RESUMEN
Area-level measures of the social exposome provide powerful tools to understand how context contributes to health disparities. Due to the geographic phenomenon of the modifiable aerial unit problem, the geographic level at which the index is constructed can threaten it utility. Previous work indicates that using smaller geographic levels lead to increased measurement precision which may result in closer alignment to policies that directly address health disparities. To provide an illustrative example of this phenomenon, we use Medicare 100% Fee-for Service hospitalization claims data to evaluate the association between area-level disadvantage and 30-day readmissions when the Area Deprivation Index (ADI) is constructed at different geographic levels. When area-level disadvantage is summarized at the "neighborhood" census block group-the study's smallest geographic level-there was a 20% higher odds of readmissions for those living in the top 20% most disadvantaged neighborhoods compared to those living in the lowest 80% neighborhoods nationwide. Yet, evidence for an association with readmissions was not found when neighborhood disadvantaged was summarized at larger geographic levels. Smaller geographic levels appear most optimal to capture these effects. In order to provide publicly available data that is truly publicly useable, greater attention in providing small area health data is needed.
RESUMEN
Importance: The association of area deprivation with outcomes in discoid lupus erythematosus (DLE) remains poorly understood. Objective: To determine the association between US Census block measures of deprivation and disease severity in adult patients with DLE. Design, Setting, and Participants: This cross-sectional study included 154 patients with DLE seen between January 1, 2007, and January 1, 2024, at a single-center referral-based specialty rheumatologic-dermatology clinic in Philadelphia, Pennsylvania. Patients were aged 18 to 73 years and were enrolled in the University of Pennsylvania's Cutaneous Lupus Erythematosus Database study. Data were analyzed between January 1, 2024, and May 8, 2024. Exposures: Residence in a highly disadvantaged area as geocoded by a state area deprivation index (ADI). Main Outcomes and Measures: The main outcome was DLE disease severity as codified by the validated Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) damage and activity scores. Results: A total of 154 adult patients with DLE (128 women [83%] and 26 men [17%]; mean [SD] age, 43 [13] years; 6 [4%] Asian individuals, 98 [64%] Black individuals, 2 [1%] Hispanic individuals, 46 [30%] White individuals, and 2 individuals [1%] with other race or ethnicity; 78 [51%] with an ADI >5; 43 who currently smoked [28%];and 56 [36%] with concurrent systemic lupus erythematosus) were included in the analysis. By multivariable logistic regression, residence within communities with an ADI greater than 5 was associated with nearly 4-fold greater odds of moderate to severe damage (odds ratio [OR], 3.90; 95% CI, 1.27-12.69] and activity (OR, 3.31; 95% CI, 1.27-9.44). Concurrent cigarette smoking was similarly associated with greater odds of moderate to severe damage (OR, 3.15; 95% CI, 1.09-10.29). After controlling for ADI and other confounders, race was not significantly associated with DLE disease severity. Conclusions and Relevance: The results of this cross-sectional study suggest that geospatial disadvantage is associated with DLE disease severity independent of race. This invites a paradigm shift that considers the social context within which racial disparities are observed, highlighting the potential for geographically targeted interventions and policy changes to improve patient outcomes in DLE.
RESUMEN
Objective: Neighborhood disadvantage is associated with worse health and cognitive outcomes. Morphological similarity network (MSN) is a promising approach to elucidate cortical network patterns underlying complex cognitive functions. We hypothesized that MSNs could capture intricate changes in cortical patterns related to neighborhood disadvantage and cognitive function, potentially explaining some of the risk for later life cognitive impairment among individuals who live in disadvantaged contexts. Methods: This cross-sectional study included cognitively unimpaired participants (n=524, age=62.96±8.377, gender (M:F)=181:343, ADI(L:H) =450,74) from the Wisconsin Alzheimer's Disease Research Center or Wisconsin Registry for Alzheimer's Prevention. Neighborhood disadvantage status was obtained using the Area Deprivation Index (ADI). Cognitive performance was assessed through six tests evaluating memory, executive functioning, and the modified preclinical Alzheimer's cognitive composite (mPACC). Morphological Similarity Networks (MSN) were constructed for each participant based on the similarity in distribution of cortical thickness of brain regions, followed by computation of local and global network features. We used linear regression to examine ADI associations with cognitive scores and MSN features. The mediating effect of MSN features on the relationship between ADI and cognitive performance was statistically assessed. Results: Neighborhood disadvantage showed negative association with category fluency, implicit learning speed, story recall and mPACC scores, indicating worse cognitive function among those living in more disadvantaged neighborhoods. Local network features of frontal and temporal brain regions differed based on ADI status. Centrality of left lateral orbitofrontal region showed a partial mediating effect between association of neighborhood disadvantage and story recall performance. Conclusion: Our findings suggest differences in local cortical organization by neighborhood disadvantage, which also partially mediated the relationship between ADI and cognitive performance, providing a possible network-based mechanism to, in-part, explain the risk for poor cognitive functioning associated with disadvantaged neighborhoods. Future work will examine the exposure to neighborhood disadvantage on structural organization of the brain.
