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1.
JAMA Netw Open ; 7(10): e2438338, 2024 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-39382896

RESUMEN

Importance: Although older adults may use potentially driver-impairing (PDI) medications that can produce psychomotor impairment, little is known about changes to PDI medication use among older adults from the time before to the time after a motor vehicle crash (MVC). Objective: To quantify use of and changes in PDI medications among older adults before and after an MVC. Design, Setting, and Participants: This cohort study used linked Medicare claims and police-reported MVC data on 154 096 person-crashes among 121 846 older drivers. Eligible persons were drivers aged 66 years or older, involved in a police-reported MVC in New Jersey from May 1, 2007, through December 31, 2017, and with continuous enrollment in Medicare fee-for-service Parts A and B for at least 12 months and Part D for at least 120 days prior to the MVC. Data were analyzed from January 2022 to May 2024. Main Outcomes and Measures: Use of benzodiazepines, nonbenzodiazepine hypnotics, opioid analgesics, and other PDI medications in the 120 days before and 120 days after the MVC. Because each person could contribute multiple MVCs during the study period if they met eligibility criteria, the unit of analysis was the number of person-crashes. The proportion of person-crashes after which PDI medications were started, discontinued, or continued was quantified as well. Results: Among 154 096 eligible person-crashes, the mean (SD) age of the drivers was 75.2 (6.7) years at the time of the MVC. Of 121 846 unique persons, 51.6% were women. In 80.0% of the person-crashes, drivers used 1 or more PDI medications before the crash, and in 81.0% of the person-crashes, drivers used 1 or more PDI medications after the crash. Use of benzodiazepines (8.1% before the crash and 8.8% after the crash), nonbenzodiazepine hypnotics (5.9% before the crash and 6.0% after the crash), and opioid analgesics (15.4% before the crash and 17.5% after the crash) was slightly higher after the MVC. After the MVC, drivers in 2.1% of person-crashes started benzodiazepines and 1.4% stopped benzodiazepines, drivers in 1.2% of person-crashes started nonbenzodiazepine hypnotics and 1.2% stopped nonbenzodiazepine hypnotics, and drivers in 8.4% of person-crashes started opioid analgesics and 6.3% stopped opioid analgesics. Conclusions and Relevance: This cohort study suggests that most older drivers involved in MVCs did not use fewer PDI medications after crashes than before crashes. Qualitative research of perceived risks vs benefits of PDI medications is necessary to understand the reasons why MVCs do not appear to motivate clinicians to deprescribe PDI medications as a strategy to avert potential harms, including additional MVCs.


Asunto(s)
Accidentes de Tránsito , Humanos , Anciano , Accidentes de Tránsito/estadística & datos numéricos , Femenino , Masculino , Anciano de 80 o más Años , Estados Unidos , Estudios de Cohortes , Analgésicos Opioides/uso terapéutico , Benzodiazepinas/uso terapéutico , Hipnóticos y Sedantes/uso terapéutico , New Jersey , Medicare/estadística & datos numéricos , Conducción de Automóvil/estadística & datos numéricos
2.
Inj Epidemiol ; 11(1): 38, 2024 Aug 12.
Artículo en Inglés | MEDLINE | ID: mdl-39135173

RESUMEN

BACKGROUND: Administrative healthcare databases, such as Medicare, are increasingly used to identify groups at risk of a crash. However, they only contain information on crash-related injuries, not all crashes. If the driver characteristics associated with crash and crash-related injury differ, conflating the two may result in ineffective or imprecise policy interventions. METHODS: We linked 10 years (2008-2017) of Medicare claims to New Jersey police crash reports to compare the demographics, clinical diagnoses, and prescription drug dispensings for crash-involved drivers ≥ 68 years with a police-reported crash to those with a claim for a crash-related injury. We calculated standardized mean differences to compare characteristics between groups. RESULTS: Crash-involved drivers with a Medicare claim for an injury were more likely than those with a police-reported crash to be female (62.4% vs. 51.8%, standardized mean difference [SMD] = 0.30), had more clinical diagnoses including Alzheimer's disease and related dementias (13.0% vs. 9.2%, SMD = 0.20) and rheumatoid arthritis/osteoarthritis (69.5% vs 61.4%, SMD = 0.20), and a higher rate of dispensing for opioids (33.8% vs 27.6%, SMD = 0.18) and antiepileptics (12.9% vs 9.6%, SMD = 0.14) prior to the crash. Despite documented inconsistencies in coding practices, findings were robust when restricted to claims indicating the injured party was the driver or was left unspecified. CONCLUSIONS: To identify effective mechanisms for reducing morbidity and mortality from crashes, researchers should consider augmenting administrative datasets with information from police crash reports, and vice versa. When those data are not available, we caution researchers and policymakers against the tendency to conflate crash and crash-related injury when interpreting their findings.

