Publications by authors named "Ray Yun Gou"

6 Publications

  • Page 1 of 1

One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery.

JAMA Surg 2021 May;156(5):430-442

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

Importance: Delirium is a common, serious, and potentially preventable problem for older adults, associated with adverse outcomes. Coupled with its preventable nature, these adverse sequelae make delirium a significant public health concern; understanding its economic costs is important for policy makers and health care leaders to prioritize care.

Objective: To evaluate current 1-year health care costs attributable to postoperative delirium in older patients undergoing elective surgery.

Design, Setting, And Participants: This prospective cohort study included 497 patients from the Successful Aging after Elective Surgery (SAGES) study, an ongoing cohort study of older adults undergoing major elective surgery. Patients were enrolled from June 18, 2010, to August 8, 2013. Eligible patients were 70 years or older, English-speaking, able to communicate verbally, and scheduled to undergo major surgery at 1 of 2 Harvard-affiliated hospitals with an anticipated length of stay of at least 3 days. Eligible surgical procedures included total hip or knee replacement; lumbar, cervical, or sacral laminectomy; lower extremity arterial bypass surgery; open abdominal aortic aneurysm repair; and open or laparoscopic colectomy. Data were analyzed from October 15, 2019, to September 15, 2020.

Exposures: Major elective surgery and hospitalization.

Main Outcomes And Measures: Cumulative and period-specific costs (index hospitalization, 30-day, 90-day, and 1-year follow-up) were examined using Medicare claims and extensive clinical data. Total inflation-adjusted health care costs were determined using data from Medicare administrative claims files for the 2010 to 2014 period. Delirium was rated using the Confusion Assessment Method. We also examined whether increasing delirium severity was associated with higher cumulative and period-specific costs. Delirium severity was measured with the Confusion Assessment Method-Severity long form. Regression models were used to determine costs associated with delirium after adjusting for patient demographic and clinical characteristics.

Results: Of the 566 patients who were eligible for the study, a total of 497 patients (mean [SD] age, 76.8 [5.1] years; 281 women [57%]; 461 White participants [93%]) were enrolled after exclusion criteria were applied. During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not. Patients with delirium had significantly higher unadjusted health care costs than patients without delirium (mean [SD] cost, $146 358 [$140 469] vs $94 609 [$80 648]). After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44 291 (95% CI, $34 554-$56 673) per patient per year, with the majority of costs coming from the first 90 days: index hospitalization ($20 327), subsequent rehospitalizations ($27 797), and postacute rehabilitation stays ($2803). Health care costs increased directly and significantly with level of delirium severity (none-mild, $83 534; moderate, $99 756; severe, $140 008), suggesting an exposure-response relationship. The adjusted mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion (95% CI, $25.7 billion-$42.2 billion) per year.

Conclusions And Relevance: These findings suggest that the economic outcomes of delirium and severe delirium after elective surgery are substantial, rivaling costs associated with cardiovascular disease and diabetes. These results highlight the need for policy imperatives to address delirium as a large-scale public health issue.
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May 2021

Delirium in Older Patients With COVID-19 Presenting to the Emergency Department.

JAMA Netw Open 2020 11 2;3(11):e2029540. Epub 2020 Nov 2.

Aging Brain Center, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts.

Importance: Delirium is common among older emergency department (ED) patients, is associated with high morbidity and mortality, and frequently goes unrecognized. Anecdotal evidence has described atypical presentations of coronavirus disease 2019 (COVID-19) in older adults; however, the frequency of and outcomes associated with delirium in older ED patients with COVID-19 infection have not been well described.

Objective: To determine how frequently older adults with COVID-19 present to the ED with delirium and their associated hospital outcomes.

Design, Setting, And Participants: This multicenter cohort study was conducted at 7 sites in the US. Participants included consecutive older adults with COVID-19 presenting to the ED on or after March 13, 2020.

Exposure: COVID-19 was diagnosed by positive nasal swab for severe acute respiratory syndrome coronavirus 2 (99% of cases) or classic radiological findings (1% of cases).

Main Outcomes And Measures: The primary outcome was delirium as identified from the medical record according to a validated record review approach.

