Relationship Between Distressing Symptoms and Changes in Disability After Major Surgery Among Community-living Older Persons.

OBJECTIVES: To evaluate the relationship between distressing symptoms and changes in disability after major surgery and to determine whether this relationship differs according to the timing of surgery (nonelective vs elective), sex, multimorbidity, and socioeconomic disadvantage. BACKGROUND: Major surgery is a common and serious health event that has pronounced deleterious effects on both distressing symptoms and functional outcomes in older persons. METHODS: From a cohort of 754 community-living persons, aged 70 or older, 392 admissions for major surgery were identified from 283 participants who were discharged from the hospital. The occurrence of 15 distressing symptoms and disability in 13 activities were assessed monthly for up to 6 months after major surgery. RESULTS: Over the 6-month follow-up period, each unit increase in the number of distressing symptoms was associated with a 6.4% increase in the number of disabilities [adjusted rate ratio (RR): 1.064; 95% CI: 1.053, 1.074]. The corresponding increases were 4.0% (adjusted RR: 1.040; 95% CI: 1.030, 1.050) and 8.3% (adjusted RR: 1.083; 95% CI: 1.066, 1.101) for nonelective and elective surgeries. Based on exposure to multiple (ie, 2 or more) distressing symptoms, the adjusted RRs (95% CI) were 1.43 (1.35, 1.50), 1.24 (1.17, 1.31), and 1.61 (1.48, 1.75) for all, nonelective, and elective surgeries. Statistically significant associations were observed for each of the other subgroups with the exception of individual-level socioeconomic disadvantage for the number of distressing symptoms. CONCLUSIONS: Distressing symptoms are independently associated with worsening disability, providing a potential target for improving functional outcomes after major surgery.

The Incidence and Cumulative Risk of Major Surgery in Older Persons in the United States.

OBJECTIVE: The objective of this study was to estimate the incidence and cumulative risk of major surgery in older persons over a 5-year period and evaluate how these estimates differ according to key demographic and geriatric characteristics. BACKGROUND: As the population of the United States ages, there is considerable interest in ensuring safe, high-quality surgical care for older persons. Yet, valid, generalizable data on the occurrence of major surgery in the geriatric population are sparse. METHODS: We evaluated data from a prospective longitudinal study of 5571 community-living fee-for-service Medicare beneficiaries, aged 65 or older, from the National Health and Aging Trends Study from 2011 to 2016. Major surgeries were identified through linkages with Centers for Medicare and Medicaid Services data. Population-based incidence and cumulative risk estimates incorporated National Health and Aging Trends Study analytic sampling weights and cluster and strata variables. RESULTS: The nationally representative incidence of major surgery per 100 person-years was 8.8, with estimates of 5.2 and 3.7 for elective and nonelec-tive surgeries. The adjusted incidence of major surgery peaked at 10.8 in persons 75 to 79 years, increased from 6.6 in the non-frail group to 10.3 in the frail group, and was similar by sex and dementia. The 5-year cumulative risk of major surgery was 13.8%, representing nearly 5 million unique older persons, including 12.1% in persons 85 to 89 years, 9.1% in those ≥90 years, 12.1% in those with frailty, and 12.4% in those with probable dementia. CONCLUSIONS: Major surgery is a common event in the lives of community-living older persons, including high-risk vulnerable subgroups.

Factors Associated With Days Away From Home in the Year After Major Surgery Among Community-living Older Persons.

OBJECTIVE: To identify the factors associated with days away from home in the year after hospital discharge for major surgery. BACKGROUND: Relatively little is known about which older persons are susceptible to spending a disproportionate amount of time in hospitals and other health care facilities after major surgery. METHODS: From a cohort of 754 community-living persons, aged 70+ years, 394 admissions for major surgery were identified from 289 participants who were discharged from the hospital. Candidate risk factors were assessed every 18 months. Days away from home were calculated as the number of days spent in a health care facility. RESULTS: In the year after major surgery, the mean (SD) and median (interquartile range) number of days away from home were 52.0 (92.2) and 15 (0-51). In multivariable analysis, 5 factors were independently associated with the number of days away from home: age 85 years and older, low score on the Short Physical Performance Battery, low peak expiratory flow, low functional self-efficacy, and musculoskeletal surgery. Based on the presence versus absence of these factors, the absolute mean differences in the number of days away from home ranged from 31.2 for age 85 years and older to 53.5 for low functional self-efficacy. CONCLUSIONS: The 5 independent risk factors can be used to identify older persons who are particularly susceptible to spending a disproportionate amount of time away from home after major surgery, and a subset of these factors can also serve as targets for interventions to improve quality of life by reducing time spent in hospitals and other health care facilities.