3.
Am J Epidemiol ; 2024 Jul 02.
Artículo en Inglés | MEDLINE | ID: mdl-38957996

RESUMEN

Non-benzodiazepine hypnotics ( "Z-drugs") are prescribed for insomnia, but might increase risk of motor vehicle crash (MVC) among older adults through prolonged drowsiness and delayed reaction times. We estimated the effect of initiating Z-drug treatment on the 12-week risk of MVC in a sequential target trial emulation. After linking New Jersey driver licensing and police-reported MVC data to Medicare claims, we emulated a new target trial each week (July 1, 2007 - October 7, 2017) in which Medicare fee-for-service beneficiaries were classified as Z-drug-treated or untreated at baseline and followed for an MVC. We used inverse probability of treatment and censoring weighted pooled logistic regression models to estimate risk ratios (RR) and risk differences with 95% bootstrap confidence limits (CLs). There were 257,554 person-trials, of which 103,371 were Z-drug-treated and 154,183 untreated, giving rise to 976 and 1,249 MVCs, respectively. The intention-to-treat RR was 1.06 (95%CLs 0.95, 1.16). For the per-protocol estimand, there were 800 MVCs and 1,241 MVCs among treated and untreated person-trials, respectively, suggesting a reduced MVC risk (RR 0.83 [95%CLs 0.74, 0.92]) with sustained Z-drug treatment. Z-drugs should be prescribed to older patients judiciously but not withheld entirely over concerns about MVC risk.

4.
Epidemiology ; 35(3): 398-407, 2024 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-38630511

RESUMEN

BACKGROUND: Tropical cyclones are associated with acute increases in mortality and morbidity, but few studies have examined their longer-term health consequences. We assessed whether tropical cyclones are associated with a higher frequency of symptom exacerbation among children with asthma in the following 12 months in eastern United States counties, 2000-2018. METHODS: We defined exposure to tropical cyclones as a maximum sustained windspeed >21 meters/second at the county center and used coarsened exact matching to match each exposed county to one or more unexposed counties. We used longitudinal, de-identified administrative claims data to estimate the county-level, monthly risk of experiencing at least one asthma exacerbation requiring medical attention among commercially insured children aged 5-17 with prior diagnosis of asthma. We used a difference-in-differences approach implemented via a Poisson fixed effects model to compare the risk of asthma exacerbation in the 12 months before versus after each storm in exposed versus unexposed counties. RESULTS: Across 43 tropical cyclones impacting the eastern United States, we did not observe evidence of an increase in the risk of symptom exacerbation in the 12 months following the storm (random-effects meta-analytic summary estimate: risk ratio = 1.03 [95% confidence interval = 0.96, 1.10], I2 = 17%). However, certain storms, such as Hurricane Sandy, were associated with a higher risk of symptom exacerbation. CONCLUSIONS: These findings are consistent with the hypothesis that some tropical cyclones are detrimental to children's respiratory health. However, tropical cyclones were not associated in aggregate with long-term exacerbation of clinically apparent asthma symptoms among a population of children with commercial health insurance.


Asunto(s)
Asma , Tormentas Ciclónicas , Niño , Humanos , Brote de los Síntomas , Asma/epidemiología , Salud Infantil , Progresión de la Enfermedad
5.
JAMA Netw Open ; 7(1): e2346295, 2024 01 02.
Artículo en Inglés | MEDLINE | ID: mdl-38289605

