Utility of cerebrovascular imaging biomarkers to detect cerebral amyloidosis.

INTRODUCTION: The relationship between cerebrovascular disease (CVD) and amyloid-ß (Aß) in Alzheimer disease (AD) is understudied. We hypothesized that magnetic resonance imaging (MRI)-based CVD biomarkers, including cerebral microbleeds (CMBs), ischemic infarction, and white matter hyperintensities (WMH), would correlate with Aß positivity on positron emission tomography (Aß-PET). METHODS: We cross-sectionally analyzed data from the Alzheimer's Disease Neuroimaging Initiative (ADNI, N=1,352). Logistic regression was used to calculate odds ratios (ORs), with Aß-PET positivity as the standard-of-truth. RESULTS: Following adjustment, WMH (OR=1.25) and superficial CMBs (OR=1.45) remained positively associated with Aß-PET positivity (p<.001). Deep CMBs and infarcts exhibited a varied relationship with Aß-PET in cognitive subgroups. The combined diagnostic model, which included CVD biomarkers and other accessible measures, significantly predicted Aß-PET (pseudo-R 2 =.41). DISCUSSION: The study highlights the translational value of CVD biomarkers in diagnosing AD, and underscores the need for more research on their inclusion in diagnostic criteria. ClinicalTrials.gov: ADNI-2 ( NCT01231971 ), ADNI-3 ( NCT02854033 ).

Assessment of Frailty and Risk of Chemotherapy Toxicity at a Geriatric-Oncology Multidisciplinary Clinic.

BACKGROUND: Multidisciplinary Geriatric-Oncology (GO-MDC) clinic performed comprehensive geriatric assessment (CGA) to determine frailty and chemotherapy toxicity risk. METHOD: Retrospective cohort study of patients ≥65 years seen between April 2017 to March 2022. We compared Eastern Cooperative Oncology Group-Performance Status (ECOG-PS) to CGA as a determinant of frailty and risk of toxicity from chemotherapy. RESULTS: Mean age of the 66 patients was 79 years. Eighty-five percent were Caucasian. Predominant cancers were breast (30%), and gynecological (26%). One-third were stage 4. The CGA identified fit (35%), vulnerable (48%), and frail (17%) patients whereas ECOG-PS classified 80% as fit. CGA assessed 57% of ECOG-fit patients as vulnerable or frail (p<0.001). High chemotherapy toxicity risk using CGA was 41% and using ECOG was 17% (p=0.002). CONCLUSION: At GO-MDC, CGA was a better predictor of frailty and toxicity risk than ECOG-PS. Treatment modification was recommended in one-third of patients.

Disparities in Utilization of Palliative Care in Patients Experiencing Homelessness.

BACKGROUND: Patients experiencing homelessness have increased disease burden, increased severity of illness, and increased barriers to accessing care. The provision of high-quality palliative care is therefore essential for this population. State of Homelessness: 18 out of every 10,000 people in the US and 10 out of every 10,000 Rhode Islanders (down from 12 in 2010) experience homelessness. Conceptual Model: High-quality palliative care for patients experiencing homelessness requires a foundation of patient-provider trust, well-trained interdisciplinary teams, coordinated transitions of care, community support, integrated healthcare systems, and comprehensive population and public health measures. CONCLUSIONS: Improving access to palliative care for those experiencing homelessness requires an interdisciplinary approach at all levels from individual providers to broader public health policies. A conceptual model rooted in patient-provider trust has the potential to address high-quality palliative care access disparities for this vulnerable population.

Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans.

Importance: Palliative care improves quality of life for patients and families but may be underused. Objective: To assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization. Design, Setting, and Participants: This cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022. Exposures: The PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention. Main Outcomes and Measures: The primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay. Results: The analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics-a 2-fold difference relative to the mean. Conclusions and Relevance: This cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.

Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward.

BACKGROUND: Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward. METHODS: This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study. RESULTS: In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use. CONCLUSIONS: The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.

Two decade trends in cardiovascular disease outcomes and cardiovascular risk factors among US veterans living with HIV.

