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OBJECTIVES: Despite the well-established association between prediabetes and hyperuricaemia, knowledge about serum urate (SU) trends during the prediabetic phase is limited. Therefore, we aimed to assess the longitudinal changes of SU in individuals with prediabetes. METHODS: Individuals with prediabetes, defined by initial haemoglobin A1c (HbA1c) levels between 5.7% and 6.4%, were identified using electronic health records from an academic health system (2007-2022). We required at least one SU test before and after the prediabetes diagnosis. The primary outcome was the longitudinal SU trends during the follow-up period, estimated with a multivariable mixed-effects model. Patients were censored at diabetes onset. Marginal effects of covariates on SU changes were estimated. Subsequent analyses examined SU variations in subgroups stratified by age, sex, body mass index (BMI), HbA1c, estimated glomerular filtration rate (eGFR) and metformin use. RESULTS: Out of 25 526 individuals with prediabetes, 1,521 met the SU cohort requirements, contributing to 6,832 SU observations. At baseline, median age was 63 years and 40% were female. Median values were SU 6.3 mg/dl, HbA1c 5.9% and BMI 30 kg/m2. Median follow-up was 7.4 years. Older age, male sex, greater BMI, and higher HbA1c were significant predictors of increased longitudinal SU levels. Individuals with a BMI ≥30 kg/m2 exhibited higher SU levels compared with those with lower BMI values. CONCLUSION: Among individuals with prediabetes, several baseline variables were significant predictors of increased SU levels over time. These longitudinal trends in SU, support the potential for early intervention during the prediabetic phase, possibly reducing the risk of gout.
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OBJECTIVE: To compare longitudinal changes in spirometric measures between patients with rheumatoid arthritis (RA) and non-RA comparators. METHODS: We analysed longitudinal data from two prospective cohorts: the UK Biobank and COPDGene. Spirometry was conducted at baseline and a second visit after 5-7 years. RA was identified based on self-report and disease-modifying antirheumatic drug use; non-RA comparators reported neither. The primary outcomes were annual changes in the per cent-predicted forced expiratory volume in 1 s (FEV1%) and per cent predicted forced vital capacity (FVC%). Statistical comparisons were performed using multivariable linear regression. The analysis was stratified based on baseline smoking status and the presence of obstructive pattern (FEV1/FVC <0.7). RESULTS: Among participants who underwent baseline and follow-up spirometry, we identified 233 patients with RA and 37 735 non-RA comparators. Among never-smoking participants without an obstructive pattern, RA was significantly associated with more FEV1% decline (ß=-0.49, p=0.04). However, in ever smokers with ≥10 pack-years, those with RA exhibited significantly less FEV1% decline than non-RA comparators (ß=0.50, p=0.02). This difference was more pronounced among those with an obstructive pattern at baseline (ß=1.12, p=0.01). Results were similar for FEV1/FVC decline. No difference was observed in the annual FVC% change in RA versus non-RA. CONCLUSIONS: Smokers with RA, especially those with baseline obstructive spirometric patterns, experienced lower FEV1% and FEV1/FVC decline than non-RA comparators. Conversely, never smokers with RA had more FEV1% decline than non-RA comparators. Future studies should investigate potential treatments and the pathogenesis of obstructive lung diseases in smokers with RA.
Subject(s)
Arthritis, Rheumatoid , Smoking , Spirometry , Humans , Arthritis, Rheumatoid/diagnosis , Arthritis, Rheumatoid/physiopathology , Male , Female , Middle Aged , Longitudinal Studies , Prospective Studies , Smoking/adverse effects , Smoking/epidemiology , Aged , Forced Expiratory Volume , Vital Capacity , Pulmonary Disease, Chronic Obstructive/physiopathology , Pulmonary Disease, Chronic Obstructive/epidemiology , Pulmonary Disease, Chronic Obstructive/diagnosis , Pulmonary Disease, Chronic Obstructive/etiology , Adult , United Kingdom/epidemiologyABSTRACT
OBJECTIVES: An estimated 5-20% of patients with rheumatoid arthritis (RA) fail multiple treatments and are considered "difficult-to-treat" (D2T), posing a substantial clinical challenge for rheumatologists. A European Alliance of Associations for Rheumatology (EULAR) task force proposed a definition of D2T-RA in 2021. We applied EULAR's D2T definition in a cohort of patients with established RA to assess prevalence and we compared clinical characteristics of participants with D2T-RA with matched comparisons. METHODS: Data from the longitudinal Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS) registry was used. Participants were classified as D2T if they met EULAR's definition. A comparison group of non-D2T RA patients were matched 2:1 to every D2T patient, and differences in characteristics were evaluated in descriptive analyses. Prevalence rates of D2T were estimated using Poisson regression. RESULTS: We estimated the prevalence of D2T-RA to be 14.4 (95% CI: 12.8-16.3 per 100 persons) among 1,581 participants with RA, and 22.3 (95% CI: 19.9-25.0 per 100 persons) among 1,021 who were biologic/targeted synthetic DMARD experienced. We observed several differences in demographics, comorbidities, and RA disease activity between D2T-RA and non-D2T RA comparisons. Varying EULAR sub-criteria among all participants in BRASS resulted in a range of D2T-RA prevalence rates, from 0.6-17.5 per 100 persons. CONCLUSION: EULAR's proposed definition of D2T-RA identifies patients with RA who have not achieved treatment targets. Future research should explore heterogeneity in these patients and evaluate outcomes to inform the design of future studies aimed at developing more effective RA management protocols.
