Association between the Neutrophil-to-Lymphocyte Ratio and Inpatient Mortality in Hospitalized Older Veterans with COVID-19 Infection.

OBJECTIVES: Determine the association of high neutrophil-to-lymphocyte ratio (NLR) values with inpatient mortality and other outcomes in older veterans hospitalized with coronavirus disease 2019 (COVID-19). METHODS: This was a retrospective, multicenter, cohort study of hospitalized adults, with laboratory-confirmed COVID-19 infection who were studied for 1 year after discharge or until death. The NLR was categorized into tertiles, and we determined frailty status with the 31-item Veterans Affairs Frailty Index. Multivariate logistic regression and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were performed to assess the association between NLR and clinical outcomes. RESULTS: The study included 615 hospitalized adult veterans, mean age 66.12 (standard deviation 14.79) years, 93.82% (n = 577) male, 57.56% (n = 354) White, 81.0% (n = 498) non-Hispanic, median body mass index of 30.70 (interquartile range 25.64-34.99, standard deviation 7.13), and median length of stay of 8 days (interquartile range 3-15). Individuals in the middle and upper tertile groups had higher inpatient mortality (8.37%, n = 17 and 18.36%, n = 38, respectively) as compared with the lower tertile (2.93%, n = 6, P < 0.001). Compared with the lowest tertile, the middle and upper tertiles had a higher risk of inpatient mortality (aOR 3.75, 95% CI 1.38-10.21, P = 0.01, and aOR 8.13, 95% CI 3.18-20.84, P < 0.001, respectively). The highest tertile had a higher odds of intensive care unit admission (aOR 4.47, 95% CI 2.33-8.58, P < 0.001) and intensive care unit transfer (aOR 3.54, 95% CI 1.84-6.81, P < 0.001). CONCLUSIONS: The NLR score is a clinically useful tool to predict in-hospital mortality in older patients with COVID-19.

The cross-sectional association of frailty with chronic past and current use of benzodiazepine drugs.

BACKGROUND: Frailty, a clinical syndrome characterized by vulnerability to stressors resulting from multisystemic loss of physiological reserve. The use of benzodiazepines in older adults has been associated with confusion, sedation, and cognitive impairment, which in turn may lead to frailty. AIMS: The purpose of this study was to determine the cross-sectional association between frailty and chronic past or current use of benzodiazepine drugs among older US Veterans. METHODS/DESIGN: This is a cross-sectional study of community-dwelling older Veterans who had determinations of frailty. Benzodiazepine prescription data were obtained via EHR. A 31-item VA Frailty Index (VA-FI) was generated at the time of the assessment. We categorized Veterans into robust (FI ≤ 0.10), pre-frail (FI 0.10-0.21), and Frail (FI ≥ 0.21). After adjusting for sociodemographic characteristics, we calculated ORs and 95% CIs using a binomial logistic regression (BLR) model to assess the cross-sectional association between benzodiazepine use and frailty. RESULTS: Population sample consisted of 17,423 Veterans, mean age 75.53 (SD = 8.03) years, 70.80% Caucasian, 97.34% male, 14,545 (83.50%) patients were non-users of benzodiazepine drugs, 2408 (13.80%) had a past use, and 470 (2.70%) were current users. In BLR, individuals with past (OR 2.51, 95% CI 2.30-2.74, p < .001) or current (OR 2.36, 95% CI 1.96-2.83, p < .001) use showed a higher association with frailty as compared to individuals who were non-users. CONCLUSIONS: The use of benzodiazepine was cross-sectionally associated with frailty in older Veterans. These results suggest that screening for frailty in patients with past or current exposure to benzodiazepine medications may be necessary for proper management.

Propensity Score Matching to Determine the Impact of Metformin on All-Cause Mortality in Older Veterans with Diabetes Mellitus.

