Healthy Days at Home Among Older Medicare Beneficiaries With Traumatic Brain Injury Requiring Inpatient Rehabilitation.

OBJECTIVE: The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. Setting: Inpatient hospital, nursing home, and home health services. PARTICIPANTS: Average of n= 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge. DESIGN: Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank. MAIN MEASURES: The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge. RESULTS: We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score (ß = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score (ß = - 0.06; 95% CI, -0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors (ß = - 0.37; 95% CI, -0.66 to -0.07). CONCLUSION: In this study, among community-dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs.

Association of Biomarkers of Neuronal Injury and Inflammation With Insomnia Trajectories After Traumatic Brain Injury: A TRACK-TBI Study.

BACKGROUND AND OBJECTIVES: Insomnia affects about one-third of patients with traumatic brain injury and is associated with worsened outcomes after injury. We hypothesized that higher levels of plasma neuroinflammation biomarkers at the time of TBI would be associated with worse 12-month insomnia trajectories. METHODS: Participants were prospectively enrolled from 18 level-1 trauma centers participating in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study from February 26, 2014, to August 8, 2018. Plasma glial fibrillary acidic protein (GFAP), high-sensitivity C-reactive protein (hsCRP), S100b, neuron-specific enolase (NSE), and ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1) were collected on days 1 (D1) and 14 (D14) after TBI. The insomnia severity index was collected at 2 weeks, 3, 6, and 12 months postinjury. Participants were classified into insomnia trajectory classes based on a latent class model. We assessed the association of biomarkers with insomnia trajectories, controlling for medical and psychological comorbidities and demographics. RESULTS: Two thousand twenty-two individuals with TBI were studied. Elevations in D1 hsCRP were associated with persistent insomnia (severe, odds ratio [OR] = 1.33 [1.11, 1.59], p = 0.002; mild, OR = 1.10 [1.02, 1.19], p = 0.011). Similarly, D14 hsCRP elevations were associated with persistent insomnia (severe, OR = 1.27 [1.02, 1.59], p = 0.03). Of interest, D1 GFAP was lower in persistent severe insomnia (median [Q1, Q3]: 154 [19, 445] pg/mL) compared with resolving mild (491 [154, 1,423], p < 0.001) and persistent mild (344 [79, 1,287], p < 0.001). D14 GFAP was similarly lower in persistent (11.8 [6.4, 19.4], p = 0.001) and resolving (13.9 [10.3, 20.7], p = 0.011) severe insomnia compared with resolving mild (20.6 [12.4, 39.6]. Accordingly, increases in D1 GFAP were associated with reduced likelihood of having persistent severe (OR = 0.76 [95% CI 0.63-0.92], p = 0.004) and persistent mild (OR = 0.88 [0.81, 0.96], p = 0.003) compared with mild resolving insomnia. No differences were found with other biomarkers. DISCUSSION: Elevated plasma hsCRP and, surprisingly, lower GFAP were associated with adverse insomnia trajectories after TBI. Results support future prospective studies to examine their utility in guiding insomnia care after TBI. Further work is needed to explore potential mechanistic connections between GFAP levels and the adverse insomnia trajectories.

Prevalence, trends, and factors associated with maternal autonomy regarding healthcare, finances, and mobility in Bangladesh: Analysis of Demographic and Health Surveys 1999-2018.