Coomprhensive data on temporal trends in cardiovascular disease (CVD) risk factors and outcomes in people living with HIV are limited. Using retrospective data on 50,284 US Veterans living with HIV (VLWH) who received care in the VA from 2001 to 2019, we calculated the prevalence and incidence estimates of CVD risk factors and outcomes, as well as the average annual percent changes (AAPC) in the estimates. The mean age of the Veterans increased from 47.8 (9.1) years to 58.0 (12.4) years during the study period. The population remained predominantly (>95%) male and majority Black (∼50%). The prevalence of the CVD outcomes increased progressively over the study period: coronary artery disease (3.9%-18.7%), peripheral artery disease (2.3%, 10.3%), ischemic cerebrovascular disease (1.1%-9.9%), and heart failure (2.4%-10.5%). There was a progressive increase in risk factor burden, except for smoking which declined after 2015. The AAPC in prevalence was statistically significant for the CVD outcomes and risk factors. When adjusted for age, the predicted prevalence of CVD risk factors and outcomes showed comparable (but attenuated) trends. There was generally a comparable (but attenuated) trend in incidence of CVD outcomes, procedures, and risk factors over the study period. The use of statins increased from 10.6% (2001) to 40.8% (2019). Antiretroviral therapy usage increased from 77.7% (2001) to 85.0% (2019). In conclusion, in a retrospective analysis of large-scale VA data we found the burden and incidence of several CVD risk factors and outcomes have increased among VLWH over the past 20 years.

Utilization of Palliative Care in Veterans Admitted With Heart Failure Experiencing Homelessness.

CONTEXT: Patients experiencing housing insecurity have numerous barriers affecting their utilization of medical care. OBJECTIVES: Determine if housing insecurity is associated with palliative care (PC) encounters and hospice services in patients with heart failure who receive care in United States Veterans Affairs (VA) medical centers. METHODS: This retrospective study included inpatients in VA hospitals with a primary diagnosis of congestive heart failure from 2010 to 2020. Housing stability was collected from coding and separated into three cohorts: at risk for homelessness, experiencing homelessness, and stably housed. The primary outcome was a PC encounter during admission and the stably housed cohort was used as the analytic reference. Inverse-probability-weighting (IPTW) was calculated to adjust the likelihood of receiving PC during the index admission. RESULTS: Seventy thousand eight hundred fourty nine veterans were identified. Veterans were identified as at risk for homelessness (n=4039, 5.7%), experiencing homelessness (n=1967, 2.8%) and stably housed (n=64,843, 91.5%). PC was delivered to veterans at risk for homelessness (n=484, 12.0%), veterans experiencing homelessness, (n=161, 8.2%) and patients with stable housing (n=6249, 9.6%). Relative to the stably housed and adjusted for IPTW, those at risk for homelessness received PC services similarly (adjusted OR=1.06, 95% CI 0.94,1.19) and those experiencing homelessness were at lower odds of receiving PC services (adjusted OR=0.62, 95% CI 0.52,0.75). CONCLUSION: Housing stability may be a factor in Veterans receiving PC during hospitalization for heart failure. While the logistical challenges of delivering PC and hospice to people experiencing homelessness are daunting, advocating for these services shows commitment to reducing suffering in life-limiting Illness.

Racial Differences in Burdensome Transitions in Heart Failure Patients with Palliative Care: A Propensity-Matched Analysis.

Background: Examining racial disparities in the treatment of heart failure (HF) patients and the effects of palliative care (PC) consultation is important to developing culturally competent clinical behaviors. Objective: To compare burdensome transitions for Black and White Veterans hospitalized with HF after PC consultation. Participants: This retrospective study evaluated Veterans admitted for HF to Veterans Administration hospitals who received PC consultation from October 2010 through August 2017. Methods: We propensity-matched Black to White Veterans using demographic, comorbidity, clinical, hospital, and survival time data. Results: Propensity matching of our cohort (n = 5638) yielded 796 Black and White Veterans (total n = 1592) who were well-matched on observed variables (standard mean difference <0.15 for all variables). Matched Black Veterans had more burdensome transitions than White Veterans (n = 218, 27.4% vs. n = 174, 21.9%; p = 0.011) over the six-month follow-up period. Conclusions: This propensity-matched cohort found racial differences in burdensome transitions among admitted HF patients after PC consultation.

New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study.

BACKGROUND: Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge. OBJECTIVE: Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge. DESIGN: Retrospective cohort. PARTICIPANTS: Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF. MAIN MEASURES: Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge. KEY RESULTS: Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge. CONCLUSIONS: Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.

Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery.

