curr Epidemiol Rep 2021 Sep 23;8(3):116-129. Epub 2021 Apr 23.

Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.

Purpose Of Review: To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL).

Recent Findings: We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators.

Summary: EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.
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http://dx.doi.org/10.1007/s40471-021-00264-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8553236PMC
September 2021

Physical frailty and cognitive impairment in older nursing home residents: a latent class analysis.

BMC Geriatr 2021 09 7;21(1):487. Epub 2021 Sep 7.

National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.

Background: Little is known about the heterogeneous clinical profile of physical frailty and its association with cognitive impairment in older U.S. nursing home (NH) residents.

Methods: Minimum Data Set 3.0 at admission was used to identify older adults newly-admitted to nursing homes with life expectancy ≥6 months and length of stay ≥100 days (n = 871,801). Latent class analysis was used to identify physical frailty subgroups, using FRAIL-NH items as indicators. The association between the identified physical frailty subgroups and cognitive impairment (measured by Brief Interview for Mental Status/Cognitive Performance Scale: none/mild; moderate; severe), adjusting for demographic and clinical characteristics, was estimated by multinomial logistic regression and presented in adjusted odds ratios (aOR) and 95% confidence intervals (CIs).

Results: In older nursing home residents at admission, three physical frailty subgroups were identified: "mild physical frailty" (prevalence: 7.6%), "moderate physical frailty" (44.5%) and "severe physical frailty" (47.9%). Those in "moderate physical frailty" or "severe physical frailty" had high probabilities of needing assistance in transferring between locations and inability to walk in a room. Residents in "severe physical frailty" also had greater probability of bowel incontinence. Compared to those with none/mild cognitive impairment, older residents with moderate or severe impairment had slightly higher odds of belonging to "moderate physical frailty" [aOR (95%CI): 1.01 (0.99-1.03); aOR (95%CI): 1.03 (1.01-1.05)] and much higher odds to the "severe physical frailty" subgroup [aOR (95%CI): 2.41 (2.35-2.47); aOR (95%CI): 5.74 (5.58-5.90)].

Conclusions: Findings indicate the heterogeneous presentations of physical frailty in older nursing home residents and additional evidence on the interrelationship between physical frailty and cognitive impairment.
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http://dx.doi.org/10.1186/s12877-021-02433-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8425049PMC
September 2021

Prevalence and the factors associated with oral anticoagulant use among nursing home residents.

J Clin Pharm Ther 2021 Dec 31;46(6):1714-1728. Epub 2021 Aug 31.

Division of Epidemiology, Department of Population and Quantitative Health Services, University of Massachusetts Medical School, Worcester, MA, USA.

What Is Known And Objective: Anticoagulants are indicated for treatment and prevention of several clinical conditions. Prior studies have examined anticoagulant utilization for specific indications and in community-dwelling populations. Decision-making regarding anticoagulant prescribing in the nursing home setting is particularly challenging because advanced age and clinical complexity places most residents at increased risk for adverse drug events. To estimate the prevalence of oral anticoagulant (OAC) use (overall, warfarin, direct oral anticoagulants (DOACs)) and identify factors associated with oral anticoagulant use among the general population of residents living in nursing homes.

Methods: This point prevalence study was conducted among 506,482 residents in US nursing homes on 31 October 2016 who were enrolled in Medicare fee-for-service. Covariates including demographics, clinical conditions, medications, cognitive impairment and functional status were obtained from Minimum Data Set 3.0 assessments and Medicare Part A and D claims. Oral anticoagulant use was identified using dispensing dates and days supply information from Medicare Part D claims. Robust Poisson models estimated adjusted prevalence ratios (aPR) for associations between covariates and 1) any anticoagulant use, and 2) DOAC versus warfarin use.

Results And Discussion: Overall, 11.8% of residents used oral anticoagulants. Among users, 44.3% used DOACs. Residents with body mass index (BMI) ≥40 kg/m (aPR: 1.66; 95% CI: 1.61 -1.71), with functional dependency in activities of daily living, polypharmacy and higher CHA DS -VASc risk ischaemic stroke scores, had a higher prevalence of oral anticoagulant use. Women (aPR: 0.78; 95% CI: 0.76-0.79), residents with limited life expectancy (aPR 0.80; 95% CI: 0.76-0.83), those with moderate-to-severe cognitive impairment (aPR: 0.67; 95% CI: 0.65-0.68), those using NSAIDs or antiplatelets, and non-white racial/ethnic groups had a lower prevalence of anticoagulant use. Residents with higher levels of polypharmacy, BMI and age had a lower prevalence of DOAC use (versus warfarin).

What Is New And Conclusion: Approximately one in eight general nursing home residents use oral anticoagulants and among oral anticoagulant users, only slightly more residents used warfarin than DOACs. The lower prevalence of anticoagulation among women and non-white racial/ethnic groups raises concerns of potential inequities in quality of care. Lower oral anticoagulant use among residents with limited life expectancy suggests possible deprescribing at the end of life. Further research is needed to inform resident-centred shared decision-making that explicitly considers treatment goals and individual-specific risks and benefits of anticoagulation at all stages of the medication use continuum.
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http://dx.doi.org/10.1111/jcpt.13508DOI Listing
December 2021

Shared Medication PLanning In (SIMPLIfy) Home Hospice: An Educational Program to Enable Goal-Concordant Prescribing In Home Hospice.