Geographic Variation in the Utilization of and Mortality After Emergency General Surgery Operations in the Northeastern and Southeastern United States.

OBJECTIVE: To define geographic variations in emergency general surgery (EGS) care, we sought to determine how much variability exists in the rates of EGS operations and subsequent mortality in the Northeastern and Southeastern United States (US). SUMMARY BACKGROUND DATA: While some geographic variations in healthcare are normal, unwarranted variations raise questions about the quality, appropriateness, and cost-effectiveness of care in different areas. METHODS: Patients ≥18 years who underwent 1 of 10 common EGS operations were identified using the State Inpatient Databases (2011-2012) for 6 states, representing Northeastern (New York) and Southeastern (Florida, Georgia, Kentucky, North Carolina, Mississippi) US. Geographic unit of analysis was the hospital service area (HSA). Age-standardized rates of operations and in-hospital mortality were calculated and mapped. Differences in rates across geographic areas were compared using the Kruskal-Wallis test, and variance quantified using linear random-effects models. Variation profiles were tabulated via standardized rates of utilization and mortality to compare geographically heterogenous areas. RESULTS: 227,109 EGS operations were geospatially analyzed across the 6 states. Age-standardized EGS operation rates varied significantly by region (Northeast rate of 22.7 EGS operations per 10,000 in population versus Southeast 21.9; P < 0.001), state (ranging from 9.9 to 29.1; P < 0.001), and HSA (1.9-56.7; P < 0.001). The geographic variability in age-standardized EGS mortality rates was also significant at the region level (Northeast mortality rate 7.2 per 1000 operations vs Southeast 7.4; P < 0.001), state-level (ranging from 5.9 to 9.0 deaths per 1000 EGS operations; P < 0.001), and HSA-level (0.0-77.3; P < 0.001). Maps and variation profiles visually exhibited widespread and substantial differences in EGS use and morality. CONCLUSIONS: Wide geographic variations exist across 6 Northeastern and Southeastern US states in the rates of EGS operations and subsequent mortality. More detailed geographic analyses are needed to determine the basis of these variations and how they can be minimized.

Evaluation of Firearm-Related Reinjury in Connecticut: An Opportunity for Gun Violence Prevention.

BACKGROUND: The regional extent of the risk of repeat firearm-related injury (FRI) and homicide mortality for victims of firearm injury in Connecticut is unknown. In this study, we evaluate the risk of repeat firearm injury in survivors of firearm violence in Connecticut. METHODS: Using medical record data from the Yale New Haven Health (YNHH) system and data from the Connecticut Office of the Chief Medical Examiner, we conducted a cohort study of patients with an FRI in 2014 to determine their risk of a repeat firearm injury or mortality from homicide in the ensuing 5 years compared with nonviolence-related trauma patient controls. RESULTS: We identified 94 patients with an FRI in the YNHH system from 2014 who survived to discharge. Of these patients, 8.5% (8 of 94) had a repeat FRI and 2% (2 of 94) died from homicide within the next 5 years. Compared with nonviolence-related trauma patients from 2014 (n = 2001), those with an FRI had 12 times the odds of a repeat firearm injury (odds ratio: 12.0, P = 0.047) in the next 5 years after adjustment for relevant covariates. CONCLUSIONS: Of the patients presenting with an initial FRI in the YNHH system, one in twelve will experience another firearm injury within the next 5 years. These data indicate that firearm-related reinjury is common in Connecticut and suggest the need for further violence prevention efforts.