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OBJECTIVE: Despite the strong association between gout and pre-diabetes, the role of metformin in gout among individuals with pre-diabetes remains uncertain. We compared the incidence rates of gout in adults with pre-diabetes starting metformin with those not using antidiabetic treatments. METHODS: We conducted a new-user, propensity score-matched cohort study using electronic health records from an academic health system (2007-2022). Pre-diabetes was defined based on haemoglobin A1c levels. Metformin users were identified and followed from the first metformin prescription date. Non-users of antidiabetic medications were matched to metformin users based on propensity score and the start of follow-up. The primary outcome was incident gout. Cox proportional hazards models estimated the HR for metformin. Linear regression analyses assessed the association between metformin use and changes in serum urate (SU) or C-reactive protein (CRP). RESULTS: We identified 25 064 individuals with pre-diabetes and propensity score-matched 1154 metformin initiators to 13 877 non-users. Baseline characteristics were well balanced (all standardised mean differences <0.1). The median follow-up was 3.9 years. The incidence rate of gout per 1000 person-years was lower in metformin users 7.1 (95% CI 5.1 to 10) compared with non-users 9.5 (95% CI 8.8 to 10.2). Metformin initiation was associated with a reduced relative risk of gout (HR 0.68, 95% CI 0.48 to 0.96). No relationship was found between metformin and changes in SU or CRP. CONCLUSIONS: Metformin use was associated with a reduced risk of gout among adults with pre-diabetes, suggesting that metformin may be important in lowering gout risk in individuals with pre-diabetes.
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BACKGROUND: Chronic cough (CC) is difficult to identify in electronic health records (EHRs) due to the lack of specific diagnostic codes. We developed a natural language processing (NLP) model to identify cough in free-text provider notes in EHRs from multiple health care providers with the objective of using the model in a rules-based CC algorithm to identify individuals with CC from EHRs and to describe the demographic and clinical characteristics of individuals with CC. METHODS: This was a retrospective observational study of enrollees in Optum's Integrated Clinical + Claims Database. Participants were 18-85 years of age with medical and pharmacy health insurance coverage between January 2016 and March 2017. A labeled reference standard data set was constructed by manually annotating 1000 randomly selected provider notes from the EHRs of enrollees with ≥ 1 cough mention. An NLP model was developed to extract positive or negated cough contexts. NLP, cough diagnosis and medications identified cough encounters. Patients with ≥ 3 encounters spanning at least 56 days within 120 days were defined as having CC. RESULTS: The positive predictive value and sensitivity of the NLP algorithm were 0.96 and 0.68, respectively, for positive cough contexts, and 0.96 and 0.84, respectively, for negated cough contexts. Among the 4818 individuals identified as having CC, 37% were identified using NLP-identified cough mentions in provider notes alone, 16% by diagnosis codes and/or written medication orders, and 47% through a combination of provider notes and diagnosis codes/medications. Chronic cough patients were, on average, 61.0 years and 67.0% were female. The most prevalent comorbidities were respiratory infections (75%) and other lower respiratory disease (82%). CONCLUSIONS: Our EHR-based algorithm integrating NLP methodology with structured fields was able to identify a CC population. Machine learning based approaches can therefore aid in patient selection for future CC research studies.
Subject(s)
Electronic Health Records , Natural Language Processing , Algorithms , Cough/diagnosis , Databases, Factual , Female , Humans , MaleABSTRACT
Little is known about the impact of real-time continuous glucose monitoring (rtCGM) on diabetes-related medical costs within the type 2 diabetes (T2D) population. A retrospective analysis of administrative claims data from the Optum Research Database was conducted. Changes in diabetes-related health care resource utilization costs were expressed as per-patient-per-month (PPPM) costs. A total of 571 T2D patients (90% insulin treated) met study inclusion criteria. Average PPPM for diabetes-related medical costs decreased by -$424 (95% confidence interval [CI] -$816 to -$31, P = 0.035) after initiating rtCGM. These reductions were driven, in part, by reductions in diabetes-related inpatient medical costs: -$358 (95% CI -$706 to -$10, P = 0.044). Inpatient hospital admissions were reduced on average -0.006 PPPM (P = 0.057) and total hospital days were reduced an average of -0.042 PPPM (P = 0.139). These findings provide real-world evidence that rtCGM use was associated with diabetes-related health care resource utilization cost reductions in patients with T2D.
