Coordinated Care Experiences Among Middle-Aged and Older Adults with Multiple Chronic Conditions: Characteristics, Correlates, and Consequences for Health and Healthcare Utilization.

BACKGROUND AND OBJECTIVES: While coordinated care (CC) seeks to improve patient experiences and ultimately health outcomes, evidence from empirical research on the impacts of CC is mixed. This study examined the relationship between CC and healthcare outcomes over a four-year period among older adults with multiple chronic conditions. RESEARCH DESIGN AND METHODS: This observational cohort study is based on data come from the 2016-2020 Health and Retirement Study. Analysis is limited to respondents with 2+ chronic conditions who completed an experimental module on CC in 2016 (n = 906). Three domains of CC were assessed: perceptions, informal (family/friends) and formal (healthcare staff) tangible support, and technical support (using a "patient portal"). The longitudinal relationship between CC and health (e.g., pain, functioning, self-rated health) and healthcare (e.g., doctor visits, hospitalization, care satisfaction) outcomes was investigated using mixed-effects models. RESULTS: Better perceptions of CC were associated with lower odds of functional difficulties (Odds ratio (OR)=0.92; 95% CI=0.88-0.99) and greater satisfaction with care (B=0.04, 95% CI=0.02-0.05). Receipt of more informal tangible support was associated with 2.97 higher odds of ADL limitations (95% CI: 1.69-5.22) and 1.77 higher odds of hospitalization (95% CI=1.32-2.38). Use of technical support was associated with better self-rated health and greater satisfaction with care. DISCUSSION AND IMPLICATIONS: The longitudinal relationship between CC and health is multi-faceted. While positive perceptions and more technical support have beneficial effects on health outcomes, higher utilization of tangible support may reflect a higher demand among older adults with more complex healthcare needs.

Medically unexplained pain and suicidal ideation among US adults.

BACKGROUND: Chronic pain is an established risk factor for suicide. Pain syndromes are complex to diagnose, particularly in cases with limited evidence of injury or pathology. The goal of this study is to assess whether pain of unknown origin (i.e., medically-unexplained pain, MUEP) is more strongly associated with suicide behaviors than pain with a diagnostic explanation. METHODS: Data comes from the National Comorbidity Survey-Replication, a nationally-representative sample of US adults. Analysis was limited to participants with a lifetime history of any type of chronic pain (n = 3421), which were categorized as having medically-explained pain (MEP, e.g., pain due to a specific health condition or resulting from an injury identified in an x-ray) or MUEP. Logistic regression, using survey procedures, was used to assess the relationship between lifetime MUEP and lifetime history of suicidal ideation and attempts. RESULTS: Approximately 1 in 10 (11.6 %) adults with chronic pain had MUEP. Those with MUEP reported earlier age of pain onset and more impairment due to health problems. Suicidal ideation was reported by 18.7 % of those with MEP and 28.4 % of those with MUEP. In fully-adjusted models, MUEP was associated with 1.60 times (95 % CI: 1.17-2.18) higher odds of suicidal ideation, and 1.89 (1.25-2.83) higher odds of suicide attempt, compared to MEP. LIMITATIONS: Cross-sectional analysis; MUEP assessed by self-report. CONCLUSIONS: Among adults with chronic pain, those with MUEP are more likely to report suicide behaviors. Findings illustrate a role for diagnostic and treatment processes in the relationship between pain and suicide.

Psychosocial Stress and Hypothalamic-Pituitary-Adrenal Axis Stress Reactivity: Variations by Race and Socioeconomic Status Among Adults at Risk of Diabetes.

OBJECTIVE: Although stress is posited to play a key role in health disparities, the extent to which commonly used self-report psychosocial stress measures are related to neurobiological stress processes, especially across diverse populations, is unresolved. This study examined how two measures of psychosocial stress, perceived stress and domain-specific stress, covary with the acute neurobiological stress response. METHODS: The Richmond Stress and Sugar Study includes a racially and socioeconomically diverse cohort of adults at risk for type 2 diabetes ( n = 125; mean age = 57 years, 48% Black, and 61% high neighborhood socioeconomic status [SES]). Hypothalamic-pituitary-adrenal axis reactivity was assessed by salivary cortisol response to the Trier Social Stress Test (TSST), a laboratory stressor. RESULTS: Higher perceived stress was associated with a lower cortisol response to the TSST (-7.5%; 95% confidence interval [CI] = -13.1% to -1.5%) but was not associated with cortisol recovery after the TSST (3%; 95% CI = -0.6% to 6.8%). In contrast, domain-specific stress was not associated with cortisol response (-2.1%; 95% CI = -20.7% to 20.9%) but was inversely associated with cortisol recovery (3.7%; 95% CI = 0.6% to 7.0%). SES modified these associations: both perceived stress and domain-specific stress were associated with TSST cortisol response only among participants from high-SES neighborhoods. There was minimal evidence of effect modification by race. CONCLUSIONS: Both self-report measures of psychosocial stress were associated with hypothalamic-pituitary-adrenal axis reactivity to an acute stressor. These associations varied by perceived versus domain-specific measurement scales and by neighborhood SES. Further efforts to refine stress measures and clarify biological linkages between social status and health are needed.