Defining Referral Regions for Inpatient Trauma Care: The Utility of a Novel Geographic Definition.

INTRODUCTION: Geographic variation is an inherent feature of the US health system. Despite efforts to account for geographic variation in trauma system strengthening, it remains unclear how trauma "regions" should be defined. The objective of this study is to evaluate the utility of a novel definition of Trauma Referral Regions (TRR) for assessing geographic variation in inpatient trauma across the age span of hospitalized trauma patients. METHODS: Using 2016-2017 State Inpatient Databases, we assessed the extent of geographic variability in three common metrics of hospital use (localization index, market share index, net patient flow) among TRRs and, as a comparison, trauma regions alternatively defined based on Hospital Referral Regions, Hospital Service Areas, and counties. RESULTS: A total of 860,593 admissions from 102 TRRs, 127 Hospital Referral Regions, 884 Hospital Service Areas, and 583 counties were included. Consistent with expectations for distinct trauma regions, TRR presented with high average localization indices (mean [standard deviation]: 83.4 [11.7%]), low market share indices (mean [standard deviation]: 11.9 [7.0%]), and net patient flows close to 1.00. Similar results were found among stratified pediatric, adult, and older adult patients. Associations between TRRs and variations in important demographic features (e.g., travel time by road to the nearest Level I or II Trauma Center) suggest that while indicative of standalone trauma regions, TRRs are also able to simultaneously capture critical variations in regional trauma care. CONCLUSIONS: TRRs offer a standalone set of geographic regions with minimal variation in common metrics of hospital use, minimal geographic clustering, and preserved associations with important demographic factors. They provide a needed, valid means of assessing geographic variation among trauma systems.

Assessing the Race, Ethnicity, and Gender Inequities in Blood Alcohol Testing After Trauma.

INTRODUCTION: Alcohol use remains a significant contributing factor in traumatic injuries in the United States, resulting in substantial patient morbidity and societal cost. Because of this, the American College of Surgeons Verification, Review, and Consultation Program requires the screening of 80% of trauma admissions. Multiple studies suggest that patients who use alcohol are subject to stigma by health care providers and may ultimately face legal and financial ramifications of a positive alcohol screening test. There is also evidence that sociodemographic factors may dictate drug and alcohol screening patterns among patients. Because this screening target is often not uniformly achieved among all patients presenting with injury, we sought to investigate whether there are any discrepancies in screening across sociodemographic groups. METHODS: We investigated the Trauma Quality Program Participant User File for all trauma cases admitted during 2017 and compared the rates of the serum alcohol screening test across different demographic factors, including race and ethnicity. We then performed an adjusted multivariable logistic regression to determine the odds ratio (OR) for receiving a test based on these demographic factors adjusted for hospital and clinical factors. RESULTS: There were 729,174 traumas included in the study. Of this group, 345,315 (47.4%) were screened with a serum alcohol test. Screening rates varied by injury mechanism and were highest among motorcycle crashes (66.0% of patients screened) and lowest among falls (32.8% of patients screened). Overall, Asian and Pacific Islander (52.5% screened), Black (57.7% screened), and other race (58.4% screened) had higher rates of alcohol screening than White patients (43.7% screened, P < 0.001). Similarly, Hispanic patients were screened at higher rates than non-Hispanic patients (56.4% screening versus 46.2% screening, P < 0.001). These differences persisted across nearly all injury categories. In multivariable logistic regression, Asian and Pacific Islanders were associated with the highest odds of being screened (OR 1.34, P < 0.001) followed by other race (OR 1.25, P < 0.001) in comparison to White patients. CONCLUSIONS: There are consistent and significant differences in alcohol screening rates across race and ethnicity, despite accounting for injury mechanism and comorbidities.

Functional Effects of Intervening Illnesses and Injuries After Hospitalization for Major Surgery in Community-living Older Persons.