Subject(s)
Diabetes Mellitus, Type 2 , Blood Glucose , Blood Glucose Self-Monitoring , Diabetes Mellitus, Type 2/complications , Diabetes Mellitus, Type 2/drug therapy , Health Care Costs , Humans , Retrospective StudiesABSTRACT
BACKGROUND: Racial and ethnic minority groups have been disproportionately affected by the US coronavirus disease 2019 (COVID-19) pandemic; however, nationwide data on COVID-19 outcomes stratified by race/ethnicity and adjusted for clinical characteristics are sparse. This study analyzed the impacts of race/ethnicity on outcomes among US patients with COVID-19. METHODS: This was a retrospective observational study of patients with a confirmed COVID-19 diagnosis in the electronic health record from 01 February 2020 through 14 September 2020. Index encounter site, hospitalization, and mortality were assessed by race/ethnicity (Hispanic, non-Hispanic Black [Black], non-Hispanic White [White], non-Hispanic Asian [Asian], or Other/unknown). Associations between racial/ethnic categories and study outcomes adjusted for patient characteristics were evaluated using logistic regression. FINDINGS: Among 202,908 patients with confirmed COVID-19, patients from racial/ethnic minority groups were more likely than White patients to be hospitalized on initial presentation (Hispanic: adjusted odds ratio 1·690, 95% CI 1·620-1·763; Black: 1·810, 1·743-1·880; Asian: 1·503, 1·381-1·636) and during follow-up (Hispanic: 1·700, 1·638-1·764; Black: 1·578, 1·526-1·633; Asian: 1·391, 1·288-1·501). Among hospitalized patients, adjusted mortality risk was lower for Black patients (0·881, 0·809-0·959) but higher for Asian patients (1·205, 1·000-1·452). INTERPRETATION: Racial/ethnic minority patients with COVID-19 had more severe disease on initial presentation than White patients. Increased mortality risk was attenuated by hospitalization among Black patients but not Asian patients, indicating that outcome disparities may be mediated by distinct factors for different groups. In addition to enacting policies to facilitate equitable access to COVID-19-related care, further analyses of disaggregated population-level COVID-19 data are needed.
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STUDY OBJECTIVES: Determine the association of insomnia symptoms with subsequent health services use, in a representative sample of U.S. older adults. METHODS: Participants were 4,289 community-dwelling Medicare beneficiaries who had continuous fee-for-service Medicare coverage 30 days before, and 1 year after the National Health and Aging Trends Study (NHATS) Round 1 interview. Participants reported past-month insomnia symptoms (i.e. sleep onset latency >30 min, difficulty returning to sleep) which we categorized as 0, 1, or 2 symptoms. Outcomes were health services use within 1 year of interviews from linked Medicare claims: emergency department (ED) visits, hospitalizations, 30-day readmissions, home health care (all measured as yes/no), and number of hospitalizations and ED visits. RESULTS: Overall, 18.5% of participants were hospitalized, 28.7% visited the ED, 2.5% had a 30-day readmission, and 11.3% used home health care. After adjustment for demographics, depressive and anxiety symptoms, medical comorbidities, and BMI, compared to participants with no insomnia symptoms, those with two insomnia symptoms had a higher odds of ED visits (odds ratio [OR) = 1.60, 95% confidence interval [CI] = 1.24-2.07, p < 0.001), hospitalizations (OR = 1.29, 95% CI = 1.01-1.65, p < 0.05), and 30-day readmissions (OR = 1.88, 95% CI = 1.88-3.29, p < 0.05). Reporting 2 insomnia symptoms, versus no insomnia symptoms, was associated with a greater number of ED visits and hospitalizations (incidence rate ratio (IRR) = 1.52, 95% CI = 1.23-1.87, p < 0.001; IRR = 1.21, 95% CI = 1.02-1.44, p < 0.05, respectively) after adjusting for demographic and health characteristics. CONCLUSIONS: Among older adults, insomnia symptoms are associated with greater health services use, including emergency department use, hospitalization, and 30-day readmission. Targeting insomnia may lower health services use.