J Pain Symptom Manage 2021 Nov 5;62(5):1092-1099. Epub 2021 Jun 5.

Ariadne Labs, Boston, Massachusetts, USA; University of Rhode Island College of Nursing, Kingston, Rhode Island, USA.

Context: Simplifying medication regimens by tapering and/or withdrawing unnecessary drugs is important to optimize quality of life and safety for patients with serious illness. Few resources are available to educate clinicians, patients and family caregivers about this process.

Objective: To describe the development of an educational program called Shared Medication PLanning In (SIMPLIfy) Home Hospice.

Methods: An environmental scan identified a state-of-the-art educational program for home hospice deprescribing that we adapted using a stakeholder panel engagement process. The stakeholder panel (two hospice administrators, three nurses, two physicians, two pharmacists, and two former family caregivers) drawn from two geographically diverse hospice agencies reviewed the educational program and recommended additional content.

Results: Iterative rounds of review and feedback resulted in: 1) a three-part clinician educational program (total duration = 1.5 hour) that presents a standardized, goal-concordant, medication review approach to align medications and conversations about regimen simplification with patient and family caregiver goals of care; 2) a patient-family caregiver medication management educational notebook that presents common symptoms, hospice medications, and medication regimen simplification principles; and 3) a brief guide including helpful phrases to use as conversation starters for key steps in the program. A professional designer created thematic coherence for all materials that was well received by stakeholder panelists and hospice staff.

Conclusion: Educational materials can support hospice programs' and clinicians' efforts to implement goal-concordant medication simplification that optimizes end-of-life outcomes for patients and family caregivers. Evaluation of outcomes including medication appropriateness and family caregiver medication administration burden are not yet available.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.05.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8556298PMC
November 2021

Advance care planning among Medicare beneficiaries with dementia undergoing surgery.

J Am Geriatr Soc 2021 08 20;69(8):2273-2281. Epub 2021 May 20.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Importance: Advance care planning (ACP), in which patients or their surrogates discuss goals and preferences for care with physicians, attorneys, friends, and family, is an important approach to help align goals with actual treatment. ACP may be particularly valuable in patients with advanced serious illnesses such as Alzheimer's disease and related dementias (ADRDs) for whom surgery carries significant risks.

Objective: To determine the frequency, timing, and factors associated with ACP billing in Medicare beneficiaries with ADRD undergoing nontrauma inpatient surgery.

Design: This national cohort study analyzes Medicare fee-for-service claims data from 2016 to 2017. All patients had a 6-month lookback and follow-up period.

Setting: National Medicare fee-for-service data.

Participants: All patients with ADRD, defined according to the Chronic Conditions Warehouse, undergoing inpatient surgery from July 1, 2016 to June 30, 2017.

Exposures: Patient demographics, medical history, and procedural outcomes.

Main Outcome: ACP billing codes from 6 months before to 6 months after admission for inpatient surgery.

Results: This study included 289,428 patients with ADRD undergoing surgery, of whom 21,754 (7.5%) had billed ACP within the 6 months before and after surgical admission. In a multivariable analysis, patients of white race, male sex, and residence in the Southern and Midwestern United States were at the highest risk of not receiving ACP. Of all patients who received ACP, 5960 (27.4%) did so before surgery while 12,658 (52.8%) received ACP after surgery. Timing of ACP after surgery was associated with an Elixhauser comorbidity index of 3 or higher (1.23, p = 0.045) and major postoperative complication or death (odds ratio 1.52, p < 0.0001).

Conclusions And Relevance: Overall ACP billing code use is low among Medicare patients with ADRD undergoing surgery. Billed ACP appears to have a reactive pattern, occurring most commonly after surgery and in association with postoperative mortality and complications. Additional study is warranted to understand barriers to use.
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http://dx.doi.org/10.1111/jgs.17226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373690PMC
August 2021

Stakeholder-engaged process for refining the design of a clinical trial in home hospice.

BMC Med Res Methodol 2021 04 30;21(1):92. Epub 2021 Apr 30.

University of Rhode Island School of Nursing, Kingston, RI, USA.

Background: Clinical trials in home hospice settings are important to build the evidence base for practice, but balancing the burden and benefit of clinical trial conduct for clinicians, patients, and family caregivers is challenging. A stakeholder-engaged process can help inform and refine key aspects of home hospice clinical trials. The aim of this study was to describe a stakeholder-engaged process to refine, design, and implement aspects of an educational intervention trial in home hospice, including recommendations for refining intervention content and delivery, recruitment and enrollment strategies, and content and frequency of outcome measurement.

Methods: A panel of interprofessional (1 hospice administrator, 3 nurses, 2 physicians, 2 pharmacists) and 2 former family caregiver stakeholders was systematically selected and invited to participate based on expertise, representing 2 geographically distinct hospices who were participating in the clinical trial. Teleconferences followed a predetermined procedural sequence: 1. pre-meeting materials distribution and review; 2. pre-meeting email solicitation of concerns in response to materials; 3. teleconference with structured and guided discussion; and 4. documentation and distribution of minutes for accuracy review and future meeting guidance. Discussion topics were distinct for each panel meeting. Written reflections on the stakeholder engagement process were collected from panel members to further refine our process.

Results: Five initial biweekly teleconferences resulted in recommendations for recruitment strategy, enrollment process, measurement frequency, patient inclusion, and primary care physician notification of the patient's trial involvement. The panel continues to participate in quarterly teleconferences to review progress and unexpected questions and concerns. Panelist reflections reveal personal and professional benefit from participation.