OBJECTIVE: To evaluate the functional effects of intervening illnesses and injuries, that is, events, in the year after major surgery. BACKGROUND: Intervening events have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after major surgery. METHODS: From a cohort of 754 community-living persons, aged 70+ years, 317 admissions for major surgery were identified from 244 participants who were discharged from the hospital. Functional status (13 activities) and exposure to intervening hospitalizations, emergency department (ED) visits, and restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months. RESULTS: In the year after major surgery, exposure rates (95% CI) per 100-person months to hospitalizations, ED visits, and restricted activity were 10.0 (8.0-12.5), 3.9 (2.8-5.4), and 12.3 (10.2-14.8) for functional recovery and 7.2 (6.1-8.5), 2.5 (1.9-3.2), 11.2 (9.8-12.9) for functional decline. Each of the 3 intervening events were independently associated with reduced recovery, with adjusted hazard ratios (95% CI) of 0.20 (0.09-0.47), 0.35 (0.15-0.81), and 0.57 (0.36-0.90) for hospitalizations, ED visits, and restricted activity. For functional decline, the corresponding odds ratios (95% CI) were 5.68 (3.87-8.33), 1.90 (1.13-3.20), and 1.30 (0.96-1.75). The effect sizes for hospitalizations and ED visits were larger than those for the covariates. CONCLUSIONS: Intervening illnesses/injuries are common in the year after major surgery, and those leading to hospitalization and ED visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors.

Anticoagulation is Associated with Increased Mortality in Splenic Injuries.

INTRODUCTION: Anticoagulation (AC) is associated with worse outcomes after trauma in some but not all studies. To further investigate the effect of AC on outcomes in patients with splenic injury, we analyzed the Trauma Quality Programs Participant Use File (PUF) METHODS: The 2017 PUF was used to identify adult (18+ y) with all mechanisms and grades of splenic injury. Demographics, comorbidities, hospital course and outcomes were compared between AC and non-AC patients. RESULTS: A total of 18,749 patients were included, 622 were on AC. The AC patients were older but had comparable gender composition to non-AC patients. Injury Severity Score (18.2 versus 22.5) and rates of serious (AIS ≥ 3) injury were all lower in the AC group (P = 0.001). AC patients received fewer units of RBC (5.7 versus 8.0 units, P < 0.001) and FFP (3.9 versus 5.4 units, P < 0.001) in the first 24 h but underwent angiography at similar rates (23.6 versus 24.5%, P = 0.8). Among those who underwent angiography, patients were more likely to undergo embolization if they were on AC (89.7 versus 73.9%, P = 0.04). Rates of splenic surgery were comparable (19.3 versus 21.5%, P = 0.2) between AC versus non-AC patients. Median LOS was longer in AC patients (6.3 versus 5.6 d, P = 0.002). AC patients had a higher mortality (13.3 versus 7.0%, P = 0.001). In a multivariable binary logistic regression, AC was an independent risk factor for mortality with OR 1.4 (95% CI: 1.1-1.9) CONCLUSIONS: Anticoagulation is associated with increased mortality in patients with splenic injury.

Choosing the Best Approach to Warfarin Reversal After Traumatic Intracranial Hemorrhage.

BACKGROUND: Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). MATERIALS AND METHODS: This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. RESULTS: Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001). CONCLUSIONS: Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.

Phenobarbital Monotherapy for the Management of Alcohol Withdrawal Syndrome in Surgical-Trauma Patients.

BACKGROUND: Benzodiazepine is first-line therapy for alcohol withdrawal syndrome (AWS), and phenobarbital is an alternative therapy. However, its use has not been well validated in the surgical-trauma patient population. OBJECTIVE: To describe the use of fixed-dose phenobarbital monotherapy for the management of patients at risk for AWS in the surgical-trauma intensive care unit. METHODS: Surgical-trauma critically ill patients who received phenobarbital monotherapy, loading dose followed by a taper regimen, for the management of AWS were included in this evaluation. The effectiveness of phenobarbital monotherapy to treat AWS and prevent development of AWS-related complications were evaluated. Safety end points assessed included significant hypotension, bradycardia, respiratory depression, and need for invasive mechanical ventilation. RESULTS: A total of 31 patients received phenobarbital monotherapy; the majority of patients were at moderate risk for developing AWS (n = 20; 65%) versus high risk (n = 11; 35%). None of the patients developed AWS-related complications; all patients were successfully managed for their AWS. Nine patients (29%) received nonbenzodiazepine adjunct therapy for agitation post-phenobarbital initiation. Three patients (10%) experienced hypotension, and 3 (10%) were intubated. None of the patients had clinically significant bradycardia or respiratory depression. CONCLUSION AND RELEVANCE: Fixed-dose phenobarbital monotherapy appears to be well tolerated and effective in the management of AWS. Further evaluation is needed to determine the extent of benefit with the use of phenobarbital monotherapy for management of AWS.