Subject(s)
Sleep Initiation and Maintenance Disorders , Aged , Emergency Service, Hospital , Hospitalization , Humans , Independent Living , Medicare , Sleep Initiation and Maintenance Disorders/epidemiology , Sleep Initiation and Maintenance Disorders/therapy , United States/epidemiologyABSTRACT
Study Objectives: Determine the associations of sleep disturbances with hospitalization risk among older women. Methods: One thousand eight hundred and twenty-seven women (mean age 83.6 years) participating in Study of Osteoporotic Fractures Year 16 (Y16) examination (2002-2004) linked with Medicare and/or HMO claims. At Y16 examination, sleep/wake parameters were measured by actigraphy (total sleep time [TST], sleep efficiency [SE], sleep latency [SL], and wake after sleep onset [WASO]) and subjective sleep measures (sleep quality [Pittsburgh Sleep Quality Index] and daytime sleepiness [Epworth Sleepiness Scale]) were assessed by questionnaire. Measures except TST were dichotomized based on clinical thresholds. Incident hospitalizations were determined from claims data. Results: Nine hundred and seventy-six women (53%) had ≥1 hospitalization in the 3 years after the Year 16 examination. Reduced SE (odds ratio [OR] = 2.39, 95% confidence interval [CI] 1.69-3.39), prolonged SL (OR = 1.41, 95% CI 1.11-1.78), greater WASO (OR = 1.57, 95% CI 1.28-1.93), shorter TST (OR = 1.98, 95% CI 1.42-2.77) and poorer sleep quality (OR = 1.33, 95% CI 1.07-1.65) were each associated with a higher age and site-adjusted odds of hospitalization; associations were attenuated after multivariable adjustment for traditional prognostic factors with the OR for reduced SE (OR = 1.60, 95% CI 1.08-2.38) and shorter TST (OR = 1.63, 95% CI 1.12-2.37) remaining significant. Among women who were hospitalized, greater WASO (rate ratio [RR] = 1.20, 95% CI 1.04-1.37) and poorer sleep quality (RR = 1.18, 95% CI 1.02-1.35) were each associated with a greater age and site-adjusted RR of inpatient days, but associations did not persist after multivariate adjustment. Conclusions: Older women with sleep disturbances have an increased risk of hospitalization partially attributable to demographics, poorer health status, and comorbidities.
Subject(s)
Hospitalization/statistics & numerical data , Inpatients/statistics & numerical data , Sleep Wake Disorders/epidemiology , Actigraphy , Aged, 80 and over , Comorbidity , Female , Humans , Odds Ratio , Risk , Sleep , Sleep Initiation and Maintenance Disorders/epidemiology , Surveys and QuestionnairesABSTRACT
BACKGROUND: This study examines the association between cystatin C (cysC) levels and risks of progression of frailty status or death in older men. METHODS: Prospective study of 2,613 men without overt frailty aged 67 years and older enrolled in the MrOS ancillary sleep study. Baseline measurements included serum cysC, serum creatinine, and frailty status. Repeat frailty status, performed an average of 3.4 years later, was assessed as an ordinal outcome of robust, intermediate stage (prefrail), frail or dead. RESULTS: Mean age was 75.7 years. Men with higher cysC were older and had a higher comorbidity burden. After adjusting for age, clinical site, and race, higher cysC was associated with nearly twofold greater odds of being classified as intermediate stage versus robust (OR quartile 4 vs 1; 1.82, 95% confidence interval [CI] 1.35-2.45), a threefold greater odds of frailty versus robust (OR quartile 4 vs 1; 3.13, 95% CI 2.03-4.82), and a more than fivefold greater odds of death versus robust (OR quartile 4 vs 1; 5.48, 95% CI 2.98-10.08). Results were similar for cysC-based estimated glomerular filtration rate (eGFR). This relationship was attenuated but persisted after adjusting for additional potential confounders including baseline frailty status, body mass index, smoking status, comorbidity burden, self-reported disability, and serum albumin. In contrast, neither serum creatinine nor creatinine-based eGFR was associated in a graded manner with higher risks of development of frailty or death. CONCLUSIONS: In this cohort of older men without overt frailty, higher cysC and cysC-based eGFR, but not creatinine or creatinine-based estimates of GFR, were associated with increased risks of frailty or death. These findings suggest that higher cysC level may be a promising biomarker for unsuccessful aging as manifested by increased risks of frailty and death.
