Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization.

Importance: Older adults with socioeconomic disadvantage develop a greater burden of disability after critical illness than those without socioeconomic disadvantage. The delivery of in-hospital rehabilitation that can mitigate functional decline may be influenced by social determinants of health (SDOH). Whether rehabilitation delivery differs by SDOH during critical illness hospitalization is not known. Objective: To evaluate whether SDOH are associated with the delivery of skilled rehabilitation during critical illness hospitalization among older adults. Design, Setting, and Participants: This cohort study used data from the National Health and Aging Trends Study linked with Medicare claims (2011-2018). Participants included older adults hospitalized with a stay in the intensive care unit (ICU). Data were analyzed from August 2022 to September 2023. Exposures: Dual eligibility for Medicare and Medicaid, education, income, limited English proficiency (LEP), and rural residence. Main Outcome and Measures: The primary outcome was delivery of physical therapy (PT) and/or occupational therapy (OT) during ICU hospitalization, characterized as any in-hospital PT or OT and rate of in-hospital PT or OT, calculated as total number of units divided by length of stay. Results: In the sample of 1618 ICU hospitalizations (median [IQR] patient age, 81.0 [75.0-86.0] years; 842 [52.0%] female), 371 hospitalizations (22.9%) were among patients with dual Medicare and Medicaid eligibility, 523 hospitalizations (32.6%) were among patients with less than high school education, 320 hospitalizations (19.8%) were for patients with rural residence, and 56 hospitalizations (3.5%) were among patients with LEP. A total of 1076 hospitalized patients (68.5%) received any PT or OT, with a mean rate of 0.94 (95% CI, 0.86-1.02) units/d. After adjustment for age, sex, prehospitalization disability, mechanical ventilation, and organ dysfunction, factors associated with lower odds of receipt of PT or OT included dual Medicare and Medicaid eligibility (adjusted odds ratio, 0.70 [95% CI, 0.50-0.97]) and rural residence (adjusted odds ratio, 0.65 [95% CI, 0.48-0.87]). LEP was associated with a lower rate of PT or OT (adjusted rate ratio, 0.55 [95% CI, 0.32-0.94]). Conclusions and Relevance: These findings highlight the need to consider SDOH in efforts to promote rehabilitation delivery during ICU hospitalization and to investigate factors underlying inequities in this practice.

Survival, Function, and Cognition After Hospitalization in Long-Term Acute Care Hospitals.

Importance: More than 70 000 Medicare beneficiaries receive care in long-term acute care hospitals (LTCHs) annually for prolonged acute illness. However, little is known about long-term functional and cognitive outcomes of middle-aged and older adults after hospitalization in an LTCH. Objective: To describe survival, functional, and cognitive status after LTCH hospitalization and to identify factors associated with an adverse outcome. Design, Setting, and Participants: This retrospective cohort study included middle-aged and older adults enrolled in the Health and Retirement Study (HRS) with linked fee-for-service Medicare claims. Included participants were aged 50 years or older with an LTCH admission between January 1, 2003, and December 31, 2016, with HRS interviews available before admission. Data were analyzed between November 1, 2021, and June 30, 2023. Main Outcomes and Measures: Function and cognition were ascertained from HRS interviews conducted every 2 years. The primary outcome was death or severe impairment in the 2.5 years after LTCH hospitalization, defined as dependencies in 2 or more activities of daily living (ADLs) or dementia. Multivariable logistic regression was performed to evaluate associations with a priori selected risk factors including pre-LTCH survival prognosis (Lee index score), pre-LTCH impairment status, and illness severity characterized by receipt of mechanical ventilation and prolonged intensive care unit stay of 3 days or longer. Results: This study included 396 participants, with a median age of 75 (IQR, 68-82) years. Of the participants, 201 (51%) were women, 125 (28%) had severe impairment, and 318 (80%) died or survived with severe impairment (functional, cognitive, or both) within 2.5 years of LTCH hospitalization. After accounting for acute illness characteristics, prehospitalization survival prognosis as determined by the Lee index score and severe baseline impairment (functional, cognitive, or both) were associated with an increased likelihood of death or severe impairment in the 2.5 years after LTCH hospitalization (adjusted odds ratio [AOR], 3.2 [95% CI, 1.7 to 6.0] for a 5-point increase in Lee index score; and AOR, 4.5 [95% CI, 1.3 to 15.4] for severe vs no impairment). Conclusions and Relevance: In this cohort study, 4 of 5 middle-aged and older adults died or survived with severe impairment within 2.5 years of LTCH hospitalization. Better preadmission survival prognosis and functional and cognitive status were associated with lower risk of an adverse outcome, and these findings should inform decision-making for older adults with prolonged acute illness.

Aging, Race, and Health Disparities: Recommendations From the Research Centers Collaborative Network.

Racial disparities in adverse health outcomes with aging have been well described. Yet, much of the research focuses on racial comparisons, with relatively less attention to the identification of underlying mechanisms. To address these gaps, the Research Centers Collaborative Network held a workshop on aging, race, and health disparities to identify research priorities and inform the investigation, implementation, and dissemination of strategies to mitigate disparities in healthy aging. This article provides a summary of the key recommendations and highlights the need for research that builds a strong evidence base with both clinical and policy implications. Successful execution of these recommendations will require a concerted effort to increase participation of underrepresented groups in research through community engagement and partnerships. In addition, resources to support and promote the training and development of health disparities researchers will be critical in making health equity a shared responsibility for all major stakeholders.