Conclusions: An interprofessional stakeholder process is feasible and invaluable for developing home hospice intervention studies, contributing to better science, successful trial implementation, and relevant, valid outcomes.

Trial Registration: Clinicaltrials.gov, NCT03972163 , Registered June 3, 2019.
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http://dx.doi.org/10.1186/s12874-021-01275-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091786PMC
April 2021

Neural Multi-Task Learning for Adverse Drug Reaction Extraction.

AMIA Annu Symp Proc 2020 25;2020:756-762. Epub 2021 Jan 25.

University of Massachusetts Medical School, Worcester, MA, USA.

A reliable and searchable knowledge database of adverse drug reactions (ADRs) is highly important and valuable for improving patient safety at the point of care. In this paper, we proposed a neural multi-task learning system, NeuroADR, to extract ADRs as well as relevant modifiers from free-text drug labels. Specifically, the NeuroADR system exploited a hierarchical multi-task learning (HMTL) framework to perform named entity recognition (NER) and relation extraction (RE) jointly, where interactions among the learned deep encoder representations from different subtasks are explored. Different from the conventional HMTL approach, NeuroADR adopted a novel task decomposition strategy to generate auxiliary subtasks for more inter-task interactions and integrated a new label encoding schema for better handling discontinuous entities. Experimental results demonstrate the effectiveness of the proposed system.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075418PMC
June 2021

Physical Frailty and Cognitive Impairment in Older Adults in United States Nursing Homes.

Dement Geriatr Cogn Disord 2021 22;50(1):60-67. Epub 2021 Apr 22.

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

Introduction: In older US nursing home (NH) residents, there is limited research on the prevalence of physical frailty, its potential dynamic changes, and its association with cognitive impairment in older adults' first 6 months of NH stay.

Methods: Minimum Data Set (MDS) 3.0 is the national database on residents in US Medicare-/Medicaid-certified NHs. MDS 3.0 was used to identify older adults aged ≥65 years, newly admitted to NHs during January 1, 2014, and June 30, 2016, with life expectancy ≥6 months at admission and NH length of stay ≥6 months (N = 571,139). MDS 3.0 assessments at admission, 3 months, and 6 months were used. In each assessment, physical frailty was measured by FRAIL-NH (robust, prefrail, and frail) and cognitive impairment by Brief Interview for Mental Status and Cognitive Performance Scale (none/mild, moderate, and severe). Demographic characteristics and diagnosed conditions were measured at admission, while presence of pain and receipt of psychotropic medications were at each assessment. Distribution of physical frailty and its change over time by cognitive impairment were described. A nonproportional odds model was fitted with a generalized estimation equation to longitudinally examine the association between physical frailty and cognitive impairment, adjusting for demographic and clinical characteristics.

Results: Around 60% of older residents were physically frail in the first 6 months. Improvement and worsening across physical frailty levels were observed. Particularly, in those who were prefrail at admission, 23% improved to robust by 3 months. At admission, 3 months, and 6 months, over 37% of older residents had severe cognitive impairment and about 70% of those with cognitive impairment were physically frail. At admission, older residents with moderate cognitive impairment were 35% more likely (adjusted odds ratio [aOR]: 1.35, 95% confidence interval [CI]: 1.33-1.37) and those with severe impairment were 74% more likely (aOR: 1.74, 95% CI: 1.72-1.77) to be frail than prefrail/robust, compared to those with none/mild impairment. The association between the 2 conditions remained positive and consistently increased over time.

Discussion/conclusion: Physical frailty was prevalent in NHs with potential to improve and was strongly associated with cognitive impairment. Physical frailty could be a modifiable target, and interventions may include efforts to address cognitive impairment.
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http://dx.doi.org/10.1159/000515140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243819PMC
November 2021

Decreasing Trends in Opioid Prescribing on Discharge to Hospice Care.

J Pain Symptom Manage 2021 11 10;62(5):1026-1033. Epub 2021 Apr 10.

Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA.

Context: There are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life.

Objective: We assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care.

Methods: This was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients' electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care).

Results: Among 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%-94.1%) in 2010 to 79.3% (95% CI = 74.3%-83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period.

Conclusions: We observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502178PMC
November 2021

"Don't talk to them about goals of care": Understanding disparities in advance care planning.

J Gerontol A Biol Sci Med Sci 2021 Mar 29. Epub 2021 Mar 29.

Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA.

Background: Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions.

Methods: In this national study, we conducted semi-structured interviews with purposively selected clinicians from six diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians' perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them.

Results: Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians' difficulty approaching ACP (Preconceived views of patients' preferences; narrow definitions of successful ACP; lacking institutional resources), while the final theme illustrated facilitators to ACP (Acknowledging bias and rejecting stereotypes; mission-driven focus on ACP; acceptance of all preferences).

Conclusions: Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP.
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http://dx.doi.org/10.1093/gerona/glab091DOI Listing
March 2021

National Trends in Statin Use among the United States Nursing Home Population (2011-2016).

Drugs Aging 2021 05 11;38(5):427-439. Epub 2021 Mar 11.

Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, 01605, MA, USA.

Background: Little is known about trends in statin use in United States (US) nursing homes.

Objectives: The aim of this study was to describe national trends in statin use in nursing homes and evaluate the impact of the introduction of generic statins, safety warnings, and guideline recommendations on statin use.