OBJECTIVES: To determine whether metformin is associated with reduced all-cause mortality in older adults with diabetes mellitus as compared with insulin or sulfonylureas, and to evaluate whether the metformin cumulative exposure followed a dose-response relation. METHODS: Retrospective cohort study with propensity score matching in veterans 65 years old and older with diabetes mellitus. Patients who had new prescriptions for metformin were matched for demographic and clinical factors with patients receiving new prescriptions for insulin or sulfonylureas using propensity score matching. All-cause mortality risks were compared between metformin and insulin/sulfonylureas using multivariate Cox regression models. A similar approach was used for tertiles of cumulative metformin doses. RESULTS: A sample of 174 veterans taking metformin was matched with 174 who took insulin/sulfonylureas. Most patients were men (97.4%), White (80.45%), and their mean ± standard deviation age was 69.15 ± 7.65 years. Metformin exposure was associated with reduced risk of all-cause mortality (hazard ratio 0.57, 95% confidence interval 0.39-0.84, P = 0.005). The upper tertile of cumulative metformin exposure was associated with lower all-cause mortality in the fully adjusted model (hazard ratio 0.28, 95% confidence interval 0.10-0.77, P = 0.013). CONCLUSIONS: This propensity matching study shows that metformin exposure is associated with a lower risk of all-cause mortality. Higher metformin cumulative exposure seems to reduce the risk of all-cause mortality in older veterans with diabetes mellitus.

The cross-sectional association of frailty with past and current exposure to strong anticholinergic drugs.

BACKGROUND: Anticholinergic drugs may contribute to frailty by impairing cognitive and physical functions. Strong anticholinergic drugs in particular may have adverse effects among older adults. OBJECTIVES: Determine the association between frailty and the use of strong anticholinergic drugs among older US Veterans. METHODS: This is a cross-sectional study of community-dwelling Veterans 65 years and older who had determinations of frailty status. Prescription data for patients using strong anticholinergic medications (never/past/current) was obtained via electronic health records. A 31-item VA Frailty Index (VA-FI) was generated at the time of the assessment. We dichotomized the groups into non-frail (FI = < 0.21) and frail (FI ≥ 0.21) patients. We used binomial logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Frailty was the dependent variable and use of strong anticholinergic drugs was the independent variable. Multivariate adjustment was conducted for age, gender, race, ethnicity, marital status, and BMI. RESULTS: Population sample consisted of 17,084 Veterans who were 71.05% Caucasian, 97.34% male, and with a mean age 75.60 (SD = 8.04) years. Among the population, 9940 (58.18%) patients had no previous use of strong anticholinergic drugs, whereas 5182 (30.33%) had past exposure and 1962 (11.49%) had current exposure. In binomial logistic regression, individuals with past (OR 3.27, 95% CI 3.03-3.54, p < 0.0005) or current (OR 4.78, 95% CI 4.30-5.31, p < 0.0005) exposure showed a higher association with frailty as compared to individuals who were never exposed. CONCLUSIONS: Past and current use of strong anticholinergic drugs were associated with frailty in older Veterans. These results suggest that screening for frailty in patients with past or current exposure to strong anticholinergic medications may be necessary for proper management.

Depression but not frailty contributed to a higher risk for all-cause hospitalizations in male older veterans.

INTRODUCTION: Frailty is a state of vulnerability to stressors resulting in higher morbidity, mortality, and utilization in older adults. Depression and frailty often coexist, suggesting a bidirectional relationship that may increase the effects of each individual condition on clinical outcomes and health-care utilization in older adults. OBJECTIVE: To determine the effects of concurrent frailty and depression on all-cause hospitalizations. METHODS/DESIGN: Prospective cohort study, conducted at a Veterans Affairs (VA) Medical Center. The participants were male, community-dwelling veterans 65 years and older. From 4 January through 30 December 2016, a 46-item frailty index was generated from data obtained from the VA electronic health record. Trained staff conducted in-depth reviews of electronic health records ascertaining depression status. Patients were followed through 31 December 2017 for all-cause hospitalizations following the initial assessment of frailty. After adjusting for covariates, the association of frailty and depression with all-cause hospitalizations was determined with the Andersen-Gill model, accounting for repeated hospitalizations. RESULTS: Five hundred fifty-three male patients were part of the study, mean age 76.3 (SD = 8.2) years. One hundred eighty-one patients (32.7%) had depression diagnoses. During a median follow-up period of 530 days (interquartile range [IQR] = 245), 123 patients (22.2%) had 240 hospitalizations. Frailty status was not associated with future hospitalizations (adjusted hazard ratio [HR] = 1.61; 95% CI, 95-2.74; P > .05). Depression was associated with higher all-cause hospitalizations (adjusted HR = 1.57; 95% CI, 1.09-2.26); P = .0157). CONCLUSIONS: Depression but not frailty was significantly associated with higher rates of all-cause hospitalization. Implementing interventions that target older adults with both frailty and depression may reduce the burden of both conditions and reduce hospitalizations.