Association Between Socioeconomic Disadvantage and Decline in Function, Cognition, and Mental Health After Critical Illness Among Older Adults : A Cohort Study.

BACKGROUND: Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older persons are at greater risk for these impairments than their less vulnerable counterparts. OBJECTIVE: To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization. DESIGN: Retrospective analysis of a longitudinal cohort study. SETTING: Community-dwelling older adults in the National Health and Aging Trends Study (NHATS). PARTICIPANTS: Participants with ICU hospitalizations between 2011 and 2017. MEASUREMENTS: Socioeconomic disadvantage was assessed as dual-eligible Medicare-Medicaid status. The outcome of function was defined as the count of disabilities in 7 activities of daily living and mobility tasks, the cognitive outcome as the transition from no or possible to probable dementia, and the mental health outcome as the Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. The analytic sample included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health. RESULTS: After accounting for sociodemographic and clinical characteristics, dual eligibility was associated with a 28% increase in disability after ICU hospitalization (incidence rate ratio, 1.28; 95% CI, 1.00 to 1.64); and nearly 10-fold greater odds of transitioning to probable dementia (odds ratio, 9.79; 95% CI, 3.46 to 27.65). Dual eligibility was not associated with symptoms of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79). LIMITATION: Administrative data, variability in timing of baseline and outcome assessments, proxy selection. CONCLUSION: Dual-eligible older persons are at greater risk for decline in function and cognition after an ICU hospitalization than their more advantaged counterparts. This finding highlights the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness and warrants investigation into factors leading to this disparity. PRIMARY FUNDING SOURCE: National Institute on Aging.

Readmissions of adults within three age groups following hospitalization for pneumonia: Analysis from the Nationwide Readmissions Database.

BACKGROUND: While 30-day readmissions following hospitalization for pneumonia have been well-studied in the elderly, their burden in young adults remains poorly understood. OBJECTIVE: To study patterns of readmissions following hospitalization for pneumonia across age groups and insurance payers. METHODS: In the Nationwide Readmission Database for the years 2013 and 2014 we identified all adults (≥18 years) discharged alive after a hospitalization with the primary diagnosis of pneumonia, and examined rates of readmissions within 30-days of discharge. Using covariates included in the Center for Medicare & Medicaid Services risk-adjustment model for pneumonia readmissions in a multivariable regression model for survey data, we identified predictors of 30-day readmission. RESULTS: We identified 629,939 index pneumonia hospitalizations with a weighted estimate of 1,472,069 nationally. Overall, 16.2% of patients were readmitted within 30 days of their hospitalization for pneumonia, with 30-day readmission rates of 12.4% in the 18-44 year age-group, 16.1% in the 45-64 year age-group, and 16.7% in the ≥65-year age-group. In risk-adjusted analyses, compared with elderly, middle-aged adults were more likely to be readmitted (risk-adjusted OR 1.05, 95% CI 1.03-1.07). Mean cost per readmission was also highest for this age group at $15,976. CONCLUSION: Middle-aged adults experience substantial rates of 30-day readmission that are comparable to those over 65 years of age, with a higher cost per readmission event. Future efforts are needed to identify potential interventions to alleviate the high burden of pneumonia readmissions in middle-aged adults.

MRI Assessment of Diastolic and Systolic Intraventricular Pressure Gradients in Heart Failure.

A deep phenotypic characterization of heart failure (HF) is important for a better understanding of its pathophysiology. In particular, novel noninvasive techniques for the characterization of functional abnormalities in HF with preserved ejection fraction are currently needed. While echocardiography is widely used to assess ventricular function, standard echocardiographic techniques provide a limited understanding of ventricular filling. The application of fluid dynamics theory, along with assessments of flow velocity fields in multiple dimensions in the ventricle, can be used to assess intraventricular pressure gradients (IVPGs), which in turn may provide valuable insights into ventricular diastolic and systolic function. Advances in imaging techniques now allow for accurate estimations of systolic and diastolic IVPGs, using noninvasive methods that are easily applicable in clinical research. In this review, we describe the basic concepts regarding intraventricular flow measurements and the derivation of IVPGs. We also review existing literature exploring the role of IVPGs in HF.

Gender bias in child care and child health: global patterns.

Gender-based discrimination is reported across the spectrum of paediatric healthcare including emergency, inpatient, outpatient and preventive care and is mostly reported from South Asia and China with sporadic reports from Africa and South America. Biases against young girls have been documented even in immunisation percentage, home food allocation, seeking medical care for childhood ailments and percentage of household healthcare expenditures allocated to them. Such gender discrimination in access to medical care is likely to have an influence on the overall health of female children. Over the last five decades, the under-5 sex ratios are worsening in India with declining number of girls. Deliberate parental neglect of girls' essential and life-saving medical care is also an important contributing factor apart from sex-selective abortions to the declining gender ratios. Corrective measures and focused action are needed.