Changes in Site of Death Among Older Adults Without a COVID-19 Diagnosis During the COVID-19 Pandemic.

BACKGROUND: Understanding how the coronavirus disease 2019 (COVID-19) pandemic affected site of death-an important patient-centered outcome related to end-of-life care-would inform healthcare system resiliency in future public health emergencies. OBJECTIVE: To evaluate the changes in site of death during the COVID-19 pandemic among older adults without a COVID-19 diagnosis. DESIGN: Using a quasi-experimental difference-in-differences method, we estimated net changes in site of death during the pandemic period (March-December 2020) from the pre-pandemic period (January-February 2020), using data on the same months in prior years (2016-2019) as the control. PARTICIPANTS: A 20% sample of Medicare Fee-for-Service beneficiaries aged 66 years and older who died in 2016-2020. We excluded beneficiaries with a hospital diagnosis of COVID-19. MAIN MEASURES: We assessed each of the following sites of death separately: (1) home or community; (2) acute care hospital; and (3) nursing home. KEY RESULTS: We included 1,133,273 beneficiaries without a hospital diagnosis of COVID-19. We found that the proportion of Medicare beneficiaries who died at home or in the community setting increased (difference-in-differences [DID] estimate, + 3.1 percentage points [pp]; 95% CI, + 2.6 to + 3.6 pp; P < 0.001) and the proportion of beneficiaries who died (without COVID-19 diagnosis) in an acute care hospital decreased (- 0.8 pp; 95% CI, - 1.2 to - 0.4 pp; P < 0.001) during the pandemic. We found no evidence that the proportion of deaths in nursing homes changed during the pandemic. CONCLUSIONS: Using national data on older adults without a COVID-19 diagnosis, we found that site of death shifted toward home or community settings during the COVID-19 pandemic. Our findings may inform clinicians and policymakers in supporting end-of-life care during future public health emergencies.

Characterizing the Suture Pullout Force for Human Small Bowel.

Performing a small bowel anastomosis, or reconnecting small bowel segments, remains a core competency and critical step for the successful surgical management of numerous bowel and urinary conditions. As surgical education and technology moves toward improving patient outcomes through automation and increasing training opportunities, a detailed characterization of the interventional biomechanical properties of the human bowel is important. This is especially true due to the prevalence of anastomotic leakage as a frequent (3.02%) postoperative complication of small bowel anastomoses. This study aims to characterize the forces required for a suture to tear through human small bowel (suture pullout force, SPOF), while analyzing how these forces are affected by tissue orientation, suture material, suture size, and donor demographics. 803 tests were performed on 35 human small bowel specimens. A uni-axial test frame was used to tension sutures looped through 10 × 20 mm rectangular bowel samples to tissue failure. The mean SPOF of the small bowel was 4.62±1.40 N. We found no significant effect of tissue orientation (p = 0.083), suture material (p = 0.681), suture size (p = 0.131), age (p = 0.158), sex (p = .083), or body mass index (BMI) (p = 0.100) on SPOF. To our knowledge, this is the first study reporting human small bowel SPOF. Little research has been published about procedure-specific data on human small bowel. Filling this gap in research will inform the design of more accurate human bowel synthetic models and provide an accurate baseline for training and clinical applications.

Greening Family Medicine clinic operations and clinical care, where do we start? A scoping review of toolkits and aids.

BACKGROUND: There is a pressing need for healthcare to respond to the climate crisis. Family physicians, given their central role in community healthcare provision, are strategically placed to lead, support, and promote sustainable healthcare, yet guidance on how to do this is fragmented. OBJECTIVE: To identify and evaluate toolkits and aids on sustainable healthcare to act as a curated resource for family physicians and their care teams interested in delivering evidence-based sustainable healthcare in their clinical practices. METHODS: A scoping review was completed of the published and grey literature across 4 databases and 2 search engines to identify articles and aids/toolkits from 1990 to present. Toolkits were subsequently evaluated for purpose, evidence-base, implementation process, adaptability to family medicine, and outcome measures. RESULTS: The search identified 17,751 articles. Screening resulted in 20 published articles and 11 toolkits. Most articles presented simple checklists to support greening clinic initiatives, 3 studies focussed on partial carbon footprint analyses, and 4 on educational initiatives. Toolkits ranged in sustainability topics and degree of depth covered, and adaptability and outcome measures. None of the resources identified have been formally evaluated for effectiveness. CONCLUSIONS: A range of aids exist to support greening of clinic operations; however, there is a significant gap in the literature for greening clinical care. Two toolkits were found to be comprehensive, one requiring tracking and reporting of sustainability initiatives. This scoping review provides a starting point for motivated family doctors and community clinics to initiate change and support more sustainable healthcare.