Results: A total of 817 older patients with COVID-19 were included, of whom 386 (47%) were male, 493 (62%) were White, 215 (27%) were Black, and 54 (7%) were Hispanic or Latinx. The mean (SD) age of patients was 77.7 (8.2) years. Of included patients, 226 (28%) had delirium at presentation, and delirium was the sixth most common of all presenting symptoms and signs. Among the patients with delirium, 37 (16%) had delirium as a primary symptom and 84 (37%) had no typical COVID-19 symptoms or signs, such as fever or shortness of breath. Factors associated with delirium were age older than 75 years (adjusted relative risk [aRR], 1.51; 95% CI, 1.17-1.95), living in a nursing home or assisted living (aRR, 1.23; 95% CI, 0.98-1.55), prior use of psychoactive medication (aRR, 1.42; 95% CI, 1.11-1.81), vision impairment (aRR, 1.98; 95% CI, 1.54-2.54), hearing impairment (aRR, 1.10; 95% CI 0.78-1.55), stroke (aRR, 1.47; 95% CI, 1.15-1.88), and Parkinson disease (aRR, 1.88; 95% CI, 1.30-2.58). Delirium was associated with intensive care unit stay (aRR, 1.67; 95% CI, 1.30-2.15) and death (aRR, 1.24; 95% CI, 1.00-1.55).

Conclusions And Relevance: In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs. In addition, delirium was associated with poor hospital outcomes and death. These findings suggest the clinical importance of including delirium on checklists of presenting signs and symptoms of COVID-19 that guide screening, testing, and evaluation.
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November 2020

Postoperative Delirium and Postoperative Cognitive Dysfunction: Overlap and Divergence.

Anesthesiology 2019 09;131(3):477-491

From the Alzheimer's Disease and Memory Disorders Center, Rhode Island Hospital, Providence, Rhode Island (L.A.D.) Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts (A.M.R., R.Y.G., S.K.I.) Harvard Medical School, Boston, Massachusetts (A.M.R., E.R.M., Z.X., L.J.K., K.V.V., S.K.I.) Departments of Medicine (E.R.M., S.K.I.) Anesthesia and Critical Care (L.J.K.), Beth Israel Deaconess Medical Center, Boston, Massachusetts Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts (Z.X.) Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts (K.V.V.) Departments of Psychiatry and Human Behavior (R.N.J.) Neurology (L.A.D., R.N.J.), Brown University Warren Alpert Medical School, Providence, Rhode Island.

Background: Postoperative delirium and postoperative cognitive dysfunction share risk factors and may co-occur, but their relationship is not well established. The primary goals of this study were to describe the prevalence of postoperative cognitive dysfunction and to investigate its association with in-hospital delirium. The authors hypothesized that delirium would be a significant risk factor for postoperative cognitive dysfunction during follow-up.

Methods: This study used data from an observational study of cognitive outcomes after major noncardiac surgery, the Successful Aging after Elective Surgery study. Postoperative delirium was evaluated each hospital day with confusion assessment method-based interviews supplemented by chart reviews. Postoperative cognitive dysfunction was determined using methods adapted from the International Study of Postoperative Cognitive Dysfunction. Associations between delirium and postoperative cognitive dysfunction were examined at 1, 2, and 6 months.

Results: One hundred thirty-four of 560 participants (24%) developed delirium during hospitalization. Slightly fewer than half (47%, 256 of 548) met the International Study of Postoperative Cognitive Dysfunction-defined threshold for postoperative cognitive dysfunction at 1 month, but this proportion decreased at 2 months (23%, 123 of 536) and 6 months (16%, 85 of 528). At each follow-up, the level of agreement between delirium and postoperative cognitive dysfunction was poor (kappa less than .08) and correlations were small (r less than .16). The relative risk of postoperative cognitive dysfunction was significantly elevated for patients with a history of postoperative delirium at 1 month (relative risk = 1.34; 95% CI, 1.07-1.67), but not 2 months (relative risk = 1.08; 95% CI, 0.72-1.64), or 6 months (relative risk = 1.21; 95% CI, 0.71-2.09).

Conclusions: Delirium significantly increased the risk of postoperative cognitive dysfunction in the first postoperative month; this relationship did not hold in longer-term follow-up. At each evaluation, postoperative cognitive dysfunction was more common among patients without delirium. Postoperative delirium and postoperative cognitive dysfunction may be distinct manifestations of perioperative neurocognitive deficits.
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September 2019

Association Between Hospital Readmission and Acute and Sustained Delays in Functional Recovery During 18 Months After Elective Surgery: The Successful Aging after Elective Surgery Study.

J Am Geriatr Soc 2017 01 29;65(1):51-58. Epub 2016 Nov 29.

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

Objectives: To examine the effect of hospital readmission on functional recovery after elective surgery in older adults.

Design: Prospective cohort of individuals aged 70 and older undergoing elective surgery, enrolled from June 2010 to August 2013.

Setting: Two academic medical centers.

Participants: Community-dwelling older adults (N = 566; mean age ± standard deviation 77 ± 5) undergoing major elective surgery and expected to be admitted for at least 3 days.