RESUMEN

Importance: The National Lung Screening Trial (NLST) found that screening for lung cancer with low-dose computed tomography (CT) reduced lung cancer-specific and all-cause mortality compared with chest radiography. It is uncertain whether these results apply to a nationally representative target population. Objective: To extend inferences about the effects of lung cancer screening strategies from the NLST to a nationally representative target population of NLST-eligible US adults. Design, Setting, and Participants: This comparative effectiveness study included NLST data from US adults at 33 participating centers enrolled between August 2002 and April 2004 with follow-up through 2009 along with National Health Interview Survey (NHIS) cross-sectional household interview survey data from 2010. Eligible participants were adults aged 55 to 74 years, and were current or former smokers with at least 30 pack-years of smoking (former smokers were required to have quit within the last 15 years). Transportability analyses combined baseline covariate, treatment, and outcome data from the NLST with covariate data from the NHIS and reweighted the trial data to the target population. Data were analyzed from March 2020 to May 2023. Interventions: Low-dose CT or chest radiography screening with a screening assessment at baseline, then yearly for 2 more years. Main Outcomes and Measures: For the outcomes of lung-cancer specific and all-cause death, mortality rates, rate differences, and ratios were calculated at a median (25th percentile and 75th percentile) follow-up of 5.5 (5.2-5.9) years for lung cancer-specific mortality and 6.5 (6.1-6.9) years for all-cause mortality. Results: The transportability analysis included 51 274 NLST participants and 685 NHIS participants representing the target population (of approximately 5 700 000 individuals after survey-weighting). Compared with the target population, NLST participants were younger (median [25th percentile and 75th percentile] age, 60 [57 to 65] years vs 63 [58 to 67] years), had fewer comorbidities (eg, heart disease, 6551 of 51 274 [12.8%] vs 1 025 951 of 5 739 532 [17.9%]), and were more educated (bachelor's degree or higher, 16 349 of 51 274 [31.9%] vs 859 812 of 5 739 532 [15.0%]). In the target population, for lung cancer-specific mortality, the estimated relative rate reduction was 18% (95% CI, 1% to 33%) and the estimated absolute rate reduction with low-dose CT vs chest radiography was 71 deaths per 100 000 person-years (95% CI, 4 to 138 deaths per 100 000 person-years); for all-cause mortality the estimated relative rate reduction was 6% (95% CI, -2% to 12%). In the NLST, for lung cancer-specific mortality, the estimated relative rate reduction was 21% (95% CI, 9% to 32%) and the estimated absolute rate reduction was 67 deaths per 100 000 person-years (95% CI, 27 to 106 deaths per 100 000 person-years); for all-cause mortality, the estimated relative rate reduction was 7% (95% CI, 0% to 12%). Conclusions and Relevance: Estimates of the comparative effectiveness of low-dose CT screening compared with chest radiography in a nationally representative target population were similar to those from unweighted NLST analyses, particularly on the relative scale. Increased uncertainty around effect estimates for the target population reflects large differences in the observed characteristics of trial participants and the target population.


Asunto(s)
Cardiopatías , Neoplasias Pulmonares , Adulto , Humanos , Persona de Mediana Edad , Detección Precoz del Cáncer , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/epidemiología , Estudios Transversales , Tomografía Computarizada por Rayos X
6.
J Am Geriatr Soc ; 72(2): 444-455, 2024 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-37905738

RESUMEN

BACKGROUND: Medications are one of the most easily modifiable risk factors for motor vehicle crashes (MVCs) among older adults, yet limited information exists on how the use of potentially driver-impairing (PDI) medications changes following an MVC. Therefore, we examined the number and types of PDI medication classes dispensed before and after an MVC. METHODS: This observational study included Medicare fee-for-service beneficiaries aged ≥67 years who were involved in a police-reported MVC in New Jersey as a driver between 2008 and 2017. Analyses were conducted at the "person-crash" level because participants could be involved in more than one MVC. We examined the use of 36 PDI medication classes in the 120 days before and 120 days after MVC. We described the number and prevalence of PDI medication classes in the pre-MVC and post-MVC periods as well as the most common PDI medication classes started and stopped following the MVC. RESULTS: Among 124,954 person-crashes, the mean (SD) age was 76.0 (6.5) years, 51.3% were female, and 83.9% were non-Hispanic White. The median (Q1 , Q3 ) number of PDI medication classes was 2 (1, 4) in both the pre-MVC and post-MVC periods. Overall, 20.3% had a net increase, 15.9% had a net decrease, and 63.8% had no net change in the number of PDI medication classes after MVC. Opioids, antihistamines, and thiazide diuretics were the top PDI medication classes stopped following MVC, at incidences of 6.2%, 2.1%, and 1.7%, respectively. The top medication classes started were opioids (8.3%), skeletal muscle relaxants (2.2%), and benzodiazepines (2.1%). CONCLUSIONS: A majority of crash-involved older adults were exposed to multiple PDI medications before and after MVC. A greater proportion of person-crashes were associated with an increased rather than decreased number of PDI medications. The reasons why clinicians refrain from stopping PDI medications following an MVC remain to be elucidated.