Hyperacute optic neuritis in a patient with COVID-19 infection and vaccination: a case report.

BACKGROUND: As scientific knowledge continues to grow regarding coronavirus disease 2019 (COVID-19) infection, several neuro-ophthalmological manifestations have emerged, including rare reports of optic neuritis. Optic neuritis is an inflammatory demyelinating condition of the optic nerve that typically presents as subacute, unilateral vision loss and pain on eye movement. Several cases of COVID-19 infection and COVID-19 vaccination related cases of optic neuritis have been reported. We present a case of hyperacute, unilateral optic neuritis after both recent COVID-19 infection and subsequent booster vaccination. CASE PRESENTATION: Within two hours after receiving her COVID-19 booster vaccination, a 58-year-old female began experiencing bilateral eye pain, worsened by eye movements. The patient had previously contracted a mild COVID-19 infection three weeks prior to receiving her booster vaccination, confirmed by a rapid antigen test. The pain persisted in her right eye for a week at which time she presented to an ophthalmology clinic. She denied any changes to her visual acuity. Neuroimaging revealed right optic nerve enhancement, and the patient was admitted to the hospital for a course of intravenous steroids, which quickly resolved her eye pain. CONCLUSION: To our knowledge, this is the first reported case of COVID-19 related optic neuritis following both COVID-19 infection and vaccination. High clinical suspicion is needed to make the appropriate diagnosis, as cases of COVID-19 related optic neuritis may exhibit mild presentations, as was the case with our patient.

Self-other agreement and criterion-related validity of moral pride and hubris.

OBJECTIVES: This research investigates the moral implications of trait-level moral pride and hubris, addressing prior limitations by gathering data from multiple sources. We raise two interrelated questions: (1) Do well-acquainted peers agree with their friends on judgments of trait-level moral pride and hubris? (2) Are moral pride and hubris related to divergent (im)moral outcomes, regardless of measurement sources? METHOD: We collected data from a sample of university students and their friends (N = 173 dyads) in Hong Kong to examine self-other agreement and criterion-related validity of trait-level moral pride and hubris. RESULTS: Our findings reveal a medium-to-large level of self-other agreement for, as well as a moral divergence of, trait-level moral pride and hubris. Notably, self-reports of moral pride predict prosocial behavior, whereas self-reports of moral hubris predict virtue-signaling behavior, regardless of whether the outcomes are self- or other-reported. Moreover, self-reports trump other-reports in predicting some outcomes, but the reverse is true for other outcomes. CONCLUSIONS: Our findings suggest that individuals' proneness to experience morally specific pride and hubris constitutes "real" traits, evoking divergent (im)moral outcomes. Furthermore, self- and other-reports each contain some unique trait-relevant information, with their relative predictive power depending on the specific predictor and outcome.

Relapse of Plasmodium vivax and Plasmodium ovale Malaria With and Without Primaquine Treatment in a Nonendemic Area.

BACKGROUND: The effect of primaquine in preventing Plasmodium vivax relapses from dormant stages is well established. For Plasmodium ovale, the relapse characteristics and the use of primaquine is not as well studied. We set to evaluate the relapsing properties of these 2 species, in relation to primaquine use among imported malaria cases in a nonendemic setting. METHODS: We performed a nationwide retrospective study of malaria diagnosed in Sweden 1995-2019, by reviewing medical records of 3254 cases. All episodes of P. vivax (n = 972) and P. ovale (n = 251) were selected for analysis. RESULTS: First time relapses were reported in 80/857 (9.3%) P. vivax and 9/220 (4.1%) P. ovale episodes, respectively (P < .01). Without primaquine, the risk for relapse was higher in P. vivax, 20/60 (33.3%), compared to 3/30 (10.0%) in P. ovale (hazard ratio [HR] 3.5, 95% confidence interval [CI] 1.0-12.0). In P. vivax, patients prescribed primaquine had a reduced risk of relapse compared to episodes without relapse preventing treatment, 7.1% vs 33.3% (HR 0.2, 95% CI .1-.3). In P. ovale, the effect of primaquine on the risk of relapse did not reach statistical significance, with relapses seen in 2.8% of the episodes compared to 10.0% in patients not receiving relapse preventing treatment (HR 0.3, 95% CI .1-1.1). CONCLUSIONS: The risk of relapse was considerably lower in P. ovale than in P. vivax infections indicating different relapsing features between the two species. Primaquine was effective in preventing P. vivax relapse. In P. ovale, relapse episodes were few, and the supportive evidence for primaquine remains limited.

