Variation in Receipt of Cancer Screening and Immunizations by 10-year Life Expectancy among U.S. Adults aged 65 or Older in 2019.

IMPORTANCE: The likelihood of benefit from a preventive intervention in an older adult depends on its time-to-benefit and the adult's life expectancy. For example, the time-to-benefit from cancer screening is >10 years, so adults with <10-year life expectancy are unlikely to benefit. OBJECTIVE: To examine receipt of screening for breast, prostate, or colorectal cancer and receipt of immunizations by 10-year life expectancy. DESIGN: Analysis of 2019 National Health Interview Survey. PARTICIPANTS: 8,329 non-institutionalized adults >65 years seen by a healthcare professional in the past year, representing 46.9 million US adults. MAIN MEASURES: Proportions of breast, prostate, and colorectal cancer screenings, and immunizations, were stratified by 10-year life expectancy, estimated using a validated mortality index. We used logistic regression to examine receipt of cancer screening and immunizations by life expectancy and sociodemographic factors. KEY RESULTS: Overall, 54.7% of participants were female, 41.4% were >75 years, and 76.4% were non-Hispanic White. Overall, 71.5% reported being current with colorectal cancer screening, including 61.4% of those with <10-year life expectancy. Among women, 67.0% reported a screening mammogram in the past 2 years, including 42.8% with <10-year life expectancy. Among men, 56.8% reported prostate specific antigen screening in the past two years, including 48.3% with <10-year life expectancy. Reported receipt of immunizations varied from 72.0% for influenza, 68.8% for pneumococcus, 57.7% for tetanus, and 42.6% for shingles vaccination. Lower life expectancy was associated with decreased likelihood of cancer screening and shingles vaccination but with increased likelihood of pneumococcal vaccination. CONCLUSIONS: Despite the long time-to-benefit from cancer screening, in 2019 many US adults age >65 with <10-year life expectancy reported undergoing cancer screening while many did not receive immunizations with a shorter time-to-benefit. Interventions to improve individualization of preventive care based on older adults' life expectancy may improve care of older adults.

Evaluation of Time to Benefit of Statins for the Primary Prevention of Cardiovascular Events in Adults Aged 50 to 75 Years: A Meta-analysis.

Importance: Guidelines recommend targeting preventive interventions toward older adults whose life expectancy is greater than the intervention's time to benefit (TTB). The TTB for statin therapy is unknown. Objective: To conduct a survival meta-analysis of randomized clinical trials of statins to determine the TTB for prevention of a first major adverse cardiovascular event (MACE) in adults aged 50 to 75 years. Data Sources: Studies were identified from previously published systematic reviews (Cochrane Database of Systematic Reviews and US Preventive Services Task Force) and a search of MEDLINE and Google Scholar for subsequently published studies until February 1, 2020. Study Selection: Randomized clinical trials of statins for primary prevention focusing on older adults (mean age >55 years). Data Extraction and Synthesis: Two authors independently abstracted survival data for the control and intervention groups. Weibull survival curves were fit, and a random-effects model was used to estimate pooled absolute risk reductions (ARRs) between control and intervention groups each year. Markov chain Monte Carlo methods were applied to determine time to ARR thresholds. Main Outcomes and Measures: The primary outcome was time to ARR thresholds (0.002, 0.005, and 0.010) for a first MACE, as defined by each trial. There were broad similarities in the definition of MACE across trials, with all trials including myocardial infarction and cardiovascular mortality. Results: Eight trials randomizing 65 383 adults (66.3% men) were identified. The mean age ranged from 55 to 69 years old and the mean length of follow-up ranged from 2 to 6 years. Only 1 of 8 studies showed that statins decreased all-cause mortality. The meta-analysis results suggested that 2.5 (95% CI, 1.7-3.4) years were needed to avoid 1 MACE for 100 patients treated with a statin. To prevent 1 MACE for 200 patients treated (ARR = 0.005), the TTB was 1.3 (95% CI, 1.0-1.7) years, whereas the TTB to avoid 1 MACE for 500 patients treated (ARR = 0.002) was 0.8 (95% CI, 0.5-1.0) years. Conclusions and Relevance: These findings suggest that treating 100 adults (aged 50-75 years) without known cardiovascular disease with a statin for 2.5 years prevented 1 MACE in 1 adult. Statins may help to prevent a first MACE in adults aged 50 to 75 years old if they have a life expectancy of at least 2.5 years. There is no evidence of a mortality benefit.

Association of dementia diagnosis with urinary tract infection in the emergency department.

OBJECTIVES: Overdiagnosis of urinary tract infections (UTI) among people living with dementia is a nationally recognized problem associated with morbidity from antibiotics as well as multidrug-resistant bacteria. However, whether this problem also exists in the emergency department (ED) is currently unknown. METHODS: To examine the association between dementia and UTI diagnosis in the ED we performed a retrospective analysis of Medicare beneficiaries older than 65 years old who presented to an ED in 2016. A diagnosis of UTI was present in 58,580 beneficiaries, and 321,479 beneficiaries without a diagnosis of UTI served as the comparison group. Our logistic regression model controlled for dementia, older age, female sex, Medicaid status, skilled nursing facility residence, history of prostate cancer, recent urinary catheter use, recurrent UTI, and multiple comorbidities. RESULTS: In our model, people living with dementia had over twice the odds (odds ratio = 2.27, 95% confidence interval = 2.21, 2.33) of being diagnosed with a UTI in the ED compared to those without dementia despite their lower prevalence of symptoms and signs localizing to the genitourinary tract (3.8% vs 8.9%, respectively). CONCLUSION: This is the first study from a national database that examines the association of dementia with UTI diagnosis among older adults who visit the ED. Our study could not establish whether the UTI diagnoses in the ED were accurate but does imply a disproportionate burden of UTI diagnoses in people living with dementia despite their lower prevalence of clinical criterion. Antimicrobial stewardship in the ED should address the complexity of UTI diagnosis in dementia.

Prognostic indices for older adults: a systematic review.

CONTEXT: To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions. OBJECTIVE: To assess the quality and limitations of prognostic indices for mortality in older adults through systematic review. DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from their inception through November 2011. STUDY SELECTION: We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was 60 years or older. We excluded indices that estimated intensive care unit, disease-specific, or in-hospital mortality. DATA EXTRACTION: For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy. RESULTS: We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6 months to 5 years for older adults in a variety of clinical settings: the community (6 indices), nursing home (2 indices), and hospital (8 indices). At least 1 measure of transportability (the index is accurate in more than 1 population) was tested for all but 3 indices. By our measures, no study was free from potential bias. Although 13 indices had C statistics of 0.70 or greater, none of the indices had C statistics of 0.90 or greater. Only 2 indices were independently validated by investigators who were not involved in the index's development. CONCLUSION: We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.