Asunto(s)
Accidentes de Tránsito , Conducción de Automóvil , Humanos , Anciano , Femenino , Estados Unidos/epidemiología , Masculino , Medicare , Factores de Riesgo , Vehículos a Motor , New Jersey
7.
Clin Trials ; 20(6): 613-623, 2023 12.
Artículo en Inglés | MEDLINE | ID: mdl-37493171

RESUMEN

BACKGROUND/AIMS: When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We used data from two large nursing home-based pragmatic cluster randomized trials to compare nursing home and resident characteristics in randomized facilities to eligible non-randomized and ineligible facilities. METHODS: We linked data from the high-dose influenza vaccine trial and the Music & Memory Pragmatic TRIal for Nursing Home Residents with ALzheimer's Disease (METRICaL) to nursing home assessments and Medicare fee-for-service claims. The target population for the high-dose trial comprised Medicare-certified nursing homes; the target population for the METRICaL trial comprised nursing homes in one of four US-based nursing home chains. We used standardized mean differences to compare facility and individual characteristics across the three groups and logistic regression to model the probability of nursing home trial participation. RESULTS: In the high-dose trial, 4476 (29%) of the 15,502 nursing homes in the target population were eligible for the trial, of which 818 (18%) were randomized. Of the 1,361,122 residents, 91,179 (6.7%) were residents of randomized facilities, 463,703 (34.0%) of eligible non-randomized facilities, and 806,205 (59.3%) of ineligible facilities. In the METRICaL trial, 160 (59%) of the 270 nursing homes in the target population were eligible for the trial, of which 80 (50%) were randomized. Of the 20,262 residents, 973 (34.4%) were residents of randomized facilities, 7431 (36.7%) of eligible non-randomized facilities, and 5858 (28.9%) of ineligible facilities. In the high-dose trial, randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (132.5 vs 145.9 and 91.9, respectively), for-profit status (91.8% vs 66.8% and 68.8%), belonging to a nursing home chain (85.8% vs 49.9% and 54.7%), and presence of a special care unit (19.8% vs 25.9% and 14.4%). In the METRICaL trial randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (103.7 vs 110.5 and 67.0), resource-poor status (4.6% vs 10.0% and 18.8%), and presence of a special care unit (26.3% vs 33.8% and 10.9%). In both trials, the characteristics of residents in randomized facilities were similar across the three groups. CONCLUSION: In both trials, facility-level characteristics of randomized nursing homes differed considerably from those of eligible non-randomized and ineligible facilities, while there was little difference in resident-level characteristics across the three groups. Investigators should assess the characteristics of clusters that participate in cluster randomized trials, not just the individuals within the clusters, when examining the applicability of trial results beyond participating clusters.


Asunto(s)
Vacunas contra la Influenza , Gripe Humana , Anciano , Humanos , Estados Unidos , Medicare , Ensayos Clínicos Controlados Aleatorios como Asunto , Casas de Salud
8.
Womens Health Issues ; 33(5): 508-514, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37301723

RESUMEN

INTRODUCTION: Despite efforts to improve postpartum health care in the United States, little is known about patterns of postpartum care beyond routine postpartum visit attendance. This study aimed to describe variation in outpatient postpartum care patterns. METHODS: In this longitudinal cohort study of national commercial claims data, we used latent class analysis to identify subgroups of patients (classes) with similar outpatient postpartum care patterns (defined by the number of preventive, problem, and emergency department outpatient visits in the 60 days after birth). We also compared classes in terms of maternal sociodemographics and clinical characteristics measured at childbirth, as well as total health spending and rates of adverse events (all-cause hospitalizations and severe maternal morbidity) measured from childbirth to the late postpartum period (61-365 days after birth). RESULTS: The study cohort included 250,048 patients hospitalized for childbirth in 2016. We identified six classes with distinct outpatient postpartum care patterns in the 60 days after birth, which we classified into three broad groups: no care (class 1 [32.4% of the total sample]); preventive care only (class 2 [18.3%]); and problem care (classes 3-6 [49.3%]). The prevalence of clinical risk factors at childbirth increased progressively from class 1 to class 6; for example, 6.7% of class 1 patients had any chronic disease compared with 15.5% of class 5 patients. Severe maternal morbidity was highest among the high problem care classes (classes 5 and 6): 1.5% of class 6 patients experienced severe maternal morbidity in the postpartum period and 0.5% in the late postpartum period, compared with less than 0.1% of patients in classes 1 and 2. CONCLUSIONS: Efforts to redesign and measure postpartum care should reflect the current heterogeneity in care patterns and clinical risks in the postpartum population.