Maternal autonomy is associated with improved healthcare utilization/outcomes for mothers and babies in low- and middle-income countries. We investigated the trends in the prevalence and factors associated with maternal autonomy in Bangladesh. This cross-sectional study analyzed the Bangladesh Demographic and Health Survey for 1999-00, 2004, 2007, 2011, 2014, and 2017-18. Maternal autonomy was defined as at least one decision-making ability regarding healthcare, large household purchases, and freedom of mobility. We included 15-49-year-old mothers with at least one live-birth in the past three years. We compared the samples based on the presence of autonomy and reported the trends in prevalence (95% confidence intervals (CIs)) across the survey years. Lastly, we performed multilevel logistic regression to report prevalence odds ratios (PORs) for the associated factors. Variables investigated as potential factors included maternal age, number of children, maternal education, paternal education, current work, religion, mass media exposure, wealth quintile, place and division of residence, and survey years. The prevalence of 'any' maternal autonomy was 72.0% (95% CI: 70.5-73.5) in 1999-00 and increased to 83.8% (95% CI: 82.7-84.9) in 2017-18. In adjusted analysis, mothers with older age, higher education, work outside the home, and mass media exposure had higher odds of autonomy than their counterparts (POR > 1, p < 0.05). For instance, compared to mothers without any formal education, the odds of autonomy were significantly (p < 0.001) higher among mothers with primary (adjusted POR: 1.2, 95% CI: 1.1-1.4), secondary (adjusted POR: 1.4, 95% CI: 1.2-1.6), and college/above (adjusted POR: 1.9, 95% CI: 1.6-2.2) education. While the level of maternal autonomy has increased, a substantial proportion still do not have autonomy. Expanding educational and earning opportunities may increase maternal autonomy. Further research should investigate other ways to improve it as well.

Occult, undiagnosed obstructive sleep apnea is associated with increased health care resource utilization and costs among older adults with comorbid depression: a retrospective cohort study among Medicare beneficiaries.

Obstructive sleep apnea and depression are highly comorbid among older adults, and each is associated with increased economic costs and health care resource utilization. The purpose of this study was to determine the economic burden of comorbid occult obstructive sleep apnea among a random sample of older adult Medicare beneficiaries in the United States. Among 41,500 participants with preexisting depression and meeting inclusion criteria, 4,573 (11%) had occult OSA. In fully adjusted models, beneficiaries with occult OSA were heavier users of inpatient (rate ratio: 1.53; 95% CI: 1.39, 1.67), outpatient (rate ratio: 1.18; 95% CI: 1.10, 1.27), emergency department (rate ratio: 1.48; 95% CI: 1.35, 1.63), and prescription (rate ratio: 1.09; 95% CI: 1.05, 1.14) services. Mean total costs were also significantly higher among beneficiaries with occult OSA ($44,390; 95% CI: $32,076, $56,703). CITATION: Wickwire EM, Albrecht JS. Occult, undiagnosed obstructive sleep apnea is associated with increased health care resource utilization and costs among older adults with comorbid depression: a retrospective cohort study among Medicare beneficiaries. J Clin Sleep Med. 2024;20(5):817-819.

Impact of dementia and socioeconomic disadvantage on days at home after traumatic brain injury among older Medicare beneficiaries: A cohort study.

INTRODUCTION: Time spent at home may aid in understanding recovery following traumatic brain injury (TBI) among older adults, including those with Alzheimer's disease and related dementias (ADRD). We examined the impact of ADRD on recovery following TBI and determined whether socioeconomic disadvantages moderated the impact of ADRD. METHODS: We analyzed Medicare beneficiaries aged ≥65 years diagnosed with TBI in 2010-2018. Home time was calculated by subtracting days spent in a care environment or deceased from total follow-up, and dual eligibility for Medicaid was a proxy for socioeconomic disadvantage. RESULTS: A total of 2463 of 20,350 participants (12.1%) had both a diagnosis of ADRD and were Medicaid dual-eligible. Beneficiaries with ADRD and Medicaid spent markedly fewer days at home following TBI compared to beneficiaries without either condition (rate ratio 0.66; 95% confidence interval [CI] 0.64, 0.69). DISCUSSION: TBI resulted in a significant loss of home time over the year following injury among older adults with ADRD, particularly for those who were economically vulnerable. HIGHLIGHTS: Remaining at home after serious injuries such as fall-related traumatic brain injury (TBI) is an important goal for older adults. No prior research has evaluated how ADRD impacts time spent at home after TBI. Older TBI survivors with ADRD may be especially vulnerable to loss of home time if socioeconomically disadvantaged. We assessed the impact of ADRD and poverty on a novel DAH measure after TBI. ADRD-related disparities in DAH were significantly magnified among those living with socioeconomic disadvantage, suggesting a need for more tailored care approaches.