BACKGROUND: Delirium after cardiac surgery is associated with prolonged intensive care unit (ICU) and hospital length of stay and elevated rates of mortality. The Society of Thoracic Surgery National Database (STS-ND) includes delirium in routine data collection but restricts its definition to hyperactive symptoms. The objective is to determine whether the Confusion Assessment Method for ICU (CAM-ICU), which includes hypo- and hyperactive symptoms, is associated with improved prediction of poor 1-year functional survival following cardiac surgery. METHODS: Clinical and administrative databases were used to determine the influence of postoperative delirium on 1-year poor functional survival, defined as being institutionalized or deceased at 1 year. Patients experiencing postoperative delirium using the STS-ND definition (2007-2009) were compared with patients with delirium identified by the CAM-ICU (2010-2012). A propensity score match was undertaken, and multivariable Cox proportional hazards regression models were generated to determine risk of poor 1-year functional survival. RESULTS: There were 2756 and 2236 patients in the STS-ND and CAM-ICU cohorts, respectively. Propensity matching resulted in a cohort of 1835 patients (82.1% matched). The overall rate of delirium in the matched study population was 7.6% in the STS-ND cohort and 13.0% in the CAM-ICU cohort (P < .001). Delirium in the CAM-ICU cohort was independently associated with poor 1-year functional survival (hazard ratio, 2.58; 95% confidence interval, 1.20-5.54; P = .02); delirium in the STS-ND cohort was not associated with poor 1-year functional survival (hazard ratio, 0.92; 95% confidence interval, 0.49-1.71; P = .79). CONCLUSIONS: A systematic screening tool identifies postoperative delirium with improved prediction of poor 1-year functional survival following cardiac surgery.

Age at Diagnosis of Heart Failure in United States Veterans With and Without HIV Infection.

Background Although HIV is associated with increased risk of heart failure (HF), it is not known if people living with HIV develop HF at a younger age compared with individuals without HIV. Crude comparisons of age at diagnosis of HF between individuals with and without HIV does not account for differences in underlying age structures between the populations. Methods and Results We used Veterans Health Administration data to compare the age at HF diagnosis between veterans with and without HIV, with adjustment for difference in population age structure. Statistical weights, calculated for each 1-year strata of veterans with HIV in each calendar year from 2000 to 2018, were applied to the veterans without HIV to standardize the age structure. We identified 5093 veterans with HIV (98% men, 34% White) with first HF episode recorded after HIV diagnosis (median age at incidence of HF, 58 years), and 1 425 987 veterans without HIV (98% men, 78% White) with HF (corresponding age, 72 years), with an absolute difference of 14 years. After accounting for difference in age structure, the adjusted median age at HF diagnosis for veterans without HIV was 63 years, 5 years difference with veterans with HIV (P<0.001). The age differences were consistent across important subgroups such as preserved versus reduced ejection fraction and inpatient versus outpatient index HF. Conclusions Veterans with HIV are diagnosed with HF at a significantly younger age compared with veterans without HIV. These findings may have implications for HF prevention in individuals with HIV. Future studies are needed to make the findings more generalizable.

The Association of a Frailty Index and Incident Delirium in Older Hospitalized Patients: An Observational Cohort Study.

INTRODUCTION/BACKGROUND: Frailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty. PURPOSE: The purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium. METHODS: A retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder. MAIN OUTCOMES AND MEASURES: Frailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview. RESULTS: A total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI <0.25, n=56 (26%)), pre-frail (FI =0.25-0.35, n=86 (39%)), and frail (FI >0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, p=0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, p=0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium. CONCLUSION: This study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium.

Temperature Screening for SARS-CoV-2 in Nursing Homes: Evidence from Two National Cohorts.