Is there an association between ageist attitudes and frailty?

BACKGROUND: Frailty is defined as a state of vulnerability to stressors that is associated with higher morbidity, mortality and healthcare utilization in older adults. Ageism is "a process of systematic stereotyping and discrimination against people because they are old." Explicit biases involve deliberate or conscious controls, while implicit bias involve unconscious processes. Multiple studies show that self-directed ageism is a risk factor for increased morbidity and mortality. The purpose of this study was to determine whether explicit ageist attitudes are associated with frailty in Veterans. METHODS: This is a cross-sectional study of Veterans 50 years and older who completed the Kogan's Attitudes towards Older People Scale (KAOP) scale to assess explicit ageist attitudes and the Implicit Association Test (IAT) to evaluate implicit ageist attitudes from July 2014 through April 2015. We constructed a frailty index (FI) of 44 variables (demographics, comorbidities, number of medications, laboratory tests, and activities of daily living) that was retrospectively applied to the time of completion of the KAOP and IAT. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by multinomial logistic regression models with frailty status (robust, prefrail and frail) as the outcome variable, and with KAOP and IAT scores as the independent variables. Age, race, ethnicity, median household income and comorbidities were considered as covariates. RESULTS: Patients were 89.76% male, 48.03% White, 87.93% non-Hispanic and the mean age was 60.51 (SD = 7.16) years. The proportion of robust, pre-frail and frail patients was 11.02% (n = 42), 59.58% (n = 227) and 29.40% (n = 112) respectively. The KAOP was completed by 381 and the IAT by 339 participants. In multinomial logistic regression, neither explicit ageist attitudes (KAOP scale score) nor implicit ageist attitudes (IAT) were associated with frailty in community dwelling Veterans after adjusting for covariates: OR = .98 (95% CI = .95-1.01), p = .221, and OR:=.97 (95% CI = .37-2.53), p = .950 respectively. CONCLUSIONS: This study shows that neither explicit nor implicit ageist attitudes were associated with frailty in community dwelling Veterans. Further longitudinal and larger studies with more diverse samples and measured with other ageism scales should evaluate the independent contribution of ageist attitudes to frailty in older adults.

The association of health literacy, numeracy and graph literacy with frailty.

BACKGROUND: Frailty is a state of vulnerability to stressors which may result in high mortality, morbidity, and health-care utilization in older adults. Whether health literacy, graph literacy and numeracy are associated with frailty is unknown. AIM: To assess the association of health literacy, numeracy and graph literacy with frailty in male veterans. METHODS: This is a retrospective study of 470 cognitively intact, non-depressed veterans who completed evaluations of health literacy, numeracy and graph literacy at Miami VA facility in 2012. A 43-item frailty index was created as a proportion of all potential variables (demographics, comorbidities, number of medications, laboratory tests, and activities of daily life). Odds ratios and 95% confidence intervals were calculated by multinomial logistic regression models with frailty status (robust, prefrail and frail) as the outcome variable, and with health literacy, numeracy, and graph literacy scores as independent variables. Age, race, ethnicity, education, socio-economic status, and comorbidities were considered as covariates. RESULTS: Patients were 100% male, 40% White, 82% non-Hispanic, mean age was 56.8 years. The proportion of robust, pre-frail and frail was 10.0%, 61.3% and 28.7%, respectively. Neither health literacy nor objective nor subjective numeracy was associated with frailty after adjustment for covariates. In contrast, higher graph literacy scores were associated with a lower risk for frailty (p = .015) even after adjusting known risk factors for frailty. DISCUSSION AND CONCLUSION: Neither health literacy nor numeracy is associated with frailty. Higher graph literacy score is associated with a lower risk for frailty even after adjusting for known risk factors for frailty.

Validation of an automatically generated screening score for frailty: the care assessment need (CAN) score.