Methods: This study employed a repeated cross-sectional prevalence design to evaluate monthly statin use in long-stay US nursing home residents enrolled in Medicare fee-for-service using the Minimum Data Set 3.0 and Medicare Part D claims between April 2011 and December 2016. Stratified by age (65-75 years, ≥ 76 years), analyses estimated trends and level changes with 95% confidence intervals (CI) following statin-related events (the availability of generic statins, American Heart Association/American College of Cardiology guideline updates, and US FDA safety warnings) through segmented regression models corrected for autocorrelation.

Results: Statin use increased from April 2011 to December 2016 (65-75 years: 38.6-43.3%; ≥ 76 years: 26.5% to 30.0%), as did high-intensity statin use (65-75 years: 4.8-9.5%; ≥ 76 years: 2.3-4.5%). The introduction of generic statins yielded little impact on the prevalence of statins in nursing home residents. Positive trend changes in high-intensity statin use occurred following national guideline updates in December 2011 (65-75 years: β = 0.16, 95% CI 0.09-0.22; ≥ 76 years: β = 0.09, 95% CI 0.06-0.12) and November 2013 (65-75 years: β = 0.11, 95% CI 0.09-0.13; ≥ 76 years: β = 0.04, 95% CI 0.03-0.05). There were negative trend changes for any statin use concurrent with FDA statin safety warnings in March 2012 among both age groups (65-75 years: β trend change = - 0.06, 95% CI - 0.10 to - 0.02; ≥ 76 years: β trend change = - 0.05, 95% CI - 0.08 to - 0.01). The publication of the results of a statin deprescribing trial yielded a decrease in any statin use among the ≥ 76 years age group (β level change = - 0.25, 95% CI - 0.48 to - 0.09; β trend change = - 0.03, 95% CI - 0.04 to - 0.01), with both age groups observing a positive trend change with high-intensity statins (65-75 years: β = 0.11, 95% CI 0.02-0.21; ≥ 76 years: β = 0.05, 95% CI 0.01-0.09).

Conclusion: Overall, statin use in US nursing homes increased from 2011 to 2016. Guidelines and statin-related events appeared to impact use in the nursing home setting. As such, statin guidelines and messaging should provide special consideration for nursing home populations, who may have more risk than benefit from statin pharmacotherapy.
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http://dx.doi.org/10.1007/s40266-021-00844-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102363PMC
May 2021

Avoiding Adverse Drug Withdrawal Events When Stopping Unnecessary Medications According to the STOPPFrail Criteria.

Sr Care Pharm 2021 Mar;36(3):136-141

3University of Massachusetts Medical School, Department of Population and Quantitative Health Sciences, Worcester, Massachusetts.

Objective: To provide clinicians with information about avoiding adverse drug withdrawal events (ADWEs) when discontinuing unnecessary medications as per the STOPPFrail criteria.

Data Sources: Searches of MEDLINE (1970-June 2020), the Cochrane Database of Systematic Reviews (through June 2020), Google Scholar (through June 2020).

Study Selection: Reviews and original studies of ADWEs.

Data Extraction: Tapering protocols for specific drugs/ classes from randomized controlled deprescribing trials.

Data Synthesis: Six drug classes were identified as being high risk for physiological ADWEs.

Conclusion: The occurrence of ADWEs is rare in comparison to adverse drug reactions in older adults. Few drugs/classes have been reported to have physiological ADWEs with abrupt discontinuation. For these we provide information about tapering protocols and symptom monitoring to avoid ADWEs.
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http://dx.doi.org/10.4140/TCP.n.2021.136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091161PMC
March 2021

Priority-Setting to Address the Geriatric Pharmacoparadox for Pain Management: A Nursing Home Stakeholder Delphi Study.

Drugs Aging 2021 04 24;38(4):327-340. Epub 2021 Feb 24.

RAND Health Care, Santa Monica, CA, USA.

Background: Evidence to guide clinical decision making for pain management in nursing home residents is scant.

Objective: Our objective was to explore the extent of consensus among expert stakeholders regarding what analgesic issues should be prioritized for comparative-effectiveness studies of beneficial and adverse effects of analgesic regimens in nursing home residents.

Methods: Two stakeholder panels (nurses only and a mix of clinicians/researchers) were engaged (n = 83). During a three-round online modified Delphi process, participants rated and commented on the need for new evidence on nonopioid analgesic regimens and opioid regimens, short-term adverse effects, long-term adverse effects, comorbid conditions, and other factors in the nursing home setting (9-point scale; 1 = not essential to 9 = very essential to obtain new evidence). The quantitative data were analyzed to determine the existence of consensus using an approach from the RAND/UCLA Appropriateness Method User's Manual. The qualitative data, consisting of participant explanations of their numeric ratings, were thematically analyzed by an experienced qualitative researcher.

Results: For nursing home residents, evidence generation was deemed essential for opioids, gabapentin (alone or with serotonin norepinephrine reuptake inhibitors [SNRIs]), and nonsteroid anti-inflammatory drugs with SNRIs. Experts prioritized the following outcomes as essential: long-term adverse effects, including delirium, cognitive decline, and decline in activities of daily living (ADLs). Kidney disease and depression were deemed essential conditions to consider in studies of pain medications. Coprescribing analgesic regimens with benzodiazepines, sedating medications, serotonergic medications, and non-SNRI antidepressants were considered essential areas of study. Experts noted that additional study was essential in residents with moderate/severe cognitive impairment and limitations in ADLs.