Self-Regulatory Coping Behaviors and Stress Reactivity: Exploring the Environmental Affordance Model of Health Disparities.

OBJECTIVES: To explore the relationship between self-regulatory coping behaviors (SRCB) and hypothalamic pituitary adrenal (HPA) stress reactivity. METHODS: Data came from the Richmond Stress and Sugar Study (n=125, median age: 57 years, 46% non-Hispanic White, 48% African American). The relationships between 11 SRCB ("health-harming" [e.g., smoking] and "health-promoting" [e.g., exercising]) with HPA stress reactivity, indicated by salivary cortisol response to the Trier Social Stress Test, was assessed using multi-level modeling. RESULTS: Health-harming and health-promoting SRCB were positively correlated (+0.33, p<0.001). Several individual behaviors were related to HPA stress reactivity, for example, smoking and meditation were associated with shallower increases in cortisol (smoking: -13.0%, 95%CI: -20.9% to -4.3%; meditation: -14.0%, 95%CI: -22.0% to -5.1%). However, SRCB summary measures were unrelated to stress reactivity. DISCUSSION: Health-harming and health-promoting SRCB are inter-related. Specific behaviors, rather than groupings as health-harming versus -promoting, are related to HPA stress reactivity.

Experiences of care coordination among older adults in the United States: Evidence from the Health and Retirement Study.

INTRODUCTION: The goal of this study was to examine variation in patient experiences and perceptions of care coordination across sociodemographic and health factors. METHODS: Data come from the 2016 Health and Retirement Study (N = 1, 216). Three domains of coordination were assessed: 1) Perceptions (e.g., patient impressions of provider-provider communication), 2) Tangible supports (e.g., meeting with a care coordinator, being accompanied to appointments), and 3) Technical supports (e.g., use of a "patient portal"). Logistic regression was used to quantify the frequency of each domain and examine variation by racial minority status, socioeconomic status, and health status. RESULTS: Approximately 42% of older adults perceived poor care coordination, including 14.8% who reported receiving seemingly conflicting advice from different providers. Only one-third had ever met with a formal care coordinator, and 40% were occasionally accompanied to appointments. Although racial minorities were less likely to have access to technical supports, they were more likely to use them. Better perceived coordination was associated with higher care satisfaction (Odds Ratio: 1.43, 95% CI: 1.27-1.61). CONCLUSIONS: Important gaps in care coordination remain for older adults. PRACTICE IMPLICATIONS: Providers should consider assessing patient perceptions of care coordination to address these gaps in an equitable manner.

Places of living and places of dying: the case for preventing suicide in residential long-term care.

This commentary addresses the increasing public health problem of suicide in later life and presents the case for preventing suicide in residential long-term care settings. We do so by examining this issue from the perspective of three levels of stakeholders - societal, organisational and individual - considering the relevant context, barriers and implications of each. We begin by discussing contemporary societal perspectives of ageing; the potential impact of ageism on prevention of late-life suicide; and the roles of gender and masculinity. This is followed by a historical analysis of the origin of residential long-term care; current organisational challenges; and person-centred care as a suicide prevention strategy. Finally, we consider suicide in long-term care from the perspective of individuals, including the experience of older adults living in residential care settings; the impact of suicide on residential care health professionals and other staff; and the impact of suicide bereavement on family, friends and other residents. We conclude with recommendations for policy reform and future research. This commentary aims to confront the often unspoken bias associated with preventing suicide among older adults, particularly those living with complex medical conditions, and invoke an open dialogue about suicide prevention in this population and setting.

A Data Science Approach to Estimating the Frequency of Driving Cessation Associated Suicide in the US: Evidence From the National Violent Death Reporting System.