BACKGROUND/OBJECTIVES: Infection screening tools classically define fever as 38.0°C (100.4°F). Frail older adults may not mount the same febrile response to systemic infection as younger or healthier individuals. We evaluate temperature trends among nursing home (NH) residents undergoing diagnostic SARS-CoV-2 testing and describe the diagnostic accuracy of temperature measurements for predicting test-confirmed SARS-CoV-2 infection. DESIGN: Retrospective cohort study evaluating diagnostic accuracy of pre-SARS-CoV-2 testing temperature changes. SETTING: Two separate NH cohorts tested diagnostically (e.g., for symptoms) for SARS-CoV-2. PARTICIPANTS Veterans residing in Veterans Affairs (VA) managed NHs and residents in a private national chain of community NHs. MEASUREMENTS: For both cohorts, we determined the sensitivity, specificity, and Youden's index with different temperature cutoffs for SARS-CoV-2 polymerase chain reaction results. RESULTS: The VA cohort consisted of 1,301 residents in 134 facilities from March 1, 2020, to May 14, 2020, with 25% confirmed for SARS-CoV-2. The community cohort included 3,368 residents spread across 282 facilities from February 18, 2020, to June 9, 2020, and 42% were confirmed for SARS-CoV-2. The VA cohort was younger, less White, and mostly male. A temperature testing threshold of 37.2°C has better sensitivity for SARS-CoV-2, 76% and 34% in the VA and community NH, respectively, versus 38.0°C with 43% and 12% sensitivity, respectively. CONCLUSION: A definition of 38.0°C for fever in NH screening tools should be lowered to improve predictive accuracy for SARS-CoV-2 infection. Stakeholders should carefully consider the impact of adopting lower testing thresholds on testing availability, cost, and burden on staff and residents. Temperatures alone have relatively low sensitivity/specificity, and we advocate any threshold be used as part of a screening tool, along with other signs and symptoms of infection.

Temperature in Nursing Home Residents Systematically Tested for SARS-CoV-2.

OBJECTIVES: Many nursing home residents infected with SARS-CoV-2 fail to be identified with standard screening for the associated COVID-19 syndrome. Current nursing home COVID-19 screening guidance includes assessment for fever, defined as a temperature of at least 38.0°C. The objective of this study was to describe the temperature changes before and after universal testing for SARS-CoV-2 in nursing home residents. DESIGN: Cohort study. SETTING AND PARTICIPANTS: The Veterans Administration (VA) operates 134 Community Living Centers (CLC), similar to nursing homes, that house residents who cannot live independently. VA guidance to CLCs directed daily clinical screening for COVID-19 that included temperature assessment. MEASURES: All CLC residents (n = 7325) underwent SARS-CoV-2 testing. We report the temperature in the window of 14 days before and after universal SARS-CoV-2 testing among CLC residents. Baseline temperature was calculated for 5 days before the study window. RESULTS: SARS-CoV-2 was identified in 443 (6.0%) residents. The average maximum temperature in SARS-CoV-2-positive residents was 37.66 (0.69) compared with 37.11 (0.36) (P = .001) in SARS-CoV-2-negative residents. Temperatures in those with SARS-CoV-2 began rising 7 days before testing and remained elevated during the 14-day follow-up. Among SARS-CoV-2-positive residents, only 26.6% (n = 118) met the fever threshold of 38.0°C during the survey period. Most residents (62.5%, n = 277) with confirmed SARS-CoV-2 did experience 2 or more 0.5°C elevations above their baseline values. One cohort of SARS-CoV-2 residents' (20.3%, n = 90) temperatures never deviated >0.5°C from baseline. CONCLUSIONS AND IMPLICATIONS: A single screening for temperature is unlikely to detect nursing home residents with SARS-CoV-2. Repeated temperature measurement with a patient-derived baseline can increase sensitivity. The current fever threshold as a screening criteria for SARS-CoV-2 infection should be reconsidered.

Palliative Care Consultation Reduces Heart Failure Transitions: A Matched Analysis.

Background Palliative care supports quality of life, symptom control, and goal setting in heart failure (HF) patients. Unlike hospice, palliative care does not restrict life-prolonging therapy. This study examined the association between palliative care during hospitalization for HF on the subsequent transitions and procedures. Methods and Results Veterans admitted to hospitals with HF from 2010 to 2015 were randomly selected for the Veterans Administration External Peer Review Program. Variables pertaining to demographic, clinical, laboratory, and usage were captured from Veterans Administration electronic records. Patients receiving hospice services before admission were excluded. Patients who received palliative care were propensity matched to those who did not. The primary outcomes were whether the patient experienced transitions or procedures in the 6 months after admission. Transitions included multiple readmissions (≥2) or intensive care admissions and procedures included mechanical ventilation, pacemaker implantation, or defibrillator implantation. Among 57 182 hospitalized HF patients, 1431 received palliative care, and were well matched to 1431 without (standardized mean differences ≤ ±0.05 on all matched variables). Palliative care was associated with significantly fewer multiple rehospitalizations (30.9% versus 40.3%, P<0.001), mechanical ventilation (2.8% versus 5.4%, P=0.004), and defibrillator implantation (2.1% versus 3.6%, P=0.01). After adjustment for facility fixed effects, palliative care consultation was associated with a significantly reduced hazard of multiple readmissions (adjusted hazard ratio=0.73, 95% CI, 0.64-0.84) and mechanical ventilation (adjusted hazard ratio=0.76, 95% CI, 0.67-0.87). Conclusions Palliative care during HF admissions was associated with fewer readmissions and less mechanical ventilation. When available, engagement of HF patients and caregivers in palliative care for symptom control, quality of life, and goals of care discussions may be associated with reduced rehospitalizations and mechanical ventilation.