Asunto(s)
Pacientes Ambulatorios , Atención Posnatal , Embarazo , Femenino , Humanos , Estados Unidos/epidemiología , Estudios Longitudinales , Análisis de Clases Latentes , Periodo Posparto
10.
AIDS Behav ; 27(3): 919-927, 2023 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-36112260

RESUMEN

While expanded HIV testing is needed in South Africa, increasing accurate self-report of HIV status is an essential parallel goal in this highly mobile population. If self-report can ascertain true HIV-positive status, persons with HIV (PWH) could be linked to life-saving care without the existing delays required by producing medical records or undergoing confirmatory testing, which are especially burdensome for the country's high prevalence of circular migrants. We used Wave 1 data from The Migration and Health Follow-Up Study, a representative adult cohort, including circular migrants and permanent residents, randomly sampled from the Agincourt Health and Demographic Surveillance System in a rural area of Mpumalanga Province. Within the analytic sample (n = 1,918), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of self-report were calculated with dried blood spot (DBS) HIV test results as the standard. Among in-person participants (n = 2,468), 88.8% consented to DBS-HIV testing. HIV prevalence was 25.3%. Sensitivity of self-report was 43.9% (95% CI: 39.5-48.5), PPV was 93.4% (95% CI: 89.5-96.0); specificity was 99.0% (95% CI: 98.3-99.4) and NPV was 83.9% (95% CI: 82.8-84.9). Self-report of an HIV-positive status was predictive of true status for both migrants and permanent residents in this high-prevalence setting. Persons who self-reported as living with HIV were almost always truly positive, supporting a change to clinical protocol to immediately connect persons who say they are HIV-positive to ART and counselling. However, 56% of PWH did not report as HIV-positive, highlighting the imperative to address barriers to disclosure.


Asunto(s)
Infecciones por VIH , Migrantes , Adulto , Humanos , Autoinforme , Infecciones por VIH/epidemiología , Sudáfrica/epidemiología , Estudios Transversales , Estudios de Seguimiento , Población Rural , Prueba de VIH
11.
J Aging Soc Policy ; : 1-15, 2022 Dec 04.
Artículo en Inglés | MEDLINE | ID: mdl-36463560

RESUMEN

In 30 states, licensing agencies can restrict the distance from home that "medically-at-risk" drivers are permitted to drive. However, where older drivers crash relative to their home or how distance to crash varies by medical condition is unknown. Using geocoded crash locations and residential addresses linked to Medicare claims, we describe how the relationship between distance from home to crash varies by driver characteristics. We find that a majority of crashes occur within a few miles from home with little variation across driver demographics or medical conditions. Thus, distance restrictions may not reduce crash rates among older adults, and the tradeoff between safety and mobility warrants consideration.

12.
Am J Epidemiol ; 2022 Feb 28.
Artículo en Inglés | MEDLINE | ID: mdl-35225329

RESUMEN

Methods for extending - generalizing or transporting - inferences from a randomized trial to a target population involve conditioning on a large set of covariates that is sufficient for rendering the randomized and non-randomized groups exchangeable. Yet, decision-makers are often interested in examining treatment effects in subgroups of the target population defined in terms of only a few discrete covariates. Here, we propose methods for estimating subgroup-specific potential outcome means and average treatment effects in generalizability and transportability analyses, using outcome model-based (g-formula), weighting, and augmented weighting estimators. We consider estimating subgroup-specific average treatment effects in the target population and its non-randomized subset, and provide methods that are appropriate both for nested and non-nested trial designs. As an illustration, we apply the methods to data from the Coronary Artery Surgery Study to compare the effect of surgery plus medical therapy versus medical therapy alone for chronic coronary artery disease in subgroups defined by history of myocardial infarction.