BACKGROUND: Frailty is a state of vulnerability to stressors that is prevalent in older adults and is associated with higher morbidity, mortality and healthcare utilization. Multiple instruments are used to measure frailty; most are time-consuming. The Care Assessment Need (CAN) score is automatically generated from electronic health record data using a statistical model. The methodology for calculation of the CAN score is consistent with the deficit accumulation model of frailty. At a 95 percentile, the CAN score is a predictor of hospitalization and mortality in Veteran populations. The purpose of this study was to validate the CAN score as a screening tool for frailty in primary care. METHODS: This is a cross-sectional, validation study compared the CAN score with a 40-item Frailty Index reference standard based on a comprehensive geriatric assessment. We included community-dwelling male patients over age 65 from an outpatient geriatric medicine clinic. We calculated the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of the CAN score. RESULTS: 184 patients over age 65 were included in the study: 97.3% male, 64.2% White, 80.9% non-Hispanic. The CGA-based Frailty Index defined 14.1% as robust, 53.3% as prefrail and 32.6% as frail. For the frail, statistical analysis demonstrated that a CAN score of 55 provides sensitivity, specificity, PPV and NPV of 91.67, 40.32, 42.64 and 90.91% respectively whereas at a score of 95 the sensitivity, specificity, PPV and NPV were 43.33, 88.81, 63.41, 77.78% respectively. Area under the receiver operating characteristics curve was 0.736 (95% CI = .661-.811). CONCLUSION: CAN score is a potential screening tool for frailty among older adults; it is generated automatically and provides acceptable diagnostic accuracy. Hence, the CAN score may be a useful tool to primary care providers for detection of frailty in their patient panels.

Association of the CAN score with the FRAIL scale in community dwelling older adults.

BACKGROUND: Frailty is a state of vulnerability to stressors which results in higher morbidity, mortality and healthcare utilization. The FRAIL scale is used as a validated screening for frailty. The Care Assessment Need (CAN) score is automatically generated from electronic health record data using a statistical model that includes data elements similar to the deficit accumulation model for frailty and predicts risk for hospitalization and/or mortality. AIM: To determine the correlation of the CAN score with the FRAIL scale. METHODS: A cross-sectional study of 503 community-dwelling older adults. We compared the FRAIL scale with the CAN score. RESULTS: The CAN score was significantly different between robust, prefrail and frail. Post hoc analysis revealed significant increases in scores from robust to prefrail and frail groups, in that order. The CAN score and FRAIL scale showed a correlation. CONCLUSIONS: The CAN score show a moderate positive association with the FRAIL scale.

Healthcare Utilization by Frail, Community-Dwelling Older Veterans: A 1-Year Follow-up Study.

OBJECTIVES: Frailty is a prevalent clinical syndrome associated with a high risk of adverse health outcomes, including disability, morbidity, and mortality, that has become a major challenge for the healthcare system. The aim of this prospective study was to determine the level of healthcare utilization in prefrail and frail community-dwelling older military veterans. METHODS: We studied a cohort of community-dwelling older veterans aged 65 years and older 1 year at the Miami Veterans Affairs Medical Center to determine their levels of healthcare utilization. We administered the 5-item FRAIL (Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight) scale, from which patients were categorized into three groups: robust, prefrail, and frail. Chart reviews were conducted to confirm weight loss and number of illnesses. One year later, information regarding hospital admissions, emergency department (ED) visits, and primary care visits was obtained. RESULTS: We evaluated 291 participants, mean age 74 ± 8 years, 112 (38.5%) of whom were African American, 179 (61.5%) were white, and 40 (13.7%) were Hispanic. Overall, 49 (16.8%) participants were frail, and 161 (55.4%) prefrail. After adjusting for age and Charlson Comorbidity Index, frail status was associated with ED admission (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.1) and primary care visits (OR 3.4, 95% CI 1.5-7.3); however, it was not significantly associated with hospital admission (OR 2.2, 95% CI 0.9-5.2). CONCLUSIONS: In a sample of community-dwelling older veterans, frailty was found to be significantly associated with an increased frequency of ED visits and primary care visits, but not with hospital admissions. Identifying patients with frailty may allow for targeted interventions that improve healthcare outcomes and may reduce healthcare utilization.

Dramatic Reduction in 30-Day Readmissions Through High-Risk Screening and Two-Phase Interdisciplinary Care.