RESUMEN
BACKGROUND: Primary hyperparathyroidism is underdiagnosed and surgical treatment is underutilized and inequitably distributed. We present a review of the current literature on disparities in the treatment of hyperparathyroidism, with a focus on gaps in knowledge and paths forward. METHODS: We searched PubMed and Scopus for abstracts related to disparities in hyperparathyroidism. RESULTS: 16 articles (of 1541) met inclusion criteria. The most commonly examined disparity was race. Notably, Black, Hispanic, and Asian patients were less likely to undergo surgery after diagnosis, face delays in obtaining treatment, and less likely to see a high-volume surgeon. Similar disparities in care were noted among those without insurance, older patients, and patients with limited English proficiency. CONCLUSION: There are clear inequities in the treatment of hyperparathyroidism. Current research is in an early "identification" phase of disparities research; a new conceptual model based on established socioecological frameworks is provided to help move the field forward to "understanding" and "intervening" in surgical disparities.
Asunto(s)
Disparidades en Atención de Salud , Hiperparatiroidismo Primario , Humanos , Hiperparatiroidismo Primario/cirugía , Hiperparatiroidismo Primario/terapia , Hiperparatiroidismo Primario/diagnóstico , Disparidades en Atención de Salud/estadística & datos numéricos , Paratiroidectomía/estadística & datos numéricosRESUMEN
OBJECTIVE: In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context. METHODS: This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography. RESULTS: Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71). CONCLUSION: Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.
Asunto(s)
Disparidades en Atención de Salud , Lupus Eritematoso Sistémico , Medicare , Reumatología , Humanos , Lupus Eritematoso Sistémico/terapia , Estados Unidos , Adulto , Masculino , Femenino , Adulto Joven , Adolescente , Disparidades en Atención de Salud/estadística & datos numéricos , Retención en el Cuidado/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Estudios de Cohortes , Modelos Logísticos , Negro o Afroamericano/estadística & datos numéricosRESUMEN
BACKGROUND: International data suggest that asthma, like other inflammatory diseases, might increase Alzheimer disease (AD) risk. OBJECTIVE: We sought to explore risk pathways and future mitigation strategies by comparing diagnostic claims-based AD incidence and prevalence among US patients with asthma with those without asthma. METHODS: This cohort study included a national Medicare 20% random sample (2013-2015). Adult patients with asthma with more than 12 months continuous Medicare were compared with subjects without asthma overall and as matched. Asthma was defined by 1 inpatient or 2 outpatient codes for asthma. The main outcomes were 2-year incident or prevalent AD defined by International Classification of Diseases, Ninth Revision code 331.0 or Tenth Revision code G30.0, G30.1, G30.8, or G30.9. RESULTS: Among 5,460,732 total beneficiaries, 678,730 patients were identified with baseline asthma and more often identified as Black or Hispanic, were Medicaid eligible, or resided in a highly disadvantaged neighborhood than those without asthma. Two-year incidence of AD was 1.4% with asthma versus 1.1% without asthma; prevalence was 7.8% versus 5.4% (both P ≤ .001). Per 100,000 patients over 2 years, 303 more incident AD diagnoses occurred in those with asthma, with 2,425 more prevalent cases (P < .001). Multivariable models showed that asthma had greater odds of 2-year AD incidence (adjusted odds ratio, 1.33 [95% CI, 1.29-1.36]; matched 1.2 [95% CI, 1.17-1.24]) and prevalence (adjusted odds ratio, 1.48 [95% CI, 1.47-1.50]; matched 1.25 [95% CI, 1.22-1.27]). CONCLUSIONS: Asthma was associated with 20% to 33% increased 2-year incidence and 25% to 48% increased prevalence of claims-based AD in this nationally representative US sample. Future research should investigate risk pathways of underlying comorbidities and social determinants as well as whether there are potential asthma treatments that may preserve brain health.