13.
Med Care Res Rev ; 78(5): 591-597, 2021 10.
Artículo en Inglés | MEDLINE | ID: mdl-31971057

RESUMEN

Although administrative claims data can be used to identify high-need (HN) Medicare beneficiaries, persistence in HN status among beneficiaries and subsequent variation in outcomes are unknown. We use national-level claims data to classify Fee-for-Service (FFS) Medicare beneficiaries as HN annually among beneficiaries continuously enrolled between 2013 and 2015. To examine persistence of HN status over time, we categorize longitudinal patterns in HN status into being never, newly, transiently, and persistently HN and examine differences in patients' demographic characteristics and outcomes. Among survivors, 23% of beneficiaries were HN at any time-4% persistently HN, 13% transiently HN, and 6% newly HN. While beneficiaries who were persistently HN had higher mortality, utilization, and expenditures, classification as HN at any time was associated with poor outcomes. These findings demonstrate longitudinal variability of HN status among FFS beneficiaries and reveal the pervasiveness of poor outcomes associated with even transitory HN status over time.


Asunto(s)
Planes de Aranceles por Servicios , Medicare , Anciano , Gastos en Salud , Humanos , Estudios Retrospectivos , Estados Unidos
14.
J Transp Health ; 192020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-32953453

RESUMEN

INTRODUCTION: Although access to a motor vehicle is essential for pursuing social and economic opportunity and ensuring health and well-being, states have increasingly used driver's license suspensions as a means of compelling compliance with a variety of laws and regulations unrelated to driving, including failure to pay a fine or appear in court. Little known about the population of suspended drivers and what geographic resources may be available to them to help mitigate the impact of a suspension. METHODS: Using data from the New Jersey Safety Health Outcomes (NJ-SHO) data warehouse 2004-2018, we compared characteristics of suspended drivers, their residential census tract, as well as access to public transportation and jobs, by reason for the suspension (driving or non-driving related). In addition, we examined trends in the incidence and prevalence of driving- and non-driving-related suspensions by sub-type over time. RESULTS: We found that the vast majority (91%) of license suspensions were for non-driving-related events, with the most common reason for a suspension being failure to pay a fine. Compared to drivers with a driving-related suspension or no suspension, non-driving-related suspended drivers lived in census tracts with a lower household median income, higher proportion of black and Hispanic residents and higher unemployment rates, but also better walkability scores and better access to public transportation and jobs. CONCLUSIONS: Our study contributes to a growing literature that shows, despite public perception that they are meant to address traffic safety, the majority of suspensions are for non-driving-related events. Further, these non-driving-related suspensions are most common in low-income communities and communities with a high-proportion of black and Hispanic residents. Although non-driving-related suspensions are also concentrated in communities with better access to public transportation and nearby jobs, additional work is needed to determine what effect this has for the social and economic well-being of suspended drivers.

15.
Neurology ; 94(17): e1782-e1792, 2020 04 28.
Artículo en Inglés | MEDLINE | ID: mdl-32269113

RESUMEN

OBJECTIVE: To evaluate the association between long-term exposure to ambient air pollution and cognitive decline in older adults residing in an urban area. METHODS: Data for this study were obtained from 2 prospective cohorts of residents in the northern Manhattan area of New York City: the Washington Heights-Inwood Community Aging Project (WHICAP) and the Northern Manhattan Study (NOMAS). Participants of both cohorts received in-depth neuropsychological testing at enrollment and during follow-up. In each cohort, we used inverse probability weighted linear mixed models to evaluate the cross-sectional and longitudinal associations between markers of average residential ambient air pollution (nitrogen dioxide [NO2], fine particulate matter [PM2.5], and respirable particulate matter [PM10]) levels in the year prior to enrollment and measures of global and domain-specific cognition, adjusting for sociodemographic factors, temporal trends, and censoring. RESULTS: Among 5,330 participants in WHICAP, an increase in NO2 was associated with a 0.22 SD lower global cognitive score at enrollment (95% confidence interval [CI], -0.30, -0.14) and 0.06 SD (95% CI, -0.08, -0.04) more rapid decline in cognitive scores between visits. Results were similar for PM2.5 and PM10 and across functional cognitive domains. We found no evidence of an association between pollution and cognitive function in NOMAS. CONCLUSION: WHICAP participants living in areas with higher levels of ambient air pollutants have lower cognitive scores at enrollment and more rapid rates of cognitive decline over time. In NOMAS, a smaller cohort with fewer repeat measurements, we found no statistically significant associations. These results add to the evidence regarding the adverse effect of air pollution on cognitive aging and brain health.