Factors affecting mechanical complications of central venous access devices in children.

PURPOSE: Factors leading to mechanical complications following insertion of central venous access devices (CVADs) in children are poorly understood. We aimed to quantify the rates and elucidate the mechanisms of these complications. METHODS: Retrospective (2016-2021) review of children (< 18 years old) receiving a CVAD. Data, reported as number of cases (%) and median (IQR), were analysed by Fisher's exact test, chi-squared test and logistic regression analysis. RESULTS: In total, 317 CVADs (245 children) were inserted. Median age was 5.0 (8.9) years, with 116 (47%) females. There were 226 (71%) implantable port devices and 91 (29%) Hickman lines. Overall, 54 (17%) lines had a mechanical complication after 0.4 (0.83) years from insertion: fracture 19 (6%), CVAD migration 14 (4.4%), occlusion 14 (4.4%), port displacement 6 (1.9%), and skin tethering to port device 1 (0.3%). Younger age and lower weight were associated with higher risk of complications (p < 0.0001). Hickman lines had a higher incidence of complications compared to implantable port devices [24/91 (26.3%) vs 30/226 (13.3%); p = 0.008]. CONCLUSION: Mechanical complications occur in 17% of CVADs at a median of < 6 months after insertion. Risk factors include younger age and lower weight. Implantable port devices have a lower complications rate. LEVEL OF EVIDENCE: Level 4: case-series with no comparison group.

ntEdit: scalable genome sequence polishing.

MOTIVATION: In the modern genomics era, genome sequence assemblies are routine practice. However, depending on the methodology, resulting drafts may contain considerable base errors. Although utilities exist for genome base polishing, they work best with high read coverage and do not scale well. We developed ntEdit, a Bloom filter-based genome sequence editing utility that scales to large mammalian and conifer genomes. RESULTS: We first tested ntEdit and the state-of-the-art assembly improvement tools GATK, Pilon and Racon on controlled Escherichia coli and Caenorhabditis elegans sequence data. Generally, ntEdit performs well at low sequence depths (<20×), fixing the majority (>97%) of base substitutions and indels, and its performance is largely constant with increased coverage. In all experiments conducted using a single CPU, the ntEdit pipeline executed in <14 s and <3 m, on average, on E.coli and C.elegans, respectively. We performed similar benchmarks on a sub-20× coverage human genome sequence dataset, inspecting accuracy and resource usage in editing chromosomes 1 and 21, and whole genome. ntEdit scaled linearly, executing in 30-40 m on those sequences. We show how ntEdit ran in <2 h 20 m to improve upon long and linked read human genome assemblies of NA12878, using high-coverage (54×) Illumina sequence data from the same individual, fixing frame shifts in coding sequences. We also generated 17-fold coverage spruce sequence data from haploid sequence sources (seed megagametophyte), and used it to edit our pseudo haploid assemblies of the 20 Gb interior and white spruce genomes in <4 and <5 h, respectively, making roughly 50M edits at a (substitution+indel) rate of 0.0024. AVAILABILITY AND IMPLEMENTATION: https://github.com/bcgsc/ntedit. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

Incidence and management of iliac artery aneurysms associated with endovascular treatment of juxtarenal and thoracoabdominal aortic aneurysms.