Asunto(s)
Enfermedad de Alzheimer , Asma , Medicare , Humanos , Asma/epidemiología , Estados Unidos/epidemiología , Masculino , Enfermedad de Alzheimer/epidemiología , Femenino , Incidencia , Anciano , Prevalencia , Estudios de Cohortes , Anciano de 80 o más Años , Persona de Mediana Edad , Factores de RiesgoRESUMEN
PURPOSE: Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge. METHOD: A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated. RESULTS: ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided. CONCLUSIONS: These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.
Asunto(s)
Trastornos de Deglución , Deglución , Demencia , Alta del Paciente , Características de la Residencia , Determinantes Sociales de la Salud , Humanos , Estudios Retrospectivos , Masculino , Trastornos de Deglución/terapia , Trastornos de Deglución/fisiopatología , Trastornos de Deglución/diagnóstico , Femenino , Demencia/terapia , Anciano , Anciano de 80 o más Años , Pacientes InternosRESUMEN
INTRODUCTION: The exposome is theorized to interact with biological mechanisms to influence risk for Alzheimer's disease but is not well-integrated into existing Alzheimer's Disease Research Center (ADRC) brain bank data collection. METHODS: We apply public data tracing, an iterative, dual abstraction and validation process rooted in rigorous historic archival methods, to develop life-course residential histories for 1254 ADRC decedents. RESULTS: The median percentage of the life course with an address is 78.1% (IQR 24.9); 56.5% of the sample has an address for at least 75% of their life course. Archivists had 89.7% agreement at the address level. This method matched current residential survey methodology 97.4% on average. DISCUSSION: This novel method demonstrates feasibility, reproducibility, and rigor for historic data collection. To our knowledge, this is the first study to show that public data tracing methods for brain bank decedent residential history development can be used to better integrate the social exposome with biobank specimens. HIGHLIGHTS: Public data tracing compares favorably to survey-based residential history. Public data tracing is feasible and reproducible between archivists. Archivists achieved 89.7% agreement at the address level. This method identifies residences for nearly 80% of life-years, on average. This novel method enables brain banks to add social characterizations.
Asunto(s)
Enfermedad de Alzheimer , Estudios de Factibilidad , Humanos , Femenino , Masculino , Anciano , Bancos de Tejidos , Reproducibilidad de los Resultados , Encéfalo , Estudios de Cohortes , Exposoma , Recolección de Datos/métodos , Anciano de 80 o más AñosRESUMEN
Dementia research lacks appropriate representation of diverse groups who often face substantial adversity and greater risk of dementia. Current research participants are primarily well-resourced, non-Hispanic White, cisgender adults who live close to academic medical centers where much of the research is based. Consequently, the field faces a knowledge gap about Alzheimer's-related risk factors in those other groups. The Alzheimer's Association hosted a virtual conference on June 14-16, 2021, supported in part by the National Institute on Aging (R13 AG072859-01), focused on health disparities. The conference was held entirely online and consisted of 2 days of core programming and a day of focused meetings centered on American Indian and Alaska Natives and on LGBTQIA+ populations. Over 1300 registrants attended discussions focused on the structural and systemic inequities experienced across diverse groups, as well as ways to investigate and address these inequities.
Asunto(s)
Nativos Alasqueños , Enfermedad de Alzheimer , Adulto , Humanos , Indio Americano o Nativo de Alaska , Inequidades en Salud , Disparidades en Atención de Salud , Factores de Riesgo , Minorías Sexuales y de Género , Estados Unidos/epidemiología , BlancoRESUMEN
Precision prevention embraces personalized prevention but includes broader factors such as social determinants of health to improve cardiovascular health. The quality, quantity, precision, and diversity of data relatable to individuals and communities continue to expand. New analytical methods can be applied to these data to create tools to attribute risk, which may allow a better understanding of cardiovascular health disparities. Interventions using these analytic tools should be evaluated to establish feasibility and efficacy for addressing cardiovascular disease disparities in diverse individuals and communities. Training in these approaches is important to create the next generation of scientists and practitioners in precision prevention. This state-of-the-art review is based on a workshop convened to identify current gaps in knowledge and methods used in precision prevention intervention research, discuss opportunities to expand trials of implementation science to close the health equity gaps, and expand the education and training of a diverse precision prevention workforce.