Conclusions: Stakeholder priorities for more evidence reflect concerns related to treating medically complex residents with complex drug regimens and included long-term adverse effects, coprescribing, and sedating medications. Carefully conducted observational studies are needed to address the vast evidence gap for nursing home residents.
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http://dx.doi.org/10.1007/s40266-021-00836-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127621PMC
April 2021

COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP): A study protocol.

Medicine (Baltimore) 2021 Feb;100(5):e23680

University of Washington, Seattle, Washington, USA.

Background: Healthcare professionals have negative implicit biases toward minority and poor patients. Few communication skills interventions target implicit bias as a factor contributing to disparities in health outcomes. We report the protocol from the COmmuNity-engaged SimULation Training for Blood Pressure Control (CONSULT-BP), a trial evaluating a novel educational and training intervention targeting graduate medical and nursing trainees that is designed to mitigate the effects of implicit bias in clinical encounters. The CONSULT-BP intervention combines knowledge acquisition, bias awareness, and practice of bias mitigating skills in simulation-based communication encounters with racially/ethnically diverse standardized patients. The trial evaluates the effect of this 3-part program on patient BP outcomes, self-reported patient medication adherence, patient-reported quality of provider communication, and trainee bias awareness.

Methods: We are conducting a cluster randomized trial of the intervention among cohorts of internal medicine (IM), family medicine (FM), and nurse practitioner (NP) trainees at a single academic medical center. We are enrolling entire specialty cohorts of IM, FM, and NP trainees over a 3-year period, with each academic year constituting an intervention cycle. There are 3 cycles of implementation corresponding to 3 sequential academic years. Within each academic year, we randomize training times to 1 of 5 start dates using a stepped wedge design. The stepped wedge design compares outcomes within training clusters before and after the intervention, as well as across exposed and unexposed clusters. Primary outcome of blood pressure control is measured at the patient-level for patients clustered within trainees. Eligible patients for outcomes analysis are: English-speaking; non-White racial/ethnic minority; Medicaid recipient (regardless of race/ethnicity); hypertension; not have pregnancy, dementia, schizophrenia, bipolar illness, or other serious comorbidities that would interfere with hypertension self-control; not enrolled in hospice. Secondary outcomes include trainee bias awareness. A unique feature of this trial is the engagement of academic and community stakeholders to design, pilot test and implement a training program addressing healthcare.

Discussion: Equipping clinicians with skills to mitigate implicit bias in clinical encounters is crucial to addressing persistent disparities in healthcare outcomes. Our novel, integrated approach may improve patient outcomes.

Trial Registration: NCT03375918.

Protocol Version: 1.0 (November 10, 2020).
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http://dx.doi.org/10.1097/MD.0000000000023680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870252PMC
February 2021

Geographic Variation of Statin Use Among US Nursing Home Residents With Life-limiting Illness.

Med Care 2021 05;59(5):425-436

Division of Epidemiology, Department of Population and Quantitative Health Sciences.

Background: Medically compromised nursing home residents continue to be prescribed statins, despite questionable benefits.

Objective: To describe regional variation in statin use among residents with life-limiting illness.

Research Design: Cross-sectional study using 2016 Minimum Data Set 3.0 assessments linked to Medicare administrative data and health service utilization area resource files.

Setting: Nursing homes (n=14,147) within hospital referral regions (n=306) across the United States.

Subjects: Long-stay residents (aged 65 y and older) with life-limiting illness (eg, serious illness, palliative care, or prognosis <6 mo to live) (n=361,170).

Measures: Prevalent statin use was determined by Medicare Part D claims. Stratified by age (65-75, 76 y or older), multilevel logistic models provided odds ratios with 95% confidence intervals.

Results: Statin use was prevalent (age 65-75 y: 46.0%, 76 y or more: 31.6%). For both age groups, nearly all resident-level variables evaluated were associated with any and high-intensity statin use and 3 facility-level variables (ie, higher proportions of Black residents, skilled nursing care provided, and average number of medications per resident) were associated with increased odds of statin use. Although in residents aged 65-75 years, no associations were observed, residents aged 76 years or older located in hospital referral regions (HRRs) with the highest health care utilization had higher odds of statin use than those in nursing homes in HRRs with the lowest health care utilization.

Conclusions: Our findings suggest extensive geographic variation in US statin prescribing across HRRs, especially for those aged 76 years or older. This variation may reflect clinical uncertainty given the largely absent guidelines for statin use in nursing home residents.
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http://dx.doi.org/10.1097/MLR.0000000000001505DOI Listing
May 2021

The Role of Limited English Proficiency and Access to Health Insurance and Health Care in the Affordable Care Act Era.

Health Equity 2020 11;4(1):509-517. Epub 2020 Dec 11.