Factors Associated With Functional Recovery Among Older Survivors of Major Surgery.

OBJECTIVE: The objectives of the current study were 2-fold: first, to evaluate the incidence and time to recovery of premorbid function within 6 months of major surgery and second, to identify factors associated with functional recovery among older persons who survive a major surgery with increased disability. BACKGROUND: Most older persons would not choose a surgical treatment resulting in persistently increased postsurgical disability, even if survival was assured. Potential predictors of functional recovery after major surgery have, however, not been well-studied among geriatric patients. METHODS: It is a prospective longitudinal study of 754 community-living persons 70 years or older. The analytic sample included 266 person-admissions in which participants survived major surgery with increased disability and were monitored on a monthly basis for 6 months. RESULTS: Of the 266 person-admissions assessed, 174 (65.4%) recovered to their presurgical level of function, with median time to recovery of 2 months (interquartile range, 1-3), whereas 16 (6.0%) died. Two factors were significantly associated with an increased likelihood of functional recovery: being nonfrail (hazard ratio 1.60; 95% confidence interval 1.03-2.51; P = 0.038) and having elective surgery (hazard ratio 1.72; 95% confidence interval 1.14-2.59; P = 0.009). Three factors were associated with a reduced likelihood of functional recovery: hearing impairment, greater increase in postsurgical disability in the month after hospital discharge, and years of education. CONCLUSIONS: Among older persons, nonfrailty and elective surgery were positively associated with functional recovery, whereas hearing impairment, greater increases in postsurgical disability, and years of education were associated with higher risk of protracted disability.

Hospital Volume and Operative Mortality for General Surgery Operations Performed Emergently in Adults.

OBJECTIVE: This study aimed to answer 2 questions: first, to what degree does hospital operative volume affect mortality for adult patients undergoing 1 of 10 common emergency general surgery (EGS) operations? Second, at what hospital operative volume threshold will nearly all patients undergoing an emergency operation realize the average mortality risk? BACKGROUND: Nontrauma surgical emergencies are an underappreciated public health crisis in the United States; redefining where such emergencies are managed may improve outcomes. The field of trauma surgery established regionalized systems of care in part because studies demonstrated a clear relationship between hospital volume and survival for traumatic emergencies. Such a relationship has not been well-studied for nontrauma surgical emergencies. METHODS: Retrospective cohort study of all acute care hospitals in California performing nontrauma surgical emergencies. We employed a novel use of an ecological analysis with beta regression to investigate the relationship between hospital operative volume and mortality. RESULTS: A total of 425 acute care hospitals in California performed 165,123 EGS operations. Risk-adjusted mortality significantly decreased as volume increased for all 10 EGS operations (P < 0.001 for each); the relative magnitude of this inverse relationship differed substantially by procedure. Hospital operative volume thresholds were defined and varied by operation: from 75 cases over 2 years for cholecystectomy to 7 cases for umbilical hernia repair. CONCLUSIONS: Survival rates for nontrauma surgical emergencies were improved when operations were performed at higher-volume hospitals. The use of ecological analysis is widely applicable to the field of surgical outcomes research.

Financial Hardship After Traumatic Injury: Risk Factors and Drivers of Out-of-Pocket Health Expenses.