RESUMEN
INTRODUCTION: Community disadvantage is associated with late-life cognition. Few studies examine its contribution to racial disparities in cognition/cognitive change. METHODS: Inverse probability weighted models estimated expected mean differences in cognition/cognitive change attributed to residing in less advantaged communities, defined as cohort top quintile of Area Deprivation Indices (ADI): childhood 66-100; adulthood ADI 5-99). Interactions by race tested. RESULTS: More Black participants resided in less advantaged communities. Semantic memory would be lower if all participants had resided in less advantaged childhood (b = -0.16, 95% confidence interval [CI] = -0.30, -0.03) or adulthood (b = -0.14, 95% CI = -0.22, -0.04) communities. Race interactions indicated that, among Black participants, less advantaged childhood communities were associated with higher verbal episodic memory (interaction p-value = 0.007) and less advantaged adulthood communities were associated with lower semantic memory (interaction p-value = 0.002). DISCUSSION: Examining racial differences in levels of community advantage and late-life cognitive decline is a critical step toward unpacking community effects on cognitive disparities.
Asunto(s)
Disfunción Cognitiva , Memoria Episódica , Adulto , Niño , Humanos , Cognición , Negro o Afroamericano , Características del Vecindario , Privación Social , Determinantes Sociales de la SaludRESUMEN
INTRODUCTION: Anti-amyloid therapies are at the forefront of efforts to treat Alzheimer's disease (AD). Identifying amyloid risk factors may aid screening and intervention strategies. While veterans face increased exposure to risk factors, whether they face a greater neuropathologic amyloid burden is not well understood. METHODS: Male decedents donating to two Alzheimer's Disease Research Center (ADRC) brain banks from 1986 to 2018 with categorized neuritic plaque density and neurofibrillary tangles (n = 597) were included. Using generalized ordered logistic regression we modeled each outcome's association with military history adjusting for age and death year. RESULTS: Having served in the military (60% of sample) is associated with post mortem neuritic amyloid plaque (for each comparison of higher to lower C scores OR = 1.26; 95% confidence interval [CI] = 1.06-1.49) and tau pathology (B score OR = 1.10; 95% CI = 1.08-1.12). DISCUSSION: This is the first study, to our knowledge, finding increased levels of verified AD neuropathology in those with military service. Targeted veteran AD therapies is a pressing need.
Asunto(s)
Enfermedad de Alzheimer , Masculino , Humanos , Enfermedad de Alzheimer/patología , Ovillos Neurofibrilares/patología , Autopsia , Encéfalo/patología , Neuropatología , Placa Amiloide/patologíaRESUMEN
Area-based social disadvantage, which measures the income, employment, and housing quality in one's community, can impact an individual's health above person-level factors. A life course approach examines how exposure to disadvantage can affect health in later life. This systematic review aimed to summarize the approaches used to assess exposure to area-based disadvantage over a life course, specifically those that define the length and timing of exposure. We reviewed the abstracts of 831 articles based on the following criteria: (1) whether the abstract described original research; (2) whether the study was longitudinal; (3) whether area-based social disadvantage was an exposure variable; (4) whether area-based social disadvantage was assessed at multiple points; and (5) whether exposure was assessed from childhood to older adulthood. Zero articles met all the above criteria, so we relaxed the fifth criterion in a secondary review. Six studies met our secondary criteria and were eligible for data extraction. The included studies followed subjects from childhood into adulthood, but none assessed disadvantages in late life. The approaches used to assess exposure included creating a cumulative disadvantage score, conducting a comparison between life course periods, and modeling the trajectory of disadvantage over time. Additional research was needed to validate the methodologies described here, specifically in terms of measuring the impact of area-based social disadvantage on health.