Subject(s)
Aging/physiology , Cystatin C/blood , Frail Elderly/statistics & numerical data , Multiple Chronic Conditions/epidemiology , Aged , Biomarkers/blood , Body Mass Index , Geriatric Assessment/methods , Health Status Disparities , Humans , Male , Mortality , Risk Factors , Smoking/epidemiology , United States/epidemiologyABSTRACT
BACKGROUND: Although there are several consensus definitions of sarcopenia, their association with health care utilization has not been studied. METHODS: We included women from the prospective Study of Osteoporotic Fractures with complete assessment of sarcopenia by several definitions at the Study of Osteoporotic Fractures Year 10 (Y10) exam (1997-1998) who also had available data from Medicare Fee- For-Service Claims (N = 566) or Kaiser Encounter data (N = 194). Sarcopenia definitions evaluated were: International Working Group, European Working Group for Sarcopenia in Older Persons, Foundation for the NIH Sarcopenia Project, Baumgartner, and Newman. Hurdle models and logistic regression were used to assess the relation between sarcopenia status (the summary definition and the components of slowness, weakness and/or lean mass) and outcomes that included hospitalizations, cumulative inpatient days/year, short-term (part A paid) skilled nursing facility stay in the 3 years following the Y10 visit. RESULTS: None of the consensus definitions, nor the definition components of weakness or low lean mass, was associated with increased risk of hospitalization or greater likelihood of short-term skilled nursing facility stay. Women with slowness by any criterion definition were about 50% more likely to be hospitalized; had a greater rate of hospitalization days amongst those hospitalized; and had 1.8 to 2.1 times greater likelihood of a short-term skilled nursing facility stay than women without slowness. There was the suggestion of a protective association of low lean mass by the various criterion definitions on short-term skilled nursing facility stay. CONCLUSION: Estimated effects of sarcopenia on health care utilization were negligible. However, slowness was associated with greater health care utilization.
Subject(s)
Hospitalization , Sarcopenia/therapy , Skilled Nursing Facilities , Age Factors , Aged , Aged, 80 and over , Body Mass Index , Cohort Studies , Female , Humans , Muscle Weakness , Risk Factors , Sarcopenia/complicationsABSTRACT
Background: This study examines effects of mobility and cognition on hospitalization and inpatient days among women late in life. Methods: Prospective study of 663 women (mean age 87.7 years) participating in the Study of Osteoporotic Fractures Year 20 examination (2006-2008) linked with their inpatient claims data. At Year 20, mobility ascertained by Short Physical Performance Battery categorized as poor, intermediate, or good. Cognitive status adjudicated based on neuropsychological tests and classified as normal, mild cognitive impairment, or dementia. Hospitalizations (n = 182) during 12 months following Year 20. Results: Reduced mobility and poorer cognition were each associated in a graded manner with higher inpatient health care utilization, even after accounting for each other and traditional prognostic indicators. For example, adjusted mean inpatient days per year were 0.94 (95% confidence interval [CI] 0.52-1.45) among women with good mobility increasing to 2.80 (95% CI 1.64-3.89) among women with poor mobility and 1.59 (95% CI 1.08-2.03) among women with normal cognition increasing to 2.53 (95% CI 1.55-3.40) among women with dementia. Women with poor mobility/dementia had a nearly sixfold increase in mean inpatient days per year (4.83, 95% CI 2.73-8.54) compared with women with good mobility/normal cognition (0.84, 95% CI 0.49-1.44). Conclusions: Among women late in life, mobility limitations and cognitive deficits were each independent predictors of higher inpatient health care utilization even after considering each other and conventional predictors. Additive effects of reduced mobility and poorer cognition may be important to consider in medical decision making and health care policy planning for the growing population of adults aged ≥85 years.
Subject(s)
Cognitive Dysfunction/epidemiology , Dementia/epidemiology , Hospitalization/statistics & numerical data , Length of Stay/statistics & numerical data , Mobility Limitation , Aged , Aged, 80 and over , Cognition , Disability Evaluation , Female , Humans , Neuropsychological Tests , Prospective Studies , United States/epidemiologyABSTRACT
BACKGROUND: Vertebral fractures (VFx) are the most common osteoporotic fracture and are associated with higher risk of impaired function, additional fractures and death. The purpose of this analysis was to test the hypotheses that VFx are also associated with greater inpatient healthcare utilization. METHODS: We studied 4709 Caucasian women enrolled in the Study of Osteoporotic Fractures (SOF) and merged SOF cohort data with Medicare claims or Kaiser encounter data. To be included in this analysis, women had to be enrolled in Medicare Fee for Service or Kaiser as of 1/1/1991 and have radiographic information on VFx status at SOF Visit 3 (1991-92). VFx status was assessed using quantitative morphometry on lateral thoracic and lumbar spine radiographs. Prevalent VFx were defined as any height ratio>3 standard deviations below normal. Women were considered to have a clinical VFx if they reported a new diagnosis of VFx and a clinical radiographic report that confirmed that a VFx was present. Any hospitalization and the number of annualized days of hospitalization were identified through inpatient claims or encounter data. Specific hospitalizations for 5 major common reasons for hospitalizations were also examined. RESULTS: Over 5-years, 2632 (55.9%) women were hospitalized. In multivariate adjusted models, women with a prevalent radiographic VFx were 21% (95% CI, 2-44%) more likely to be hospitalized for any reason. This association was independent of a number of risk factors including smoking. The annualized rate of inpatient day was, however, similar, 1.67 and 1.48 among women with and without a VFx, respectively, p=0.49. Women with an incident clinical VFx were more likely to be hospitalized including women without evidence of a prevalent radiographic VFx (odds ratio (OR)=5.33; 95% confidence interval (CI)=1.81-15.71) and women with a prevalent radiographic VFx (OR=2.13; 95% CI, 1.05-4.33). Women with a VFx were more likely to be hospitalized specifically for hip fracture or chronic obstructive pulmonary disease (COPD) but not stroke, myocardial infarction or congestive heart failure. The association with COPD was attenuated to non-significance after adjusting for smoking. CONCLUSION: Our results extend the potential public health impact of radiographic and clinical VFx to include an increased risk of any hospitalization.