BACKGROUND: This study reports the clinical impact of iliac artery aneurysms (IAAs) in a population of patients with juxtarenal and thoracoabdominal aortic aneurysms being treated with fenestrated or branched aortic endografts. METHODS: Data from 364 patients with IAA (33%) were extracted from the 1118 patients treated for juxtarenal or thoracoabdominal aortic aneurysms with a fenestrated or branched aortic endograft in a physician-sponsored investigational device exemption trial (2001-2016). IAAs were defined as ≥21 mm in diameter, as measured by an imaging core laboratory. Outcomes were assessed by univariate and multivariable analysis. RESULTS: IAAs were unilateral in 219 (60%) and bilateral in 145 (40%) of the 364 patients. Treatment was iliac leg endoprosthesis without coverage of the hypogastric artery (seal distal to the IAA in the common iliac artery), placement of a hypogastric branched endograft in 105 (21%), and hypogastric artery coverage with extension into the external iliac artery in 103 (20%); 67 (13%) were untreated. Procedure duration was longer for those with IAA (5.3 ± 1.79 hours vs 4.6 ± 1.74 hours; P < .001), although hospital stay was not. There was no difference in aneurysm-related mortality and all-cause mortality for patients with unilateral and bilateral IAAs compared with those without an IAA. Treatment of patients with a hypogastric branched endograft had similar all-cause mortality compared with treatment of patients without a hypogastric branched endograft but also with an IAA. Reintervention rates were significantly higher in those with bilateral IAAs compared with no IAA (hazard ratio, 1.886; P < .001). Spinal cord ischemia trended higher in patients with bilateral IAA. CONCLUSIONS: IAA management at the time of fenestrated or branched endovascular aneurysm repair increases procedure time without increasing hospitalization. The reintervention rate and spinal cord ischemia rate are higher in patients with bilateral IAA compared with those with no IAA.

What was visualized? A method for describing content of performance summary displays in feedback interventions.

BACKGROUND: Visual displays such as charts and tables may significantly moderate the effects of audit and feedback interventions, but the systematic study of these intervention components will likely remain limited without a method for isolating the information content of a visual display from its form elements. The objective of this study is to introduce such a method based on an application of visualization frameworks to enable a systematic approach to answer the question, "What was visualized?" in studies of audit and feedback. METHODS: The proposed method uses 3 steps to systematically identify and describe the content of visual displays in feedback interventions: 1) identify displays, 2) classify content, and 3) identify elements. The use of a visualization framework led us to identify information content types as representations of measures (metrics or indicators), ascribees (feedback recipients and comparators), performance levels, and time intervals. We illustrate the proposed method in a series of 3 content analyses, one for each step, to identify visual displays and their information content in published example performance summaries. RESULTS: We analyzed a convenience sample of 44 published studies of audit and feedback. Through each step, two coders had good agreement. We identified 42 visual displays of performance, containing 6 unique combinations of content types. What was visualized most commonly in the sample was performance levels across a recipient and comparators (i.e. ascribees) for a single measure and single time interval (n = 16). Content types varied in their inclusion of measures, ascribees, and time intervals. CONCLUSIONS: The proposed method appears to be feasible to use as a systematic approach to describing visual displays of performance. The key implication of the method is that it offers more granular and consistent description for empirical, theoretical, and design studies about the information content of feedback interventions.

Erratum to "Epac1 Restores Normal Insulin Signaling through a Reduction in Inflammatory Cytokines".

[This corrects the article DOI: 10.1155/2018/3809092.].

ARKS: chromosome-scale scaffolding of human genome drafts with linked read kmers.

BACKGROUND: The long-range sequencing information captured by linked reads, such as those available from 10× Genomics (10xG), helps resolve genome sequence repeats, and yields accurate and contiguous draft genome assemblies. We introduce ARKS, an alignment-free linked read genome scaffolding methodology that uses linked reads to organize genome assemblies further into contiguous drafts. Our approach departs from other read alignment-dependent linked read scaffolders, including our own (ARCS), and uses a kmer-based mapping approach. The kmer mapping strategy has several advantages over read alignment methods, including better usability and faster processing, as it precludes the need for input sequence formatting and draft sequence assembly indexing. The reliance on kmers instead of read alignments for pairing sequences relaxes the workflow requirements, and drastically reduces the run time. RESULTS: Here, we show how linked reads, when used in conjunction with Hi-C data for scaffolding, improve a draft human genome assembly of PacBio long-read data five-fold (baseline vs. ARKS NG50 = 4.6 vs. 23.1 Mbp, respectively). We also demonstrate how the method provides further improvements of a megabase-scale Supernova human genome assembly (NG50 = 14.74 Mbp vs. 25.94 Mbp before and after ARKS), which itself exclusively uses linked read data for assembly, with an execution speed six to nine times faster than competitive linked read scaffolders (~ 10.5 h compared to 75.7 h, on average). Following ARKS scaffolding of a human genome 10xG Supernova assembly (of cell line NA12878), fewer than 9 scaffolds cover each chromosome, except the largest (chromosome 1, n = 13). CONCLUSIONS: ARKS uses a kmer mapping strategy instead of linked read alignments to record and associate the barcode information needed to order and orient draft assembly sequences. The simplified workflow, when compared to that of our initial implementation, ARCS, markedly improves run time performances on experimental human genome datasets. Furthermore, the novel distance estimator in ARKS utilizes barcoding information from linked reads to estimate gap sizes. It accomplishes this by modeling the relationship between known distances of a region within contigs and calculating associated Jaccard indices. ARKS has the potential to provide correct, chromosome-scale genome assemblies, promptly. We expect ARKS to have broad utility in helping refine draft genomes.