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

Limited English proficiency adversely impacts people's ability to access health services. This study examines the association between English language proficiency and insurance access and use of a usual care provider after the implementation of the Affordable Care Act (ACA). Using cross-sectional data from the 2016 Medical Panel Expenditures Survey, we identified 24,099 adults (weighted =240,035,048) and categorized them by self-reported English-language proficiency. We classified participants according to responses to: "How well do you speak English? Would you say… Very well; well; Not well; Not at all?" (having limited English proficiency: not well; not at all, English proficient: well; very well; and English only: not applicable) and "What language do you speak at home? Would you say… English, Spanish, Other." Using these two recoded variables, we created a variable with five categories: (1) Spanish speaking, with limited English proficiency, (2) other language speaking, with limited English proficiency, (3) Spanish speaking, English proficient, (4) other language speaking, English proficient, and (5) English only. Health insurance and usual care provider were determined by self-report. Among those <65 years, the percent covered by public insurance (Spanish: 21%, Other languages: 28%, English only 14%), who were uninsured (Spanish: 46%, Other languages: 17%, English only: 8%), and who lacked a usual care provider (Spanish: 45%, Other languages: 35%, English only: 26%) differed by English language proficiency. Among those ≥65 years, fewer people with limited English proficiency relative to English only were dually covered by Medicare and private insurance (Spanish: 12%, Other languages: 15%, English only: 59%), and a higher percent lacked a usual care provider (Spanish: 15%, Other languages: 11%, English only: 7%). Differences persisted with adjustment for covariates. Post the ACA, persons with limited English proficiency remain at a risk of being uninsured relative to those who only speak English.
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http://dx.doi.org/10.1089/heq.2020.0057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757700PMC
December 2020

Geographic Variation in Anticoagulant Use and Resident, Nursing Home, and County Characteristics Associated With Treatment Among US Nursing Home Residents.

J Am Med Dir Assoc 2021 01;22(1):164-172.e9

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.

Objectives: To quantify geographic variation in anticoagulant use and explore what resident, nursing home, and county characteristics were associated with anticoagulant use in a clinically complex population.

Design: A repeated cross-sectional design was used to estimate current oral anticoagulant use on December 31, 2014, 2015, and 2016.

Setting And Participants: Secondary data for United States nursing home residents during the period 2014-2016 were drawn from the Minimum Data Set 3.0 and Medicare Parts A and D. Nursing home residents (≥65 years) with a diagnosis of atrial fibrillation and ≥6 months of Medicare fee-for-service enrollment were eligible for inclusion. Residents in a coma or on hospice were excluded.

Methods: Multilevel logistic models evaluated the extent to which variation in anticoagulant use between counties could be explained by resident, nursing home, and county characteristics and state of residence. Proportional changes in cluster variation (PCVs), intraclass correlation coefficients (ICCs), and adjusted odds ratios (aORs) were estimated.

Results: Among 86,736 nursing home residents from 11,860 nursing homes and 1694 counties, 45% used oral anticoagulants. The odds of oral anticoagulant use were 18% higher in 2016 than 2014 (aOR: 1.18; 95% confidence interval: 1.14-1.22). Most states had counties in the highest (51.3-58.9%) and lowest (31.1%-41.4%) deciles of anticoagulant use. Compared with the null model, adjustment for resident characteristics explained one-third of the variation between counties (PCV: 34.8%). The full model explained 65.5% of between-county variation. Within-county correlation was a small proportion (ICC < 2.2%) of total variation.

Conclusions And Implications: In this older adult population at high risk for ischemic stroke, less than half of the residents received treatment with anticoagulants. Variation in treatment across counties was partially attributable to the characteristics of residents, nursing homes, and counties. Comparative evidence and refinement of predictive algorithms specific to the nursing home setting may be warranted.
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http://dx.doi.org/10.1016/j.jamda.2020.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092949PMC
January 2021

Recent Trends in the Use of Medicare Advance Care Planning Codes.

J Palliat Med 2020 12;23(12):1568-1570

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1089/jpm.2020.0437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7698819PMC
December 2020

Statin Discontinuation and Life-Limiting Illness in Non-Skilled Stay Nursing Homes at Admission.

J Am Geriatr Soc 2020 12 17;68(12):2787-2796. Epub 2020 Aug 17.

Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

Objectives: To estimate 30-day statin discontinuation among newly admitted nursing home residents overall and within categories of life-limiting illness.

Design: Retrospective cohort using Minimum Data Set 3.0 nursing home admission assessments from 2015 to 2016 merged to Medicare administrative data files.

Setting: U.S. Medicare- and Medicaid-certified nursing home facilities (n = 13,092).

Participants: Medicare fee-for-service beneficiaries, aged 65 years and older, newly admitted to nursing homes for non-skilled nursing facility stays on statin pharmacotherapy at the time of admission (n = 73,247).

Measurements: Residents were categorized using evidence-based criteria to identify progressive, terminal conditions or limited prognoses (<6 months). Discontinuation was defined as the absence of a new Medicare Part D claim for statin pharmacotherapy in the 30 days following nursing home admission.

Results: Overall, 19.9% discontinued statins within 30 days of nursing home admission, with rates that varied by life-limiting illness classification (no life-limiting illness: 20.5%; serious illness: 18.6%; receipt of palliative care consult: 34.5%; clinician designated as end-of-life: 45.0%). Relative to those with no life-limiting illness, risk of 30-day statin discontinuation increased with life-limiting illness severity (serious illness: adjusted risk ratio (aRR) = 1.06; 95% confidence interval (CI) = 1.02-1.10; palliative care index diagnosis: aRR = 1.15; 95% CI = 1.10-1.21; palliative care consultation: aRR = 1.58; 95% CI = 1.43-1.74; clinician designated as end of life: aRR = 1.59; 95% CI = 1.42-1.79). Nevertheless, most remained on statins after entering the nursing home regardless of life-limiting illness status.