Efficacy and safety of biological agents in the older rheumatoid arthritis patients compared to Young: A systematic review and meta-analysis.

OBJECTIVE: Biologic anti-rheumatic drugs are used with less frequency among older patients compared to young patients. This population is less represented in studies performed to evaluate the efficacy and safety of this drugs. We aimed to assess the efficacy and safety of biological agents between the older RA patients compared to young. METHODS: A comprehensive, systematic search was conducted in major indexing databases using key terms for RA and each biological agent. The review process was completed by 2 investigators. Both randomized controlled trials and observational studies of at least 6-month duration conducted in adult RA patients were included. Outcomes of interest were clinical efficacy and safety. Effect-estimates were pooled using random-effects modeling if 4 or more studies used the same scale and time-frame for measuring outcomes. RESULTS: 24 studies (16 focusing on anti-TNF agents) representing 63,705 patients (24% were older) were included. Older RA patients had worse baseline RA disease activity, longer disease duration at the time of enrollment in the trial (14.4 ±â€¯3.6 vs. 10.9 ±â€¯3.6 years; p < 0.001) and higher steroid use (73.2 vs. 64.7%, p < 0.001) than younger. 5 out of 6 studies assessing anti-TNF agents showed worse efficacy outcomes in older patients. The pooled OR of infection and ADRs with anti-TNF agents in older compared to young RA patients was OR 1.59 (95% CI: 1.45-1.76) and 1.40 (95% CI: 1.23-1.61) respectively. CONCLUSIONS: Older patients had worse safety and efficacy with biological agents but also had worse baseline disease activity. There was significant heterogeneity in reporting outcomes and very limited studies in biological agents other than anti-TNF drugs.

A contemporary population-based analysis of the incidence, cost, and outcomes of postoperative delirium following major urologic cancer surgeries.

PURPOSE: Postoperative delirium (PD) is associated with poor outcomes and increased health care costs. The incidence, outcomes, and cost of delirium for major urologic cancer surgeries have not been previously characterized in a population-based analysis. MATERIALS AND METHODS: We performed a population-based, retrospective cohort study of patients with PD at 490 US hospitals between 2003 and 2013 to evaluate the incidence, outcomes, and cost of delirium after radical prostatectomy, radical nephrectomy, partial nephrectomy, and radical cystectomy (RC). Delirium was defined using ICD-9 codes in combination with postoperative antipsychotics, sitters, and restraints. Regression models were constructed to assess mortality, discharge disposition, length of stay (LOS), and direct hospital admission costs. Survey-weighted adjustment for hospital clustering achieved estimates generalizable to the US population. RESULTS: We identified 165,387 patients representing a weighted total of 1,097,355 patients. The overall incidence of PD was 2.7%, with the greatest incidence occurring after RC, with 6,268 cases (11%). Delirious patients had greater adjusted odds of in-hospital mortality (odds ratio [OR] = 3.65, P<0.001), 90-day mortality (OR = 1.47, P = 0.013), discharge with home health services (OR = 2.25, P<0.001), discharge to skilled nursing facilities (OR = 4.64, P<0.001), and a 0.9-day increase in median LOS (P<0.001). Patients with delirium also experienced a $2,697 increase in direct admission costs (P<0.001), with the greatest costs incurred in RC patients ($30,859 vs. $26,607; P<0.001). CONCLUSIONS: Patients with PD after urologic cancer surgeries experienced worse outcomes, prolonged LOS, and increased admission costs. The greatest incidence and costs were seen after RC. Further research is warranted to identify high-risk patients and devise preventative strategies.

A Multivariable Prediction Model for Mortality in Individuals Admitted for Heart Failure.