OBJECTIVES: Thirty-day readmissions are common, serious, and costly. Most important, often they are preventable. The purpose of this quality improvement study was to evaluate an interdisciplinary, two-phase intervention to reduce 30-day readmissions among high-risk medical patients. One or two high-risk patients were selected each weekday by a hospitalist using literature-based, locally tested criteria that included common medical illnesses, active psychiatric illness, and recent or recurrent hospital admissions. METHODS: Patients admitted to 1 of 5 medical hospitalist teams were selected to receive the intervention; patients admitted to the 4 remaining teams were used for comparison. The two-phase care coordination intervention consisted of a daily interdisciplinary team meeting for the selected high-risk patients and postdischarge interventions that included outpatient care coordination until the patients' first follow-up appointment. The care plan addressed medical/geriatric assessment, social stability, medication reconciliation, nutritional needs, care coordination including future appointments/testing, and community services. Eighty-five patients in the intervention group were compared with 84 patients from the comparison group using propensity score matching. Patient characteristics were similar at baseline. RESULTS: The intervention group demonstrated a reduction in 30-day readmissions by 52% (11 vs 23, P = 0.019). Length of stay was reduced: 5.5 days compared with 7.2 days (P = 0.258). CONCLUSIONS: This intervention produced a significant reduction in 30-day readmissions for high-risk patients and a trend for shorter lengths of stay compared with similarly matched patients. Future research trials are needed to verify these results.

The Association of Graph Literacy With Use of and Skills Using an Online Personal Health Record in Outpatient Veterans.

Personal health records (PHRs) are intended to increase patients' access to and ownership over their health care information for self-management purposes. The purpose of this study was to determine the association of graph literacy with adoption of an online PHR and, among adopters with self-reported skills, the frequency of use and intent to return to use the PHR . We conducted a cross-sectional survey of veterans receiving outpatient care. We measured health literacy, numeracy, graph literacy, and Internet and PHR adoption and use. We compared subgroups of veterans using analyses of covariance. We used hierarchical logistic regression models to estimate the effects of the literacy variables on PHR use. A total of 600 veterans (age = 22-94) participated in the survey. After we adjusted for known covariates, we found that adopters of a PHR were more likely to demonstrate higher health and graph literacy than nonadopters. Among PHR adopters, self-reported frequent and skillful users were more likely to have higher graph literacy than lower frequency and less skillful users. Adopters with higher intentions to return to use the PHR were more likely to show lower graph literacy than those less likely to return to use the PHR. Inadequate graph literacy was associated with lower adoption of a PHR and, among users, with lower self-reported frequent use and skills . As PHR use becomes more widespread, stakeholders will need to consider patients' levels of graph literacy when implementing PHRs.

Group-based differences in anti-aging bias among medical students.

Medical students (MS) may develop ageist attitudes early in their training that may predict their future avoidance of caring for the elderly. This study sought to determine MS' patterns of explicit and implicit anti-aging bias, intent to practice with older people and using the quad model, the role of gender, race, and motivation-based differences. One hundred and three MS completed an online survey that included explicit and implicit measures. Explicit measures revealed a moderately positive perception of older people. Female medical students and those high in internal motivation showed lower anti-aging bias, and both were more likely to intend to practice with older people. Although the implicit measure revealed more negativity toward the elderly than the explicit measures, there were no group differences. However, using the quad model the authors identified gender, race, and motivation-based differences in controlled and automatic processes involved in anti-aging bias.

The association of non-severe COVID-19 infection and progression to frailty among robust older veterans.