Conclusion: Statin use continues in a large proportion of Medicare beneficiaries after admission to a nursing home. Additional deprescribing research, which identifies how to engage nursing home residents and healthcare providers in a process to safely and effectively discontinue medications with questionable benefits, is warranted.
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http://dx.doi.org/10.1111/jgs.16777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127623PMC
December 2020

Feasibility and Acceptability of Digital Legacy-Making: An Innovative Story-Telling Intervention for Adults With Cancer.

Am J Hosp Palliat Care 2021 Jul 10;38(7):772-777. Epub 2020 Nov 10.

12262University of Massachusetts Medical School, Worcester, MA, USA.

Background: This study examined the feasibility, burden and acceptability of a legacy-making intervention in adults with cancer and preliminary effects on patient quality-of-life (QOL) measures.

Method: We conducted a Stage IB pilot, intervention study. The intervention was a digital video legacy-making interview of adults with advanced cancer to create a digital video of their memories and experiences. Baseline and post-video QOL assessments included: Functional Assessment of Cancer Therapy-General (FACT-G), Patient Dignity Inventory (PDI), Hospital Anxiety and Depression Scale (HADS), and Emotional Thermometers for distress, anxiety, anger, help and depression. Participants received a final copy of the digital video for distribution to their families.

Results: Adults (n = 16) ages 38-83 years old with an advanced or life-limiting cancer diagnosis completed an intervention. Feasibility and acceptability was strong with 0% attrition. While the pilot study was not powered for quantitative significance, there were changes from baseline to post-intervention in the participants' total or subscale FACT-G scores, PDI, HADS anxiety or depression scores, and Emotional Thermometer scores.

Conclusions: A digital video legacy-making intervention is feasible for adults with cancer without significant negative outcomes for individuals completing the study. It remains unclear whether this intervention contributes to positive quality of life outcomes.
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http://dx.doi.org/10.1177/1049909120971569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107182PMC
July 2021

Variation in Hospice Patient and Admission Characteristics by Referral Location.

Med Care 2020 12;58(12):1069-1074

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.

Background: Little is known regarding differences between patients referred to hospice from different care locations.

Objective: The objective this study was to describe the associations between hospice referral locations and hospice patient and admission characteristics.

Research Design: Cross-sectional analysis of hospice administrative data.

Subjects: Adult (age older than 18 y) decedents of a national, for-profit, hospice chain across 19 US states who died between January 1, 2012, and December 31, 2016.

Measures: Patients' primary hospice diagnosis, hospice length stay, and hospice care site. We also determined the frequency of opioid prescriptions with and without a bowel regimen on hospice admission.

Results: Among 78,647 adult decedents, the mean age was 79.2 (SD=13.5) years, 56.4% were female, and 69.9% were a non-Hispanic White race. Most hospice referrals were from the hospital (51.9%), followed by the community (21.9%), nursing homes (17.4%), and assisted living (8.8%). Cancer (33.6%) was the most prevalent primary hospice diagnosis; however, this varied significantly between referral locations (P<0.001). Similarly, home hospice (32.8%) was the most prevalent site; however, this also varied significantly between referral locations (P<0.001). More hospital-referred patients (55.6%) had a hospice length of stay <7 days compared with patients referred from nursing homes (30.3%), the community (28.9%), or assisted living (18.7%), P<0.001. Hospital-referred patients also had the lowest frequency (58.4%) of coprescribed opioids and bowel regimen on hospice admission compared with other referral locations.

Conclusion: We observed significant differences in hospice patient and admission characteristics by referral location.
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http://dx.doi.org/10.1097/MLR.0000000000001415DOI Listing
December 2020

Opioid prescribing on discharge to skilled nursing facilities.

Pharmacoepidemiol Drug Saf 2020 09 29;29(9):1183-1188. Epub 2020 Jul 29.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Purpose: Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs.

Methods: This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay.

Results: Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF.

Conclusion: Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted.
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http://dx.doi.org/10.1002/pds.5075DOI Listing
September 2020

Interdisciplinary or Interprofessional: Why Terminology in Teamwork Matters to Hospice and Palliative Care.

J Palliat Med 2020 09 7;23(9):1157-1158. Epub 2020 Jul 7.

Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington, USA.

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http://dx.doi.org/10.1089/jpm.2020.0299DOI Listing
September 2020

Comparative Safety and Effectiveness of Direct-Acting Oral Anticoagulants Versus Warfarin: a National Cohort Study of Nursing Home Residents.

J Gen Intern Med 2020 08 6;35(8):2329-2337. Epub 2020 Apr 6.

Department of Population and Quantitative Health Sciences , University of Massachusetts Medical School, Worcester, MA, USA.

Background: Research comparing direct-acting oral anticoagulants (DOACs) to warfarin has excluded nursing home residents, a vulnerable and high-risk population.

Objective: To compare the safety and effectiveness of DOACs versus warfarin.

Design: New-user cohort study (2011-2016).

Patients: US nursing home residents aged > 65 years with non-valvular atrial fibrillation enrolled in fee-for-service Medicare for > 6 months.

Exposures: Initiators of DOACs (2881 apixaban, 1289 dabigatran, 3735 rivaroxaban) were 1:1 propensity matched to warfarin initiators.

Main Measures: Outcomes included ischemic stroke or transient ischemic attack (i.e., ischemic cerebrovascular event), bleeding (extracranial or intracranial), other vascular events, death, and a composite of all outcomes. Absolute rate differences (RD) and cause-specific hazard ratios (HR) with 95% confidence intervals (CI) were estimated. Subgroup analyses were performed by alignment of DOAC dosing with labeling.