Epac1 Restores Normal Insulin Signaling through a Reduction in Inflammatory Cytokines.

We have previously reported that Epac1 reduced inflammatory cytokines, which is protective to the diabetic retina. We have also published that impaired insulin signaling occurs in the diabetic retina. A reduction in interleukin-1 beta (IL-1ß) and tumor necrosis factor alpha (TNFα) by Epac1 could potentially restore normal insulin signal transduction. Confocal microscopy was performed to localize the insulin receptor in the retina of Epac1 floxed and endothelial cell-specific Epac1 knockout mice. Whole retinal lysates from Epac1 floxed and endothelial cell-specific Epac1 knockout mice were used to investigate proteins involved in the insulin signaling cascade. Primary human REC were cultured in normal and high glucose followed by Epac1 agonist treatment or transfection with IL-1ß or TNFα siRNA for protein analyses of insulin signaling proteins. Decreased expression of the insulin receptor was observed in the Epac1 knockout mouse retinal vasculature compared to floxed littermates. Work in mice showed that loss of Epac1 decreased insulin signaling proteins. Treatment with an Epac1 agonist decreased p38 and JNK signaling and increased insulin signaling, as did inhibition of IL-1ß or TNFα using siRNA when added to REC grown in high glucose. Taken together, Epac1 can restore normal insulin signaling in the retinal vasculature through reductions in inflammatory cytokines.

Narrow linewidth two-electrode 1560 nm laterally coupled distributed feedback lasers with third-order surface etched gratings.

We report on the design and characterization of a re-growth free InGaAsP/InP multiple quantum well two-electrode laterally coupled distributed feedback (LC-DFB) lasers. Third-order surface etched gratings have been defined on the ridge sidewalls along the laser cavity by means of stepper lithography. The lasers oscillate in single-mode around 1560 nm with high side mode suppression ratios (>52 dB), a wavelength tuning (≥ 3nm), an output power (≥ 6 mW), and narrow linewidth (<170 kHz) under various current injection ranges at room temperature. A minimum linewidth of 94 kHz has been recorded for 1500 µm-long two-electrode LC-DFB laser while providing non-uniform current injection through the two electrodes. The effect of the width of the inter-electrode gap on these different performance measures is also studied.

Narrow linewidth 1560 nm InGaAsP split-contact corrugated ridge waveguide DFB lasers.

We demonstrate a split-contact corrugated ridge waveguide InGaAsP distributed feedback laser at 1560 nm. The laser cavity has been defined with uniform third-order gratings etched along the sidewalls of the ridge waveguide. The gratings were fabricated using a standard I-line stepper lithography technique along with an inductively coupled reactive ion-etching process. Stable single-mode operation has been achieved with side-mode suppression ratios ≥50 dB, output powers ≥7 mW, a wavelength tuning range ≥2.3 nm, and narrow linewidths (≤140 kHz) for different biasing conditions, with a minimum of 70 kHz. The effect of p-contact partition on device performance is also studied.

Granuloma faciale treated with topical dapsone: a case report.

Granuloma faciale (GF) is an unusual, treatment-resistant skin disorder that commonly affects the face. Several medical and surgical interventions are available that offer varying degrees of benefit. Both the condition and the treatment modalities can lead to significant disfigurement. The use of oral dapsone in the treatment of GF has been described in the literature, but there are no reports, to our knowledge, of the use of topical dapsone 5% gel (Aczone; Allergan Inc, Irvine, CA). We present a case of a patient with GF on the nasal tip successfully treated with topical dapsone.