BACKGROUND: Studies have shown that frailty was increased in hospitalized COVID-19 patients. However, it is not clear whether non-severe COVID-19 increases the risk for pre-frailty and frailty development. Our study aimed to determine the risk of developing frailty and pre-frailty in robust veterans who contracted non-severe COVID-19. METHODS: We conducted a retrospective cohort study to assess the association of SARS-CoV-2 infection with the development of pre-frailty and frailty status among robust U.S. veterans using VA COVID-19 Shared Data Resource. We included patients 55 years and older who had at least one SARS-CoV-2 testing between March 15, 2020, and November 30, 2020, had been active patients in the past 12 months, and had a VA frailty index of zero (robust status) at the time of testing. Cox proportional hazard model was used to assess the association between COVID-19 infection and developing frailty or pre-frailty and frailty. We also assessed the association by patients' age groups, sex, and race. FINDINGS: We identified 82070 veterans mean age 68.3 ± 7.8, 74738 (91.1%) male, 53899 (65.7%) white, 7557 (9.2%) with mild COVID-19 infection. Over the follow up period of 36 months, testing positive for COVID-19 was associated with a 66% increase in the hazard of becoming frail (adjusted HR = 1.66, 95%CI: 1.32-2.08), and a 68% increase in the hazard of becoming pre-frail (adjusted HR = 1.68, 95%CI: 1.45-1.94). Among male patients, mild COVID-19 infection was associated with a 54% increase in the hazard of becoming frail (adjusted HR = 1.54, 95% CI: 1.21-1.96), while among female patients there was a 330% increase (adjusted HR = 4.30, 95% CI: 2.13-8.64). CONCLUSIONS AND RELEVANCE: Non-severe COVID-19 infection that occurred in robust older adults increased the risk of developing frailty. Further multi-center prospective cohort studies evaluating the mechanism of action and clinical trials of treatment options for post-COVID frailty are indicated in Veterans to support clinical care.

Association of Frailty and Cardiopulmonary Resuscitation Outcomes in Older U.S. Veterans.

Objectives: Determine the association between frailty and immediate survival of cardiopulmonary resuscitation (CPR) in older Veterans. Secondary outcomes: compare in-hospital mortality, duration of resuscitation efforts, hospital and intensive care unit (ICU) length of stay, neurologic outcomes, and discharge disposition between frail and non-frail Veterans. Methods: Retrospective cohort study including Veterans 50 years and older, who were "Full Code" and had in-hospital cardiac arrest between 7/1/2017 and 6/30/2020, at the Miami VAMC. Frailty Index for the VA (VA-FI) was used to determine frailty status. Immediate Survival was determined by return of spontaneous circulation (ROSC) and in-hospital mortality was determined by all-cause mortality. We compared outcomes between frail and non-frail Veterans using chi-square test. After adjusting for age, gender, race, and previous hospitalizations, we used multivariate binomial logistic regression with 95% confidence intervals to analyze the relationship between immediate survival and frailty, and in-hospital mortality and frailty. Results: 91% Veterans were non-Hispanic, 49% Caucasian, 96% male, mean age 70.7 ± 8.5 years, 73% frail and 27% non-frail. Seventy-six (65.5%) Veterans had ROSC, without difference by frailty status (P = .891). There was no difference based on frailty status of in-hospital mortality, discharge disposition, or neurologic outcomes. Frail and non-frail Veterans had resuscitation efforts lasting the same amount of time. Conclusions and Implications: CPR outcomes were not different depending on frailty status in our Veteran population. With these results, we cannot use frailty - as measured by the VA-FI - as a prognosticator of CPR outcomes in Veterans.

Health literacy, numeracy, and graphical literacy among veterans in primary care and their effect on shared decision making and trust in physicians.

Studies reveal high levels of inadequate health literacy and numeracy in African Americans and older veterans. The authors aimed to investigate the distribution of health literacy, numeracy, and graph literacy in these populations. They conducted a cross-sectional survey of veterans receiving outpatient care and measured health literacy, numeracy, graph literacy, shared decision making, and trust in physicians. In addition, the authors compared subgroups of veterans using analyses of covariance. Participants were 502 veterans (22-82 years). Low, marginal, and adequate health literacy were found in, respectively, 29%, 26%, and 45% of the veterans. The authors found a significant main effect of race qualified by an age and race interaction. Inadequate health literacy was more common in African Americans than in Whites. Younger African Americans had lower health literacy (p <.001), graph literacy (p <.001), and numeracy (p <.001) than did Whites, even after the authors adjusted for covariates. Older and younger participants did not differ in health literacy, objective numeracy, or graph literacy after adjustment. The authors found no health literacy or age-related differences regarding preferences for shared decision making. African Americans expressed dissatisfaction with their current role in decision making (p =.03). Older participants trusted their physicians more than younger participants (p =.01). In conclusion, African Americans may be at a disadvantage when reviewing patient education materials, potentially affecting health care outcomes.

Effects on performance of individual versus dyadic practice during an avatar-based three-dimensional virtual home safety simulation.