Subject(s)
Delivery of Health Care/statistics & numerical data , Inpatients , Spinal Fractures/diagnostic imaging , Aged , Female , Hospitalization , Humans , Proportional Hazards ModelsABSTRACT
RATIONALE: Seasonal nadirs in 25-hydroxyvitamin D (25[OH]D) concentrations overlap with increased incidence and severity of obstructive sleep apnea (OSA) in winter. We hypothesized that, because lower 25(OH)D concentrations might lead to upper airway muscle dysfunction, low 25(OH)D would be associated with higher apnea-hypopnea index (AHI), a measure of OSA severity. OBJECTIVES: To determine if lower 25(OH)D concentration is associated with greater prevalence and increased severity of OSA, independent of established OSA risk factors. METHODS: Using unconditional logistic regression, we performed a cross-sectional analysis in the Outcomes of Sleep Disorders in Older Men study, which included in-home overnight polysomnography, serum 25(OH)D measurement, and collection of demographic and comorbidity data. The primary outcome was severe sleep apnea, as defined by AHI of 30/h or more. MEASUREMENTS AND MAIN RESULTS: Among 2,827 community-dwelling, largely white (92.2%), elderly (aged 76.4 ± 5.5 yr [mean±SD]) males, mean 25(OH)D concentration was 28.8 (±8.8) ng/ml. Subjects within the lowest quartile of 25(OH)D (6-23 ng/ml) had greater odds of severe sleep apnea in unadjusted analyses (odds ratio = 1.45; 95% confidence interval = 1.02-2.07) when compared with the highest 25(OH)D quartile (35-84 ng/ml). However, further adjustment for established OSA risk factors strongly attenuated this association (multivariable adjusted odds ratio = 1.05; 95% confidence interval = 0.72-1.52), with body mass index and neck circumference as the main confounders. There was also no evidence of an independent association between lower 25(OH)D levels and increased odds of mild (AHI = 5.0-14.9/h) or moderate (AHI = 15.0-29.9/h) sleep apnea. CONCLUSIONS: Among community-dwelling older men, the association between lower 25(OH)D and sleep apnea was largely explained by confounding by larger body mass index and neck circumference.
Subject(s)
Seasons , Sleep Apnea, Obstructive/epidemiology , Vitamin D/analogs & derivatives , Aged , Aged, 80 and over , Body Mass Index , Cohort Studies , Cross-Sectional Studies , Humans , Logistic Models , Male , Multivariate Analysis , Odds Ratio , Polysomnography , Risk Factors , Sleep Apnea, Obstructive/blood , United States/epidemiology , Vitamin D/bloodABSTRACT
OBJECTIVE: To compare standardized estimates of the true resource costs of outpatient health care to the allowable and billed charges for that care among Medicare Fee for Service (FFS) beneficiaries. DATA SOURCES/STUDY SETTING: Medicare Carrier and Outpatient Standard Analytic (SAF) files linked to participant data in the Study of Osteoporotic Fractures from 2004 through 2010. Participants were 3,435 female Medicare Fee for Service enrollees age 80 and older recruited in one rural and three metropolitan areas of the United States. STUDY DESIGN: We estimated standardized costs for Carrier and OP-SAF claims using Medicare payment weights, and compared them to allowable and billed charges for those claims. We used semilog linear regression to estimate the associations of age, race, bone mineral density, prior fracture, and geriatric depression scale score with allowable charges, billed charges, and standardized costs. RESULTS: Estimated associations of patient characteristics with standardized costs were not statistically different than the associations with allowable charges (chi-squared [χ(2)]: 8.6, p = .13) but were different from associations with billed charges (χ(2): 25.5, p < .001). CONCLUSION: Allowable charges for outpatient utilization in the Carrier file and OP-SAF may be good surrogates for standardized costs that reflect patient medical and surgical acuity.