Asunto(s)
Renta , Acontecimientos que Cambian la Vida , Humanos , Anciano , Niño , EmpleoRESUMEN
Importance: Understanding how socioeconomic factors are associated with cognitive aging is important for addressing health disparities in Alzheimer disease. Objective: To examine the association of neighborhood disadvantage with cognition among a multiethnic cohort of older adults. Design, Setting, and Participants: In this cross-sectional study, data were collected between September 1, 2017, and May 31, 2022. Participants were from the Health and Aging Brain Study-Health Disparities, which is a community-based single-center study in the Dallas/Fort Worth area of Texas. A total of 1614 Mexican American and non-Hispanic White adults 50 years and older were included. Exposure: Neighborhood disadvantage for participants' current residence was measured by the validated Area Deprivation Index (ADI); ADI Texas state deciles were converted to quintiles, with quintile 1 representing the least disadvantaged area and quintile 5 the most disadvantaged area. Covariates included age, sex, and educational level. Main Outcomes and Measures: Performance on cognitive tests assessing memory, language, attention, processing speed, and executive functioning; measures included the Spanish-English Verbal Learning Test (SEVLT) Learning and Delayed Recall subscales; Wechsler Memory Scale, third edition (WMS-III) Digit Span Forward, Digit Span Backward, and Logical Memory 1 and 2 subscales; Trail Making Test (TMT) parts A and B; Digit Symbol Substitution Test (DSST); Letter Fluency; and Animal Naming. Raw scores were used for analyses. Associations between neighborhood disadvantage and neuropsychological performance were examined via demographically adjusted linear regression models stratified by ethnic group. Results: Among 1614 older adults (mean [SD] age, 66.3 [8.7] years; 980 women [60.7%]), 853 were Mexican American (mean [SD] age, 63.9 [7.9] years; 566 women [66.4%]), and 761 were non-Hispanic White (mean [SD] age, 69.1 [8.7] years; 414 women [54.4%]). Older Mexican American adults were more likely to reside in the most disadvantaged areas (ADI quintiles 3-5), with 280 individuals (32.8%) living in ADI quintile 5, whereas a large proportion of older non-Hispanic White adults resided in ADI quintile 1 (296 individuals [38.9%]). Mexican American individuals living in more disadvantaged areas had worse performance than those living in ADI quintile 1 on 7 of 11 cognitive tests, including SEVLT Learning (ADI quintile 5: ß = -2.50; 95% CI, -4.46 to -0.54), SEVLT Delayed Recall (eg, ADI quintile 3: ß = -1.11; 95% CI, -1.97 to -0.24), WMS-III Digit Span Forward (eg, ADI quintile 4: ß = -1.14; 95% CI, -1.60 to -0.67), TMT part A (ADI quintile 5: ß = 7.85; 95% CI, 1.28-14.42), TMT part B (eg, ADI quintile 5: ß = 31.5; 95% CI, 12.16-51.35), Letter Fluency (ADI quintile 4: ß = -2.91; 95% CI, -5.39 to -0.43), and DSST (eg, ADI quintile 5: ß = -4.45; 95% CI, -6.77 to -2.14). In contrast, only non-Hispanic White individuals living in ADI quintile 4 had worse performance than those living in ADI quintile 1 on 4 of 11 cognitive tests, including SEVLT Learning (ß = -2.35; 95% CI, -4.40 to -0.30), SEVLT Delayed Recall (ß = -0.95; 95% CI, -1.73 to -0.17), TMT part B (ß = 15.95; 95% CI, 2.47-29.44), and DSST (ß = -3.96; 95% CI, -6.49 to -1.43). Conclusions and Relevance: In this cross-sectional study, aging in a disadvantaged area was associated with worse cognitive functioning, particularly for older Mexican American adults. Future studies examining the implications of exposure to neighborhood disadvantage across the life span will be important for improving cognitive outcomes in diverse populations.
Asunto(s)
Cognición , Americanos Mexicanos , Características del Vecindario , Blanco , Femenino , Humanos , Estudios Transversales , Función Ejecutiva , Masculino , Persona de Mediana Edad , Anciano , Estados UnidosRESUMEN
Importance: Residence in a disadvantaged neighborhood may be associated with an increased risk for cognitive impairment and dementia but is understudied in nationally representative populations. Objective: To investigate the association between the Area Deprivation Index (ADI) and dementia. Design, Setting, and Participants: Retrospective cohort study within the US Veterans Health Administration from October 1, 1999, to September 30, 2021, with a national cohort of older veterans receiving care in the largest integrated health care system in the United States. For each fiscal year, a 5% random sample was selected from all patients (n = 2â¯398â¯659). Patients with missing ADI information (n = 492â¯721) or missing sex information (n = 6) and prevalent dementia cases (n = 25â¯379) were excluded. Participants had to have at least 1 follow-up visit (n = 1â¯662â¯863). The final analytic sample was 1â¯637â¯484. Exposure: Neighborhoods were characterized with the ADI, which combines several sociodemographic indicators (eg, income, education, employment, and housing) into a census block group-level index of disadvantage. Participants were categorized into ADI rank quintiles by their census block group of residence (higher ADI rank quintile corresponds with more deprivation). Main Outcome and Measures: Time to dementia diagnosis (using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes) was estimated with Cox proportional hazards models with age as the time scale, and the sensitivity of the findings was evaluated with Fine-Gray proportional hazards models, accounting for competing risk of death. Results: Among the 1â¯637â¯484 Veterans Health Administration patients, the mean (SD) age was 68.6 (7.7) years, and 1â¯604â¯677 (98.0%) were men. A total of 7318 patients were Asian (0.4%), 151â¯818 (9.3%) were Black, 10â¯591 were Hispanic (0.6%), 1â¯422â¯713 (86.9%) were White, and 45â¯044 (2.8%) were of other or unknown race and ethnicity. During a mean (SD) follow-up of 11.0 (4.8) years, 12.8% of veterans developed dementia. Compared with veterans in the least disadvantaged neighborhood quintile, those in greater disadvantage groups had an increased risk of dementia in models adjusted for sex, race and ethnicity, and psychiatric and medical comorbid conditions (first quintile = reference; second quintile adjusted hazard ratio [HR], 1.09 [95% CI, 1.07-1.10]; third quintile adjusted HR, 1.14 [95% CI, 1.12-1.15]; fourth quintile adjusted HR, 1.16 [95% CI, 1.14-1.18]; and fifth quintile adjusted HR, 1.22 [95% CI, 1.21-1.24]). Repeating the main analysis using competing risk for mortality led to similar results. Conclusions and Relevance: Results of this study suggest that residence within more disadvantaged neighborhoods was associated with higher risk of dementia among older veterans integrated in a national health care system.
Asunto(s)
Demencia , Veteranos , Masculino , Humanos , Estados Unidos/epidemiología , Anciano , Femenino , Estudios Retrospectivos , Factores de Riesgo , Características de la Residencia , Demencia/diagnósticoRESUMEN
BACKGROUND: The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness. METHODS: We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival. RESULTS: The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups. CONCLUSIONS: A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.
Asunto(s)
Cuidados Paliativos al Final de la Vida , Cuidado de Transición , Veteranos , Humanos , Rol de la Enfermera , HospitalizaciónRESUMEN
BACKGROUND: Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup. OBJECTIVES: We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect. RESEARCH DESIGN: Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership. SUBJECTS: Participants were ED patients (age 60 y and above) discharged to a community residence. MEASURES: Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors. RESULTS: We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13-2.91; odds ratio: 2.24, 95% CI: 1.25-4.03). CONCLUSIONS: Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.
Asunto(s)
Transferencia de Pacientes , Cuidado de Transición , Humanos , Anciano , Persona de Mediana Edad , Análisis de Clases Latentes , Alta del Paciente , Servicio de Urgencia en HospitalRESUMEN
INTRODUCTION: Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion. RESEARCH DESIGN AND METHODS: This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black. RESULTS: Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black. CONCLUSIONS: A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.
Asunto(s)
Negro o Afroamericano , Diabetes Mellitus , Pie Diabético , Disparidades en Atención de Salud , Anciano , Humanos , Amputación Quirúrgica , Estudios de Cohortes , Pie Diabético/epidemiología , Pie Diabético/terapia , Medicare , Estudios Retrospectivos , Estados Unidos/epidemiología , Población Rural , Características de la ResidenciaRESUMEN
Resilience, which relates to one's ability to respond to stressors, typically declines with age and the development of comorbid conditions in older organisms. Although progress has been made to improve our understanding of resilience in older adults, disciplines have employed different frameworks and definitions to study various aspects of older adults' response to acute or chronic stressors. "Overview of the Resilience World: State of the Science," a bench-to-bedside conference on October 12-13, 2022, was sponsored by the American Geriatrics Society and National Institute on Aging. This conference, summarized in this report, explored commonalities and differences among the frameworks of resilience most commonly used in aging research in the three domains of resilience: physical, cognitive, and psychosocial. These three main domains are intertwined, and stressors in one domain can lead to effects in other domains. The themes of the conference sessions included underlying contributors to resilience, the dynamic nature of resilience throughout the life span, and the role of resilience in health equity. Although participants did not agree on a single definition of "resilience(s)," they identified common core elements of a definition that can be applied to all domains and noted unique features that are domain specific. The presentations and discussions led to recommendations for new longitudinal studies of the impact of exposures to stressors on resilience in older adults, the use of new and existing cohort study data, natural experiments (including the COVID-19 pandemic), and preclinical models for resilience research, as well as translational research to bring findings on resilience to patient care.