BACKGROUND: Trauma-related disorders rank among the top five most costly medical conditions to the health care system. However, the impact of out-of-pocket (OOP) health expenses for traumatic conditions is not known. In this cross-sectional study, we use nationally representative data to investigate whether patients with a traumatic injury experienced financial hardship from OOP health expenses. METHODS: Using data from the Medical Expenditure Panel Survey from 2010 to 2015, we analyzed the financial burden associated with a traumatic injury. Primary outcomes were excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income). A multivariable logistic regression analysis evaluated whether these outcomes were associated with traumatic injury, adjusting for demographic, socioeconomic, and health care factors. We then completed a descriptive analysis to elucidate drivers of total OOP expenses. RESULTS: Of the 90,964 families in the cohort, 6434 families had a traumatic injury requiring a visit to the emergency room and 668 families had a traumatic injury requiring hospitalization. Overall 1 in 8 households with an injured family member requiring hospitalization experienced financial hardship. These families were more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). The largest burden of OOP expenses was due to prescription drug costs, with inpatient costs as a major driver of OOP expenses for those requiring hospitalization. CONCLUSIONS: Households with an injured family member requiring hospitalization are significantly more vulnerable to financial hardship from OOP health expenses than the noninjured population. Prescription drug and inpatient costs were the most significant drivers of OOP health expenses.

Functional Trajectories Before and After Major Surgery in Older Adults.

OBJECTIVES: We hypothesized that distinct sets of functional trajectories can be identified in the year before and after major surgery, with unique transition probabilities from pre to postsurgical functional trajectories, and that outcomes would be better among participants undergoing elective versus nonelective surgery. BACKGROUND: Major surgery is common and can be highly morbid in older persons. The relationship between the course of disability (ie, functional trajectory) before and after surgery in older adults has not been well-studied for most operations. METHODS: Prospective cohort study of 754 community-living persons 70 years or older. The analytic sample included 250 participants who underwent their first major surgery during the study period. RESULTS: Before surgery, 4 functional trajectories were identified: no disability (n = 60, 24.0%), and mild (n = 84, 33.6%), moderate (n = 73, 29.2%), and severe (n = 33, 13.2%) disability. After surgery, 4 functional trajectories were identified: rapid (n = 39, 15.6%), gradual (n = 76, 30.4%), partial (n = 70, 28.0%), and little (n = 57, 22.8%) improvement. Rapid improvement was seen for n = 31 (51.7%) participants with no disability before surgery, but was uncommon among those with mild disability (n = 8, 9.5%) and was not observed in the moderate and severe trajectory groups. For participants with mild to moderate disability before surgery, gradual improvement (n = 46, 54.8%) and partial improvement (n = 36, 49.3%) were most common. Most participants with severe disability (n = 27, 81.8%) before surgery exhibited little improvement. Outcomes were better for participants undergoing elective versus nonelective surgery. CONCLUSIONS: Functional prognosis in the year after major surgery is highly dependent on premorbid function.

Association Between Cognitive Trajectories and Subsequent Health Status, Depressive Symptoms, and Mortality Among Older Adults in the United States: Findings From a Nationally Representative Study.

BACKGROUND: Cognitive decline may be an early indicator of major health issues in older adults, though research using population-based data is lacking. Researchers objective was to assess the relationships between distinct cognitive trajectories and subsequent health outcomes, including health status, depressive symptoms, and mortality, using a nationally representative cohort. METHODS: Data were drawn from the National Health and Aging Trends Study. Global cognition was assessed annually between 2011 and 2018. The health status of 4 413 people, depressive symptoms in 4 342 individuals, and deaths among 5 955 living respondents were measured in 2019. Distinct cognitive trajectory groups were identified using an innovative Bayesian group-based trajectory model. Ordinal logistic, Poisson, and logistic regression models were used to examine the associations between cognitive trajectories and subsequent health outcomes. RESULTS: Researchers identified five cognitive trajectory groups with distinct baseline values and subsequent changes in cognitive function. Compared with the group with stably high cognitive function, worse cognitive trajectories (ie, lower baseline values and sharper declines) were associated with higher risks of poor health status, depressive symptoms, and mortality, even after adjusting for relevant covariates. CONCLUSIONS: Among older adults, worse cognitive trajectories are strongly associated with subsequent poor health status, high depressive symptoms, and high mortality risks. Regular screening of cognitive function may help to facilitate early identification and interventions for older adults susceptible to adverse health outcomes.