Asunto(s)
Contaminantes Atmosféricos/efectos adversos , Contaminación del Aire/efectos adversos , Disfunción Cognitiva/epidemiología , Anciano , Estudios de Cohortes , Estudios Transversales , Exposición a Riesgos Ambientales/efectos adversos , Femenino , Humanos , Masculino , Ciudad de Nueva York , Material Particulado/efectos adversos , Estudios Prospectivos
16.
Environ Int ; 136: 105440, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31926436

RESUMEN

BACKGROUND: There is mounting evidence that long-term exposure to air pollution is related to accelerated cognitive decline in aging populations. Factors that influence individual susceptibility remain largely unknown, but may involve the apolipoprotein E genotype E4 (APOE-ε4) allele. OBJECTIVES: We assessed whether the association between long-term exposure to ambient air pollution and cognitive decline differed by APOE-ε4 status and cognitive risk factors. METHODS: The Washington Heights Inwood Community Aging Project (WHICAP) is a prospective study of aging and dementia. Neuropsychological testing and medical examinations occur every 18-24 months. We used mixed-effects models to evaluate whether the association between markers of ambient air pollution (nitrogen dioxide [NO2]), fine [PM2.5], and coarse [PM10] particulate matter) and the rate of decline in global and domain-specific cognition differed across strata defined by APOE-ε4 genotypes and cognitive risk factors, adjusting for sociodemographic factors and temporal trends. RESULTS: Among 4821 participants with an average of 6 years follow-up, higher concentrations of ambient air pollution were associated with more rapid cognitive decline. This association was more pronounced among APOE-ε4 carriers (p < 0.001). A one interquartile range increase in NO2 was associated with an additional decline of 0.09 standard deviations (SD) (95%CI -0.1, -0.06) in global cognition across biennial visits among APOE-ε4 positive individuals and a 0.07 SD (95%CI -0.09, -0.05) decline among APOE-ε4 negative individuals. Results for PM2.5, PM10 and cognitive domains were similar. The association between air pollutants and rate of cognitive decline also varied across strata of race-ethnicity with the association strongest among White non-Hispanic participants. CONCLUSIONS: These results add to the body of evidence on the adverse impact of ambient air pollution on cognitive aging and brain health and provide new insights into the genetic and behavioral factors that may impact individual susceptibility.


Asunto(s)
Contaminantes Atmosféricos , Contaminación del Aire , Apolipoproteínas E , Disfunción Cognitiva , Anciano , Contaminantes Atmosféricos/toxicidad , Apolipoproteína E4 , Apolipoproteínas E/efectos de los fármacos , Disfunción Cognitiva/inducido químicamente , Femenino , Genotipo , Humanos , Masculino , Estudios Prospectivos , Washingtón
17.
J Am Geriatr Soc ; 68(1): 70-77, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31454082

RESUMEN

OBJECTIVES: High-need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes. DESIGN: Latent class analysis was used to identify phenotypes within a sample of HN fee-for-service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post-acute assessment data. SETTING: Not applicable. PARTICIPANTS: Two cross-sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643). MEASUREMENTS: The following variables were used to identify phenotypes: acute and post-acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes. RESULTS: Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4. CONCLUSIONS: Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70-77, 2019.


Asunto(s)
Enfermedad Crónica/economía , Comorbilidad , Gastos en Salud/estadística & datos numéricos , Hospitalización , Isquemia Miocárdica/economía , Aceptación de la Atención de Salud/estadística & datos numéricos , Fenotipo , Anciano , Anciano de 80 o más Años , Estudios Transversales , Planes de Aranceles por Servicios/economía , Femenino , Servicios de Atención de Salud a Domicilio/economía , Servicios de Atención de Salud a Domicilio/estadística & datos numéricos , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Humanos , Revisión de Utilización de Seguros/estadística & datos numéricos , Masculino , Medicare/economía , Alta del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Instituciones de Cuidados Especializados de Enfermería/economía , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Atención Subaguda/economía , Estados Unidos
18.
Popul Health Manag ; 23(4): 313-318, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-31816254