Subject(s)
Ambulatory Care/economics , Health Expenditures/statistics & numerical data , Insurance, Health, Reimbursement/economics , Medicare/economics , Age Factors , Aged , Bone Density , Depression/economics , Depression/epidemiology , Fee-for-Service Plans/economics , Female , Humans , Osteoporotic Fractures/economics , Osteoporotic Fractures/epidemiology , Racial Groups , United StatesABSTRACT
BACKGROUND: This study examines the effects of mobility and cognition on mortality risk in women late in life. METHODS: A prospective study was conducted among 1,495 women (mean age 87.6 years) participating in the Study of Osteoporotic Fractures Year 20 examination (2006-2008). Mobility (ascertained by Short Physical Performance Battery [SPPB]) was categorized as poor (SPPB 0-3, n = 312), intermediate (SPPB 4-9, n = 799), or good (SPPB 10-12, n = 384). Cognitive status (adjudicated based on neuropsychological tests) was classified as normal (n = 873), mild cognitive impairment (n = 354), or dementia (n = 268). Deaths (n = 749) were identified from Year 20 through July 31, 2014 (average follow-up 4.9 years). RESULTS: There was not strong evidence of an interaction between mobility and cognition for prediction of mortality risk (p interaction term .16). Compared to women with good mobility, mortality risks were increased among women with intermediate mobility (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.02-1.57) and those with poor mobility (HR 1.64, 95% CI 1.24-2.16) after consideration of cognition and other mortality risk factors. Similarly, mortality risks were higher among women with mild cognitive impairment (HR 1.46, 95% CI 1.21-1.76) and those with dementia (HR 1.88, 95% CI 1.54-2.31) compared to women with normal cognition after consideration of mobility and other mortality risk factors. CONCLUSIONS: Among women late in life, 5-year mortality risk was substantially increased among women with deficits in mobility even after accounting for cognition and traditional prognostic indicators. Similarly, deficits in cognition were associated with increased 5-year mortality despite consideration of mobility and conventional risk factors.
Subject(s)
Cognition Disorders/diagnosis , Mobility Limitation , Mortality/trends , Aged, 80 and over , Female , Humans , Kaplan-Meier Estimate , Neuropsychological Tests , Phenotype , Prospective Studies , Risk Factors , United States/epidemiologyABSTRACT
OBJECTIVE: Women, especially those with hot flashes, report poor sleep quality during various stages of the menopausal transition and postmenopause. Sleep measurements vary widely because of the copious instruments available. The Pittsburgh Sleep Quality Index (PSQI) is a frequently used questionnaire that produces a single score for sleep quality. This one-factor structure has not received consistent support in the literature. The goal of this analysis was to determine the best factor structure of the PSQI in women with hot flashes. METHODS: A confirmatory factor analysis was conducted on PSQI baseline data from three randomized controlled clinical trials enrolling perimenopausal and postmenopausal women with hot flashes (Nâ=â849) from the Menopause Strategies: Finding Lasting Answers for Symptoms and Health network. Several a priori factor models were compared. RESULTS: One-factor and two-factor models did not fit the data. A three-factor model comprising sleep efficiency, perceived sleep quality, and daily disturbance showed good fit; however, the sleep medication item was dropped because of poor fit and low rates of sleep medication use. The three-factor model was examined in African-American and white subsamples and was found to be similar in both groups; however, two items showed small group differences in strength as indicators. CONCLUSIONS: Sleep quality in midlife women with hot flashes, as measured by the PSQI, seems to comprise three correlated factors. Minor measurement differences detected between groups are of research interest but do not necessitate different scoring practices. Additional research is needed to further define sleep quality and its associations with health-related outcomes.
Subject(s)
Hot Flashes/complications , Menopause , Sleep Initiation and Maintenance Disorders/etiology , Women's Health , Factor Analysis, Statistical , Female , Hot Flashes/prevention & control , Humans , Middle Aged , Perimenopause , Postmenopause , Psychometrics , Quality of Life , Reproducibility of Results , Sleep Initiation and Maintenance Disorders/prevention & control , Surveys and Questionnaires/standardsABSTRACT
OBJECTIVE: Circadian rest-activity rhythms (CARs) have been cross-sectionally associated with depressive symptoms, although no longitudinal research has examined whether CARs are a risk factor for developing depressive symptoms. METHODS: We examined associations of CARs (measured with actigraphy over a mean of 4.8 days) with depressive symptoms (measured with the Geriatric Depression Scale) among 2,892 community-dwelling older men (mean age: 76.2 ± 5.5 years) from the MrOS Sleep Study who were without cognitive impairment. Among 2,124 men with minimal (0-2) symptoms at baseline, we assessed associations between CAR parameters and increases to mild (3-5) or clinically significant (≥6) symptoms after an average of 1.2 (±0.32) years. RESULTS: Cross-sectional associations between rhythm height parameters were independent of chronic diseases, lifestyle, sleep, and self-reported physical activity covariates. For example, men in the lowest mesor quartile had twice the adjusted odds (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.36-3.04, p = 0.0005) of having prevalent clinically significant symptoms (compared to minimal). Longitudinally, low CAR robustness (being in the lowest quartile of the pseudo-F statistic) was independently associated with increasing odds of developing symptoms (i.e., AOR for having clinically significant depressive symptoms at follow-up = 2.58, 95% CI: 1.11-5.99, p = 0.03). CONCLUSION: CAR disturbances are indicative of depressive symptomology. Low CAR robustness may independently contribute to the risk of worsening depression symptomology.