National Estimates of Short- and Longer-Term Hospital Readmissions After Major Surgery Among Community-Living Older Adults.

Importance: Nationally representative estimates of hospital readmissions within 30 and 180 days after major surgery, including both fee-for-service and Medicare Advantage beneficiaries, are lacking. Objectives: To provide population-based estimates of hospital readmission within 30 and 180 days after major surgery in community-living older US residents and examine whether these estimates differ according to key demographic, surgical, and geriatric characteristics. Design, Setting, and Participants: A prospective longitudinal cohort study of National Health and Aging Trends Study data (calendar years 2011-2018), linked to records from the Centers for Medicare & Medicaid Services (CMS). Data analysis was conducted from April to August 2023. Participants included community-living US residents of the contiguous US aged 65 years or older who had at least 1 major surgery from 2011 to 2018. Data analysis was conducted from April 10 to August 28, 2023. Main Outcomes and Measures: Major operations and hospital readmissions within 30 and 180 days were identified through data linkages with CMS files that included both fee-for-service and Medicare Advantage beneficiaries. Data on frailty and dementia were obtained from the annual National Health and Aging Trends Study assessments. Results: A total of 1780 major operations (representing 9 556 171 survey-weighted operations nationally) were identified from 1477 community-living participants; mean (SD) age was 79.5 (7.0) years, with 56% being female. The weighted rates of hospital readmission were 11.6% (95% CI, 9.8%-13.6%) for 30 days and 27.6% (95% CI, 24.7%-30.7%) for 180 days. The highest readmission rates within 180 days were observed among participants aged 90 years or older (36.8%; 95% CI, 28.3%-46.3%), those undergoing vascular surgery (45.8%; 95% CI, 37.7%-54.1%), and persons with frailty (36.9%; 95% CI, 30.8%-43.5%) or probable dementia (39.0%; 95% CI, 30.7%-48.1%). In age- and sex-adjusted models with death as a competing risk, the hazard ratios for hospital readmission within 180 days were 2.29 (95% CI, 1.70-3.09) for frailty and 1.58 (95% CI, 1.15-2.18) for probable dementia. Conclusions and Relevance: In this nationally representative cohort study of community-living older US residents, the likelihood of hospital readmissions within 180 days after major surgery was increased among older persons who were frail or had probable dementia, highlighting the potential value of these geriatric conditions in identifying those at increased risk.

Immunotherapy Initiation at the End of Life in Patients With Metastatic Cancer in the US.

Importance: While immunotherapy is being used in an expanding range of clinical scenarios, the incidence of immunotherapy initiation at the end of life (EOL) is unknown. Objective: To describe patient characteristics, practice patterns, and risk factors concerning EOL-initiated (EOL-I) immunotherapy over time. Design, Setting, and Participants: Retrospective cohort study using a US national clinical database of patients with metastatic melanoma, non-small cell lung cancer (NSCLC), or kidney cell carcinoma (KCC) diagnosed after US Food and Drug Administration approval of immune checkpoint inhibitors for the treatment of each disease through December 2019. Mean follow-up was 13.7 months. Data analysis was performed from December 2022 to May 2023. Exposures: Age, sex, race and ethnicity, insurance, location, facility type, hospital volume, Charlson-Deyo Comorbidity Index, and location of metastases. Main Outcomes and Measures: Main outcomes were EOL-I immunotherapy, defined as immunotherapy initiated within 1 month of death, and characteristics of the cohort receiving EOL-I immunotherapy and factors associated with its use. Results: Overall, data for 242 371 patients were analyzed. The study included 20 415 patients with stage IV melanoma, 197 331 patients with stage IV NSCLC, and 24 625 patients with stage IV KCC. Mean (SD) age was 67.9 (11.4) years, 42.5% were older than 70 years, 56.0% were male, and 29.3% received immunotherapy. The percentage of patients who received EOL-I immunotherapy increased over time for all cancers. More than 1 in 14 immunotherapy treatments in 2019 were initiated within 1 month of death. Risk-adjusted patients with 3 or more organs involved in metastatic disease were 3.8-fold more likely (95% CI, 3.1-4.7; P < .001) to die within 1 month of immunotherapy initiation than those with lymph node involvement only. Treatment at an academic or high-volume center rather than a nonacademic or very low-volume center was associated with a 31% (odds ratio, 0.69; 95% CI, 0.65-0.74; P < .001) and 30% (odds ratio, 0.70; 95% CI, 0.65-0.76; P < .001) decrease in odds of death within a month of initiating immunotherapy, respectively. Conclusions and Relevance: Findings of this cohort study show that the initiation of immunotherapy at the EOL is increasing over time. Patients with higher metastatic burden and who were treated at nonacademic or low-volume facilities had higher odds of receiving EOL-I immunotherapy. Tracking EOL-I immunotherapy can offer insights into national prescribing patterns and serve as a harbinger for shifts in the clinical approach to patients with advanced cancer.