Driving cessation is a common transition experienced by aging adults that confers both a symbolic and literal loss of independence due to the central role of automobiles for mobility in the US. Prior research has shown that driving cessation has negative implications for mental health, social participation, and access to healthcare. Given these sequelae of driving cessation and prior work showing that late-life transitions related to independence (e.g., transitioning into residential care) are associated with suicide, we sought to estimate the frequency of driving cessation associated suicide. Data include suicide (n = 59,080) and undetermined (n = 6,862) deaths aged ≥55 from the National Violent Death Reporting System (NVDRS, 2003-2017). Each case in the NVDRS has both quantitative data (e.g., demographic characteristics) and qualitative text narratives, derived from coroner/medical examiner reports, which describe the most salient circumstances and features of each death. To identify cases associated with driving cessation, we employed a supervised random forest algorithm to develop a Natural Language Processing (NLP) classifier. Identified driving cessation associated cases were then categorized and characterized using descriptive statistics and qualitative content analysis. From 2003 to 2017, there were an estimated 305 cases of suicide/undetermined deaths associated with driving cessation in the NVDRS, representing 0.04% of all cases. Cases associated with driving cessation were older, more likely to be male, more likely to have a physical health problem, more likely to have experienced a recent crisis, and more likely to have lived in a rural county than other decedents. Qualitative analysis identified functional impairment, alcohol-related driving limitations, loss of employment, and recent car accidents as common themes among cases associated with driving cessation. This analysis illustrates the utility of NLP in identifying novel correlates of suicide in later life. Although driving cessation associated suicide is a rare outcome, further research is warranted on understanding the conditions under which driving cessation is associated with suicidal behavior, and how to support the well-being of aging adults during these types of major life transitions.

Not discussed: Inequalities in narrative text data for suicide deaths in the National Violent Death Reporting System.

BACKGROUND: The rate of suicide in the US has increased substantially in the past two decades, and new insights are needed to support prevention efforts. The National Violent Death Reporting System (NVDRS), the nation's most comprehensive registry of suicide mortality, has qualitative text narratives that describe salient circumstances of these deaths. These texts have great potential for providing novel insights about suicide risk but may be subject to information bias. OBJECTIVE: To examine the relationship between decedent characteristics and the presence and length of NVDRS text narratives (separately for coroner/medical examiner (C/ME) and law enforcement (LE) reports) among 233,108 suicide and undetermined deaths from 2003-2017. METHODS: Generalized estimating equations (GEE) logistic and quasi-Poisson modeling was used to examine variation in the narratives (proportion of missing texts and character length of the non-missing texts, respectively) as a function of decedent age, sex, race/ethnicity, education, marital status, military history, and homeless status. Models adjusted for site, year, location of death, and autopsy status. RESULTS: The frequency of missing narratives was higher for LE vs. C/ME texts (19.8% vs. 5.2%). Decedent characteristics were not consistently associated with missing text across the two types of narratives (i.e., Black decedents were more likely to be missing the LE narrative but less likely to be missing the C/ME narrative relative to non-Hispanic whites). Conditional on having a narrative, C/ME were significantly longer than LE (822.44 vs. 780.68 characters). Decedents who were older, male, had less education and some racial/ethnic minority groups had shorter narratives (both C/ME and LE) than younger, female, more educated, and non-Hispanic white decedents. CONCLUSION: Decedent characteristics are significantly related to the presence and length of narrative texts for suicide and undetermined deaths in the NVDRS. Findings can inform future research using these data to identify novel determinants of suicide mortality.

Stress Reactivity as a Contributor to Racial and Socioeconomic Disparities: Rationale and Baseline Results From the Richmond Stress and Sugar Study.