Measurements: Readmission was assessed in multiple interviews with participants and family members over 18 months and validated against medical record review. Physical function was assessed according to ability to perform instrumental activities of daily living (IADLs) and activities of daily living (ADL), Medical Outcomes Study 12-item Short-Form Survey Physical Component Summary score, and a standardized functional composite.

Results: Two hundred fifty-five (45%) participants experienced 503 readmissions. Readmissions were associated with delays in functional recovery in all measures of physical function. Having two or more readmissions over 18 months was associated with persistent and significantly greater risk of IADL dependence (relative risk (RR) = 1.8, 95% confidence interval (CI) = 1.5-2.3) and ADL dependence (RR = 3.3, 95% CI = 1.7-6.4). Degree of functional impairment increased progressively with number of readmissions. Readmissions within 2 months resulted in delayed functional recovery to baseline by 18 months, and readmissions between 12 and 18 months after surgery resulted in loss of functional recovery previously achieved.

Conclusion: Readmission after elective surgery may contribute to delays in functional recovery and persistent functional deficits in older adults.
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January 2017

Trajectory of Functional Recovery After Postoperative Delirium in Elective Surgery.

Ann Surg 2017 04;265(4):647-653

*Division of Aging, Brigham and Women's Hospital, Boston, MA †Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, MA ‡Harvard Medical School, Boston, MA §Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA ¶Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA ||Department of Psychiatry and Human Behavior, Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI **Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA ††Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA.

Objective: To describe functional recovery after elective surgery and to determine whether improvements differ among individuals who develop delirium.

Background: No large studies of older adults have investigated whether delirium influences the trajectory of functional recovery after elective surgery. The prospective observational study assessed this association among 566 individuals aged 70 years and older.

Methods: Patients undergoing major elective surgery were assessed daily while in hospital for presence and severity of delirium using the Confusion Assessment Method, and their functional recovery was followed for 18 months thereafter. The Activities of Daily Living and Instrumental Activities of Daily Living Scales and the Physical Component Summary of the Short Form-12 were obtained before surgery and at 1, 2, 6, 12, and 18 months. A composite index (standard deviation 10, minimally clinically significant difference 2) derived from these scales was then analyzed using mixed-effects regression.

Results: Mean age was 77 years; 58% of participants were women and 24% developed postoperative delirium. Participants with delirium demonstrated lesser functional recovery than their counterparts without delirium; at 1 month, the covariate-adjusted mean difference on the physical function composite was -1.5 (95% confidence interval -3.3, -0.2). From 2 to 18 months, the corresponding difference was -1.8 (95% confidence interval -3.2, -0.3), an effect comparable with the minimally clinically significant difference.

Conclusions: Delirium was associated with persistent and clinically meaningful impairment of functional recovery, to 18 months. Use of multifactorial preventive interventions for patients at high risk for delirium and tailored transitional care planning may help to maximize the functional benefits of elective surgery.
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April 2017

Neighborhood effects on use of African-American Vernacular English.

Proc Natl Acad Sci U S A 2015 Sep 8;112(38):11817-22. Epub 2015 Sep 8.

Harris School of Public Policy, University of Chicago, Chicago, IL 60637 National Bureau of Economic Research, Cambridge, MA 02138;

African-American Vernacular English (AAVE) is systematic, rooted in history, and important as an identity marker and expressive resource for its speakers. In these respects, it resembles other vernacular or nonstandard varieties, like Cockney or Appalachian English. But like them, AAVE can trigger discrimination in the workplace, housing market, and schools. Understanding what shapes the relative use of AAVE vs. Standard American English (SAE) is important for policy and scientific reasons. This work presents, to our knowledge, the first experimental estimates of the effects of moving into lower-poverty neighborhoods on AAVE use. We use data on non-Hispanic African-American youth (n = 629) from a large-scale, randomized residential mobility experiment called Moving to Opportunity (MTO), which enrolled a sample of mostly minority families originally living in distressed public housing. Audio recordings of the youth were transcribed and coded for the use of five grammatical and five phonological AAVE features to construct a measure of the proportion of possible instances, or tokens, in which speakers use AAVE rather than SAE speech features. Random assignment to receive a housing voucher to move into a lower-poverty area (the intention-to-treat effect) led youth to live in neighborhoods (census tracts) with an 11 percentage point lower poverty rate on average over the next 10-15 y and reduced the share of AAVE tokens by ∼3 percentage points compared with the MTO control group youth. The MTO effect on AAVE use equals approximately half of the difference in AAVE frequency observed between youth whose parents have a high school diploma and those whose parents do not.
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September 2015