The effect of the COVID-19 pandemic on community violence in Connecticut.

INTRODUCTION: Natural disasters may lead to increases in community violence due to broad social disruption, economic hardship, and large-scale morbidity and mortality. The effect of the COVID-19 pandemic on community violence is unknown. METHODS: Using trauma registry data on all violence-related patient presentations in Connecticut from 2018 to 2021, we compared the pattern of violence-related trauma from pre-COVID and COVID pandemic using an interrupted time series linear regression model. RESULTS: There was a 55% increase in violence-related trauma in the COVID period compared with the pre-COVID period (IRR: 1.55; 95%CI: 1.34-1.80; p-value<0.001) driven largely by penetrating injuries. This increase disproportionately impacted Black/Latinx communities (IRR: 1.61; 95%CI: 1.36-1.90; p-value<0.001). CONCLUSION: Violence-related trauma increased during the COVID-19 pandemic. Increased community violence is a significant and underappreciated negative health and social consequence of the COVID-19 pandemic, and one that excessively burdens communities already at increased risk from systemic health and social inequities.

Distressing symptoms after major surgery among community-living older persons.

BACKGROUND: Relatively little is known about how distressing symptoms change among older persons in the setting of major surgery. Our objective was to evaluate changes in distressing symptoms after major surgery and determine whether these changes differ according to the timing of surgery (nonelective vs. elective), sex, multimorbidity, and socioeconomic disadvantage. METHODS: From a prospective longitudinal study of 754 nondisabled community-living persons, 70 years of age or older, 368 admissions for major surgery were identified from 274 participants who were discharged from the hospital from March 1998 to December 2017. The occurrence of 15 distressing symptoms was ascertained in the month before and 6 months after major surgery. Multimorbidity was defined as more than two chronic conditions. Socioeconomic disadvantage was assessed at the individual level, based on Medicaid eligibility, and neighborhood level, based on an area deprivation index (ADI) score above the 80th state percentile. RESULTS: In the month before major surgery, the occurrence and mean number of distressing symptoms were 19.6% and 0.75, respectively. In multivariable analyses, the rate ratios, denoting proportional increases in the 6 months after major surgery relative to presurgery values, were 2.56 (95% confidence interval [CI], 1.91-3.44) and 2.90 (95% CI, 2.01-4.18) for the occurrence and number of distressing symptoms, respectively. The corresponding values were 3.54 (95% CI, 2.06-6.08) and 4.51 for nonelective surgery (95% CI, 2.32-8.76) and 2.12 (95% CI, 1.53-2.92) and 2.20 (95% CI, 1.48-3.29) for elective surgery; p-values for interaction were 0.030 and 0.009. None of the other subgroup differences were statistically significant, although men had a greater proportional increase in the occurrence and number of distressing symptoms than women. CONCLUSIONS: Among community-living older persons, the burden of distressing symptoms increases substantially after major surgery, especially in those having nonelective procedures. Reducing symptom burden has the potential to improve quality of life and enhance functional outcomes after major surgery.