OBJECTIVE: There are pronounced racial and socioeconomic disparities in type 2 diabetes. Although "stress" as a general phenomenon is hypothesized to contribute to these disparities, few studies have objective measures of stress reactivity in diverse samples to test hypotheses about purported mechanisms. This study describes the rationale and baseline characteristics of a cohort designed to address the question: how does stress contribute to disparities in diabetes risk? METHODS: The Richmond Stress and Sugar Study recruited 125 adults at elevated risk of type 2 diabetes using a two-by-two sampling frame wherein non-Hispanic whites and African Americans (AAs) were each recruited from neighborhoods of higher and lower socioeconomic status (SES). Stress reactivity was assessed using the Trier Social Stress Test (TSST) and salivary cortisol. Analyses of variance and multilevel modeling were used to examine how stress reactivity varied both within and across race and neighborhood SES. RESULTS: The mean (SD) age was 57.4 (7.3) years, 49% were female, 54% were AA or another racial/ethnic minority, and mean hemoglobin A1c level was in the prediabetes range (5.8%; range, 5.50%-5.93%). Living in a lower-SES neighborhood was associated with 16% (95% confidence interval [CI] = -0.04 to 34) higher pre-TSST cortisol, 8.4% (95% CI = -14 to -3) shallower increase in response to the TSST, and 1% (95% CI = 0.3 to 1.7) steeper decline post-TSST than living in the higher neighborhood SES. Post-TSST cortisol decline was 3% greater among AA compared with non-Hispanic whites. Race-by-SES interaction terms were generally small and nonsignificant. CONCLUSIONS: SES is associated with stress reactivity among adults at high risk of diabetes.

Beyond Depression: Estimating 12-Months Prevalence of Passive Suicidal Ideation in Mid- and Late-Life in the Health and Retirement Study.

OBJECTIVES: To provide valid estimates of the 12-month prevalence of passive suicidal ideation among older adults, without conditioning on depression status, using the Health and Retirement Study (HRS). METHODS: Data come from the 2012 HRS (n = 17,434) and 2004/5 Baltimore Epidemiologic Catchment Area (ECA) Study (n = 755). In the HRS, passive suicidal ideation (i.e., thought a lot about death-your own, someone else's, or death in general) is only assessed on respondents who reported dysphoria/anhedonia; in the ECA, ideation is assessed on all respondents, regardless of depression. We compare two approaches to estimating the 12-month prevalence of passive suicidal ideation in the HRS without conditioning on depression symptoms: 1) a probit selection model within the HRS, and 2) a prediction model developed using appended ECA data applied to the HRS. RESULTS: Using observed data alone on those who screened positive for depression, 6% of older adults reported passive suicidal ideation in the past year. Depending on the approach used, between 5.4% and 9.2% of HRS respondents who screened negative for depression would have reported passive suicidal ideation had they been assessed. Correcting for this selection bias, between 10.9% and 13.4% of U.S. adults over age 50 experienced passive suicidal ideation in 2012. CONCLUSIONS: Population surveillance of suicidal ideation among older adults is biased by survey approaches that only assess ideation in the context of depression.

Suicide Among Older Adults Living in or Transitioning to Residential Long-term Care, 2003 to 2015.

Importance: Almost 25% of Medicare beneficiaries live in residential long-term care (LTC) (eg, independent or assisted living facility or nursing home). There are few reliable statistics on completed suicide in LTC, in part because of data limitations. Objectives: To estimate the number of suicides associated with residential LTC (ie, among persons in a facility, transitioning into or out of a facility, or otherwise associated with LTC) among adults 55 and older and, secondarily, to identify whether machine learning tools could improve the quality of suicide surveillance data. Design, Setting, and Participants: Cross-sectional epidemiologic study (conducted in 2018) of restricted-access data from the National Violent Death Reporting System (NVDRS) (2003-2015) using restricted-access case narratives from suicides and undetermined deaths among adults 55 years and older in 27 states. Participants were all suicides and undetermined deaths (N = 47 759) among persons 55 years and older. Exposure: Long-term care cited in the coroner/medical examiner case narrative, whether as a reason for self-harm or the injury location, identified using machine learning natural language processing (NLP) algorithms plus manual review of texts. Main Outcomes and Measures: Number and characteristics (eg, demographics, health history, and means of injury) of suicides associated with LTC. The κ statistic was used to estimate the reliability of the existing NVDRS injury location codes relative to cases identified by the algorithm. Results: Among 47 759 persons 55 years and older (median age, 64 years; 77.6% male; 90.0% non-Hispanic white), this study identified 1037 suicide deaths associated with LTC, including 428 among older adults living in LTC, 449 among older adults transitioning to LTC, and 160 otherwise associated with LTC. In contrast, there were only 263 cases coded with the existing NVDRS location code "supervised residential facility," which had poor agreement with cases that the algorithm identified as occurring in LTC (κ statistic, 0.30; 95% CI, 0.26-0.35). Conclusions and Relevance: Over a 13-year period, approximately 2.2% of suicides among adults 55 years and older were associated with LTC in some manner. Clinicians, administrators, and policy makers should consider ways to promote the mental health and well-being of older adults experiencing functioning limitations and their families. Natural language processing may be a useful way to improve abstraction of variables in the NVDRS.