Subject(s)
Aging , Chronobiology Disorders , Depression , Actigraphy/methods , Aged , Aged, 80 and over , Aging/physiology , Aging/psychology , Chronobiology Disorders/complications , Chronobiology Disorders/diagnosis , Chronobiology Disorders/epidemiology , Chronobiology Disorders/psychology , Comorbidity , Depression/diagnosis , Depression/epidemiology , Depression/etiology , Depression/physiopathology , Follow-Up Studies , Geriatric Assessment/methods , Humans , Independent Living/psychology , Life Style , Male , Motor Activity , Psychiatric Status Rating Scales , Risk Factors , Sleep , United States/epidemiologyABSTRACT
OBJECTIVE: To investigate the longitudinal relationship between subjective and objective sleep disturbance and depressive symptoms. DESIGN: Longitudinal. SETTING: Three US clinical centers. PARTICIPANTS: Nine hundred fifty-two community-dwelling older women (70 y or older). MEASUREMENTS: At baseline, subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and objective sleep measures were assessed with wrist actigraphy. Depressive symptoms were assessed with the Geriatric Depression Scale (GDS) at baseline and approximately 5 y later. The analysis was restricted to women with few (GDS 0-2) depressive symptoms at baseline. RESULTS: There was an independent association between greater PSQI score (per standard deviation increase, indicating worse subjective sleep quality) at baseline and greater odds of worsening depressive symptoms (≥ 2-point increase in GDS) (Multivariate Odds Ratio [MOR] 1.19, confidence interval [CI] 1.01-1.40, P = 0.036). Higher scores specifically on the sleep quality (MOR 1.41, CI 1.13-1.77, P < 0.003) and sleep latency (MOR 1.21, CI 1.03-1.41, P = 0.018) PSQI subscales were also associated with greater odds for worsening depressive symptoms. Objective assessments revealed an association between baseline prolonged wake after sleep onset (WASO ≥ 60 min) and worsening depressive symptoms at follow-up (MOR 1.36, CI 1.01-1.84, P = 0.046). There were no associations between other objectively assessed sleep measures and worsening depressive symptoms. CONCLUSIONS: In older women with few or no depressive symptoms at baseline, those with more subjectively reported sleep disturbance and more objectively assessed fragmentation of sleep at baseline had greater odds of worsening depressive symptoms 5 y later. Future studies investigating this relationship in more detail are indicated. CITATION: Maglione JE, Ancoli-Israel S, Peters KW, Paudel ML, Yaffe K, Ensrud KE, Stone KL, Study of Osteoporotic Fractures Research Group. Subjective and objective sleep disturbance and longitudinal risk of depression in a cohort of older women.
Subject(s)
Depression/complications , Sleep Wake Disorders/complications , Sleep Wake Disorders/diagnosis , Actigraphy , Aged , Aged, 80 and over , Depression/diagnosis , Depression/physiopathology , Depression/psychology , Female , Humans , Longitudinal Studies , Odds Ratio , Sleep/physiology , Sleep Wake Disorders/physiopathology , Sleep Wake Disorders/psychology , United StatesABSTRACT
OBJECTIVE: To compare cost estimates for hospital stays calculated using diagnosis-related group (DRG) weights to actual Medicare payments. DATA SOURCES/STUDY SETTING: Medicare MedPAR files and DRG tables linked to participant data from the Study of Osteoporotic Fractures (SOF) from 1992 through 2010. Participants were women age 65 and older recruited in three metropolitan and one rural area of the United States. STUDY DESIGN: Costs were estimated using DRG payment weights for 1,397 hospital stays for 795 SOF participants for 1 year following a hip fracture. Medicare cost estimates included Medicare and secondary insurer payments, and copay and deductible amounts. PRINCIPAL FINDINGS: The mean (SD) of inpatient DRG-based cost estimates per person-year were $16,268 ($10,058) compared with $19,937 ($15,531) for MedPAR payments. The correlation between DRG-based estimates and MedPAR payments was 0.71, and 51 percent of hospital stays were in different quintiles when costs were calculated based on DRG weights compared with MedPAR payments. CONCLUSIONS: DRG-based cost estimates of hospital stays differ significantly from Medicare payments, which are adjusted by Medicare for facility and local geographic characteristics. DRG-based cost estimates may be preferable for analyses when facility and local geographic variation could bias assessment of associations between patient characteristics and costs.