This pilot study tests the effects on individual performance of dyadic versus individual practice in a 3D virtual world (VW) home safety assessment. Sixty medical students in three conditions (dyadic spatially separated with paired avatars DPA; individual with avatar IND; and dyadic spatially together with single avatar DSA) participated in a geriatric home safety simulation. The participants, via avatars, conducted an assessment of physical hazards. Participants then worked individually in a separate 3D VW home assessment. Dyadic practice, spatially together with a single avatar (DSA), improved individual performance in the subsequent 3D VW home assessment.

Frailty as a risk factor for post-acute sequelae of COVID-19 among US veterans during the Delta and Omicron waves.

BACKGROUND: Older populations have suffered the highest rates of SARS-CoV-2 infection and associated complications, including Post-Acute Sequelae of SARS-CoV-2 infection (PASC). Frailty is a geriatric syndrome that often coexists with COVID-19 infection. The vulnerability to stressors caused by multisystemic dysfunction that characterizes frailty may predispose older adults to develop PASC. METHODS: Retrospective cohort study using the VA COVID-19 Shared Data Resource to identify US veterans testing positive for SARS-CoV-2 between July 2021 and February 2022, without prior positive tests and who were alive 30 days after infection. Frailty was calculated using a 31-item VA Frailty Index generated from electronic health records. We categorized Veterans into robust (FI ≤ 0.10), prefrail (FI: >0.10- < 0.21), and frail (FI ≥ 0.21). We assessed the association between frailty and PASC and vaccination and PASC using Cox survival model, adjusting for covariates. RESULTS: We identified 245,857 COVID-19-positive veterans surviving 30 days after infection. The mean age was 57.5 ± 16.5 years; 87.2% were males, 68.1% were white, and 9.0% were Hispanic. Almost half of the sample (48.9%) were classified as robust, while 28.3% were pre-frail and 22.7% were frail; 99,886 (40.6%) were fully vaccinated, and 33,516 (13.6%) received booster doses. Over a median follow-up of 143 days (IQR = 101), 23,890 (9.7%) patients developed PASC. Within 6 months after infection, frailty and pre-frailty were associated with a 41% (adjusted HR [aHR]:1.40 (95% CI: 1.35-1.47) and 15% (aHR: 1.17 (95% CI: 1.11-1.19) increase in the risk of PASC compared with the robust, respectively. Vaccination and booster doses before infection were associated with a 27% (aHR: 0.73 (95% CI: 0.71-0.75) and 33% (aHR: 0.66 (95% CI: 0.63-0.69) reduction in the risk of developing PASC, respectively. CONCLUSIONS: Frailty was associated with an increased risk of developing PASC. Vaccination was associated with a decreased risk of PASC, further reduced by booster doses. Early recognition of frailty in patients with COVID-19 may assist in the early identification and management of PASC.

Using anthropomorphic avatars resembling sedentary older individuals as models to enhance self-efficacy and adherence to physical activity: psychophysiological correlates.

The prevalence of obesity and associated health complications are currently at unprecedented levels. Physical activity in this population can improve patient outcomes. Virtual reality (VR) self-modeling may improve self-efficacy and adherence to physical activity. We conducted a comparative study of 30 participants randomized to 3 versions of a 3D avatar-based VR intervention about exercise: virtual representation of the self exercising condition; virtual representation of other person exercising and control condition. Participants in the virtual representation of the self group significantly increased their levels of physical activity. The improvement in physical activity for participants in the visual representation of other person exercising was marginal. The improvement for the control group was not significant. However, the effect sizes for comparing the pre and post intervention physical activity levels were quite large for all three groups. We did not find any group difference in the improvements of physical activity levels and self-efficacy among sedentary, overweight or obese individuals.

Medical students' attitudes toward obese patient avatars of different skin color.

Physicians' biases for skin color and obesity may negatively affect health-care outcomes. Identification of these biases is the first step to address the problem. We randomized 128 U.S medical students into one of four animated videos of avatar physician-patient counseling sessions, varying the weight and skin color of an elderly patient avatar: white-thin, black-thin, white-obese and black-obese. Medical students viewed white obese avatars as unattractive, ugly, noncompliant, lazy, and sloppy. Medical students' comments suggested a paternalistic attitude toward avatar patients. Avatar-mediated experiences can elicit medical students' bias potentially enabling medical educators to implement bias reduction interventions.