OBJECTIVES: To derive and validate a 30-day mortality clinical prediction rule for heart failure based on admission data and prior healthcare usage. A secondary objective was to determine the discriminatory function for mortality at 1 and 2 years. DESIGN: Observational cohort. SETTING: Veterans Affairs inpatient medical centers (n=124). PARTICIPANTS: The derivation (2010-12; n=36,021) and validation (2013-15; n=30,364) cohorts included randomly selected veterans admitted for HF exacerbation (mean age 71±11; 98% male). MEASUREMENTS: The primary outcome was 30-day mortality. Secondary outcomes were 1- and 2-year mortality. Candidate variables were drawn from electronic medical records. Discriminatory function was measured as the area under the receiver operating characteristic curve. RESULTS: Thirteen risk factors were identified: age, ejection fraction, mean arterial pressure, pulse, brain natriuretic peptide, blood urea nitrogen, sodium, potassium, more than 7 inpatient days in the past year, metastatic disease, and prior palliative care. The model stratified participants into low- (1%), intermediate- (2%), high- (5%), and very high- (15%) mortality risk groups (C-statistic=0.72, 95% confidence interval (CI)=0.71-0.74). These findings were confirmed in the validation cohort (C-statistic=0.70, 95% CI=0.68-0.71). Subgroup analysis of age strata confirmed model discrimination. CONCLUSION: This simple prediction rule allows clinicians to risk-stratify individuals on admission for HF using characteristics captured in electronic medical record systems. The identification of high-risk groups allows individuals to be targeted for discussion of goals and treatment.

Staff Perceptions of Key Factors Guiding Nursing Home Search and Selection Within the Veterans Health Administration.

Background and Objectives: Veterans enter nursing homes (NHs) for short-term postacute, rehabilitation, respite, or end-of-life care. They also enter NHs on a long-term basis due to frailty, disability, functional deficits, and cognitive impairment. Little is known about how a particular NH is chosen once the decision to enter a NH has been made. This study identified VA staff perceptions of the key factors influencing the search and selection of NHs within the Veterans Health Administration (VHA). Research Design and Methods: Data derived from 35 semistructured interviews with discharge planning and contracting staff from 12 Veterans Affairs Medical Centers (VAMCs). Results: VA staff placed a premium on Veteran and family preferences in the NH selection process, though VA staff knowledge and familiarity with placement options established the general parameters within which NH placement decisions were made. Geographic proximity to Veterans' homes and families was a major factor in NH choice. Other key considerations included Veterans' specialty care needs (psychiatric, postacute, ventilator) and Veteran/facility demographics (age, race/ethnicity, Veteran status). VA staff tried to remain neutral in NH selection, thus instructing families to visit facilities and review publicly available quality data. VA staff report that amenities (private rooms, activities, smoking) and aesthetics (cleanliness, smell, layout, décor) often outweighed objective quality indicators in Veteran and family decision making. Discussion and Implications: Findings suggest that VAMCs facilitate Veteran and family decision making around NH selection. They also suggest that VAMCs endeavor to identify and recruit a broader array of higher quality NHs to better match the specific needs of Veterans and families to the choice set available.

Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients.

BACKGROUND: The American College of Surgeons and the American Geriatrics Society have suggested that preoperative cognitive screening should be performed in older surgical patients. We hypothesized that unrecognized cognitive impairment in patients without a history of dementia is a risk factor for development of postoperative complications. METHODS: We enrolled 211 patients 65 yr of age or older without a diagnosis of dementia who were scheduled for an elective hip or knee replacement. Patients were cognitively screened preoperatively using the Mini-Cog and demographic, medical, functional, and emotional/social data were gathered using standard instruments or review of the medical record. Outcomes included discharge to place other than home (primary outcome), delirium, in-hospital medical complications, hospital length-of-stay, 30-day emergency room visits, and mortality. Data were analyzed using univariate and multivariate analyses. RESULTS: Fifty of 211 (24%) patients screened positive for probable cognitive impairment (Mini-Cog less than or equal to 2). On age-adjusted multivariate analysis, patients with a Mini-Cog score less than or equal to 2 were more likely to be discharged to a place other than home (67% vs. 34%; odds ratio = 3.88, 95% CI = 1.58 to 9.55), develop postoperative delirium (21% vs. 7%; odds ratio = 4.52, 95% CI = 1.30 to 15.68), and have a longer hospital length of stay (hazard ratio = 0.63, 95% CI = 0.42 to 0.95) compared to those with a Mini-Cog score greater than 2. CONCLUSIONS: Many older elective orthopedic surgical patients have probable cognitive impairment preoperatively. Such impairment is associated with development of delirium postoperatively, a longer hospital stay, and lower likelihood of going home upon hospital discharge.