RESUMEN

A small proportion of high-need (HN) Medicare beneficiaries account for a large share of medical expenditures in the United States. Identifying hospitals with the best outcomes for HN patients is central to identifying and spreading evidence-based practices to improve care for this population. The objective of this study was to identify and characterize top-performing hospitals for HN patients. Administrative claims data from 2013-2014 were used to identify HN beneficiaries and their treating hospital; hospitals were ranked based on their HN beneficiaries' outcomes in 2015. Hospitalization, mortality, and days spent in community were assessed, and all outcomes were risk standardized for age, sex, dual eligibility, and hospital referral region. American Hospital Association and aggregated inpatient claims data characterized hospitals. Logistic regression models estimated the odds of ranking in the top 20% on all outcomes. Of 2253 hospitals with at least 500 HN patients in the United States, 92 (4.1%) ranked in the top 20% across all outcomes. No hospital characteristics were associated with being top performing across all outcomes, but urban hospitals were significantly less likely to perform well on hospitalization and private, for-profit hospitals performed better on mortality. Small hospitals, Accountable Care Organization providers, and those providing palliative care services were more likely to rank highly on days spent in the community. Top-performing hospitals served fewer minority, dual eligible, and HN patients, suggesting that case mix may explain some of the differences in performance, and that additional work is needed to examine programs and practices at outstanding hospitals.


Asunto(s)
Hospitales , Medicare , Grupos Diagnósticos Relacionados/estadística & datos numéricos , Gastos en Salud , Necesidades y Demandas de Servicios de Salud , Capacidad de Camas en Hospitales/estadística & datos numéricos , Hospitales/normas , Hospitales/estadística & datos numéricos , Humanos , Personal de Hospital/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos
20.
BMC Geriatr ; 19(1): 210, 2019 08 05.
Artículo en Inglés | MEDLINE | ID: mdl-31382895

RESUMEN

BACKGROUND: Respiratory infections among older adults in long-term care facilities (LTCFs) are a major global concern, yet a rigorous systematic synthesis of the literature on the burden of respiratory infections in the LTCF setting is lacking. To address the critical need for evidence regarding the global burden of respiratory infections in LTCFs, we assessed the burden of respiratory infections in LTCFs through a systematic review of the published literature. METHODS: We identified articles published between April 1964 and March 2019 through searches of PubMed (MEDLINE), EMBASE, and the Cochrane Library. Experimental and observational studies published in English that included adults aged ≥60 residing in LTCFs who were unvaccinated (to identify the natural infection burden), and that reported measures of occurrence for influenza, respiratory syncytial virus (RSV), or pneumonia were included. Disagreements about article inclusion were discussed and articles were included based on consensus. Data on study design, population, and findings were extracted from each article. Findings were synthesized qualitatively. RESULTS: A total of 1451 articles were screened for eligibility, 345 were selected for full-text review, and 26 were included. Study population mean ages ranged from 70.8 to 90.1 years. Three (12%) studies reported influenza estimates, 7 (27%) RSV, and 16 (62%) pneumonia. Eighteen (69%) studies reported incidence estimates, 7 (27%) prevalence estimates, and 1 (4%) both. Seven (27%) studies reported outbreaks. Respiratory infection incidence estimates ranged from 1.1 to 85.2% and prevalence estimates ranging from 1.4 to 55.8%. Influenza incidences ranged from 5.9 to 85.2%. RSV incidence proportions ranged from 1.1 to 13.5%. Pneumonia prevalence proportions ranged from 1.4 to 55.8% while incidence proportions ranged from 4.8 to 41.2%. CONCLUSIONS: The reported incidence and prevalence estimates of respiratory infections among older LTCF residents varied widely between published studies. The wide range of estimates offers little useful guidance for decision-making to decrease respiratory infection burden. Large, well-designed epidemiologic studies are therefore still necessary to credibly quantify the burden of respiratory infections among older adults in LTCFs, which will ultimately help inform future surveillance and intervention efforts.


Asunto(s)
Costo de Enfermedad , Cuidados a Largo Plazo/métodos , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/terapia , Anciano , Anciano de 80 o más Años , Atención a la Salud/métodos , Atención a la Salud/tendencias , Humanos , Cuidados a Largo Plazo/tendencias , Infecciones del Sistema Respiratorio/epidemiología , Factores de Riesgo
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