Benchmarking informatics approaches for virus discovery: caution is needed when combining in silico identification methods.

Understanding the ecological impacts of viruses on natural and engineered ecosystems relies on the accurate identification of viral sequences from community sequencing data. To maximize viral recovery from metagenomes, researchers frequently combine viral identification tools. However, the effectiveness of this strategy is unknown. Here, we benchmarked combinations of six widely used informatics tools for viral identification and analysis (VirSorter, VirSorter2, VIBRANT, DeepVirFinder, CheckV, and Kaiju), called "rulesets." Rulesets were tested against mock metagenomes composed of taxonomically diverse sequence types and diverse aquatic metagenomes to assess the effects of the degree of viral enrichment and habitat on tool performance. We found that six rulesets achieved equivalent accuracy [Matthews Correlation Coefficient (MCC) = 0.77, Padj ≥ 0.05]. Each contained VirSorter2, and five used our "tuning removal" rule designed to remove non-viral contamination. While DeepVirFinder, VIBRANT, and VirSorter were each found once in these high-accuracy rulesets, they were not found in combination with each other: combining tools does not lead to optimal performance. Our validation suggests that the MCC plateau at 0.77 is partly caused by inaccurate labeling within reference sequence databases. In aquatic metagenomes, our highest MCC ruleset identified more viral sequences in virus-enriched (44%-46%) than in cellular metagenomes (7%-19%). While improved algorithms may lead to more accurate viral identification tools, this should be done in tandem with careful curation of sequence databases. We recommend using the VirSorter2 ruleset and our empirically derived tuning removal rule. Our analysis provides insight into methods for in silico viral identification and will enable more robust viral identification from metagenomic data sets. IMPORTANCE: The identification of viruses from environmental metagenomes using informatics tools has offered critical insights in microbial ecology. However, it remains difficult for researchers to know which tools optimize viral recovery for their specific study. In an attempt to recover more viruses, studies are increasingly combining the outputs from multiple tools without validating this approach. After benchmarking combinations of six viral identification tools against mock metagenomes and environmental samples, we found that these tools should only be combined cautiously. Two to four tool combinations maximized viral recovery and minimized non-viral contamination compared with either the single-tool or the five- to six-tool ones. By providing a rigorous overview of the behavior of in silico viral identification strategies and a pipeline to replicate our process, our findings guide the use of existing viral identification tools and offer a blueprint for feature engineering of new tools that will lead to higher-confidence viral discovery in microbiome studies.

A Novel Evaluation Model for Assessing ChatGPT on Otolaryngology-Head and Neck Surgery Certification Examinations: Performance Study.

BACKGROUND: ChatGPT is among the most popular large language models (LLMs), exhibiting proficiency in various standardized tests, including multiple-choice medical board examinations. However, its performance on otolaryngology-head and neck surgery (OHNS) certification examinations and open-ended medical board certification examinations has not been reported. OBJECTIVE: We aimed to evaluate the performance of ChatGPT on OHNS board examinations and propose a novel method to assess an AI model's performance on open-ended medical board examination questions. METHODS: Twenty-one open-ended questions were adopted from the Royal College of Physicians and Surgeons of Canada's sample examination to query ChatGPT on April 11, 2023, with and without prompts. A new model, named Concordance, Validity, Safety, Competency (CVSC), was developed to evaluate its performance. RESULTS: In an open-ended question assessment, ChatGPT achieved a passing mark (an average of 75% across 3 trials) in the attempts and demonstrated higher accuracy with prompts. The model demonstrated high concordance (92.06%) and satisfactory validity. While demonstrating considerable consistency in regenerating answers, it often provided only partially correct responses. Notably, concerning features such as hallucinations and self-conflicting answers were observed. CONCLUSIONS: ChatGPT achieved a passing score in the sample examination and demonstrated the potential to pass the OHNS certification examination of the Royal College of Physicians and Surgeons of Canada. Some concerns remain due to its hallucinations, which could pose risks to patient safety. Further adjustments are necessary to yield safer and more accurate answers for clinical implementation.

Association between physician age and patterns of end-of-life care among older Americans.

BACKGROUND: End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS: We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS: Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS: We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.