Key Results: Median age (84 years), CHADS-Vasc (5), and ATRIA risk scores (3) were similar across medications. Clinical outcome rates were similar for dabigatran and rivaroxaban users versus warfarin users. However, ischemic cerebrovascular event rates were higher among dabigatran and rivaroxaban users that received reduced dosages without an indication. Overall, apixaban users had higher ischemic cerebrovascular event rates (HR 1.86; 95% CI 1.00-3.45) and lower bleeding rates (HR 0.66; 95% CI 0.49-0.88), but outcome rates varied by dosing alignment. Mortality rates (per 100 person-years) were lower for apixaban (RDs - 9.30; 95% CI - 13.18 to - 5.42), dabigatran (RDs - 10.79; 95% CI - 14.98 to - 6.60), and rivaroxaban (RDs - 8.92; 95% CI - 12.01 to - 5.83) versus warfarin; composite outcome findings were similar.

Conclusions: Among US nursing home residents, the DOACs were each associated with lower mortality versus warfarin. Misaligned DOAC dosing was common in nursing homes and was associated with clinical and mortality outcomes. Overall, DOAC users had lower rates of adverse outcomes including mortality compared with warfarin users.
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http://dx.doi.org/10.1007/s11606-020-05777-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403286PMC
August 2020

Prevalent Statin Use in Long-Stay Nursing Home Residents with Life-Limiting Illness.

J Am Geriatr Soc 2020 04 14;68(4):708-716. Epub 2020 Feb 14.

Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.

Objectives: To evaluate the prevalence and factors associated with statin pharmacotherapy in long-stay nursing home residents with life-limiting illness.

Design: Cross-sectional.

Setting: US Medicare- and Medicaid-certified nursing home facilities.

Participants: Long-stay nursing home resident Medicare fee-for-service beneficiaries aged 65 years or older with life-limiting illness (n = 424 212).

Measurements: Prevalent statin use was estimated as any low-moderate intensity (daily dose low-density lipoprotein-cholesterol [LDL-C] reduction <30%-50%) and high-intensity (daily dose LDL-C reduction >50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90-day look-back period. Life-limiting illness was operationally defined to capture those near the end of life using evidence-based criteria to identify progressive terminal conditions or limited prognoses (<6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors.

Results: A total of 34% of residents with life-limiting illness were prescribed statins (65-75 y = 44.0%, high intensity = 11.1%; >75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life-limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors.

Conclusion: Despite having a life-limiting illness, more than one-third of clinically compromised long-stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted. J Am Geriatr Soc 68:708-716, 2020.
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http://dx.doi.org/10.1111/jgs.16336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072406PMC
April 2020

Utilization of ACP CPT codes among high-need Medicare beneficiaries in 2017: A brief report.

PLoS One 2020 5;15(2):e0228553. Epub 2020 Feb 5.

Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, United States of America.

Importance: Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service.

Objective: To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population.

Design: Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries.

Setting: Nationally representative FFS Medicare 20% sample.

Participants: Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill & frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled (<65). All participants had data available for years 2016-2017.

Exposure: Receipt of a billed ACP discussion, CPT codes 99497 or 99498.

Main Outcome And Measure: Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region.

Results: Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill & frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p < .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the <65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p < .05 compared with non-high needs).

Conclusions And Relevance: While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228553PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7001931PMC
April 2020

Health Care Worker Perceptions of Gaps and Opportunities to Improve Hospital-to-Hospice Transitions.

J Palliat Med 2020 07 31;23(7):900-906. Epub 2019 Dec 31.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Care transitions from the hospital to hospice are a difficult time, and gaps during this transitions could cause poor care experiences and outcomes. However, little is known about what gaps exist in the hospital-to-hospice transition. To understand the process of hospital-to-hospice transition and identify common gaps in the transition that result in unsafe or poor patient and family caregiver experiences. We conducted a qualitative descriptive study using semistructured interviews with health care workers who are directly involved in hospital-to-hospice transitions. Participants were asked to describe the common practice of discharging patients to hospice or admitting patients from a hospital, and share their observations about hospital-to-hospice transition gaps. Fifteen health care workers from three hospitals and three hospice programs in Portland, Oregon. All interviews were audio recorded and analyzed using qualitative descriptive methods to describe current practices and identify gaps in hospital-to-hospice transitions. Three areas of gaps in hospital-to-hospice transitions were identified: (1) low literacy about hospice care; (2) changes in medications; and (3) hand-off information related to daily care. Specific concerns included hospital providers giving inaccurate descriptions of hospice; discharge orders not including comfort medications for the transition and inadequate prescriptions to manage medications at home; and lack of information about daily care hindering smooth transition and continuity of care. Our findings identify gaps and suggest opportunities to improve hospital-to-hospice transitions that will serve as the basis for future interventions to design safe and high-quality hospital-to-hospice care transitions.
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http://dx.doi.org/10.1089/jpm.2019.0513DOI Listing
July 2020

A Telephone-Based Dementia Care Management Intervention-Finding the Time to Listen.

Authors:
Jennifer Tjia

JAMA Intern Med 2019 12;179(12):1667-1668

University of Massachusetts Medical School, Worcester, Massachusetts.

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http://dx.doi.org/10.1001/jamainternmed.2019.4111DOI Listing
December 2019
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