Trajectories of Recovery Following Traumatic Brain Injury Among Older Medicare Beneficiaries.

It is well-known that older adults have poorer recovery following traumatic brain injury (TBI) relative to younger adults with similar injury severity. However, most older adults do recover well from TBI. Identifying those at increased risk of poor recovery could inform appropriate management pathways, facilitate discussions about palliative care or unmet needs, and permit targeted intervention to optimize quality of life or recovery. We sought to explore heterogeneity in recovery from TBI among older adults as measured by home time per month, a patient-centered metric defined as time spent at home and not in a hospital, urgent care, or other facility. Using data obtained from Medicare administrative claims data for years 2010-2018, group-based trajectory modeling was employed to identify unique trajectories of recovery among a sample of United States adults age 65 and older who were hospitalized with TBI. We next determined which patient-level characteristics discriminated poor from favorable recovery using logistic regression. Among 20,350 beneficiaries, four unique trajectories were identified: poor recovery (n = 1929; 9.5%), improving recovery (n = 2,793; 13.7%), good recovery (n = 13,512; 66.4%), and declining recovery (n = 2116; 10.4%). The strongest predictors of membership in the poor relative to the good recovery trajectory group were diagnosis of Alzheimer's disease and related dementias (ADRD; odd ratio [OR] 2.42; 95% confidence interval [CI] 2.16, 2.72) and dual eligibility for Medicaid, a proxy for economic vulnerability (OR 5.13; 95% CI 4.59, 5.74). TBI severity was not associated with recovery trajectories. In conclusion, this study identified four unique trajectories of recovery over one year following TBI among older adults. Two-thirds of older adults hospitalized with TBI returned to the community and stayed there. Recovery of monthly home time was complete for most by 3 months post injury. An important sub-group comprising 10% of patients who did not return home was characterized primarily by eligibility for Medicaid and diagnosis of ADRD. Future studies should seek to further characterize and investigate identified recovery groups to inform management and development of interventions to improve recovery.

Prognostic Value of Frailty for Outcome Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Frailty is a known predictor of negative health outcomes. The role of frailty in predicting outcomes after traumatic brain injury (TBI), however, is unclear. This systematic review aimed to evaluate the association between frailty and adverse outcomes in patients with TBI. We identified relevant articles that investigated the relationship between frailty and outcomes in patients with TBI by searching PubMed/MEDLINE, Web of Science, Scopus, and EMBASE from inception until 23 March 2023. To evaluate the risk of bias in the included studies, we utilized the Newcastle-Ottawa Scale (NOS). In addition, quantitative synthesis and meta-analyses were performed. We identified 12 studies that met our inclusion criteria; three were prospective. Of included studies, eight had low risk, three had moderate risk, and one had high risk of bias. Frailty was significantly associated with death in five studies, with an increased risk of in-hospital death and complications observed in frail patients. Frailty was associated with longer hospital stays and unfavorable outcome measured by the Extended Glasgow Outcome Scale (GOSE) in four studies. The meta-analysis found that higher frailty significantly increased the odds of non-routine discharge and unfavorable outcome as measured by GOSE scores of 4 or lower. The pooled odds ratio (OR) for non-routine discharge, was 1.80, with a 95% confidence interval (CI) of 1.15-2.84; and for unfavorable outcome, it was 1.91, with a 95% CI of 1.09-3.36. The analysis, however, did not find a significant predictive role for frailty on death (30-day or in-hospital death). The OR for higher frailty and death was 1.42 with a 95% CI of 0.92-2.19. Frailty should be considered in the evaluation of patients with TBI to identify those who may be at increased risk of negative outcomes.

Patient Engagement and Provider Effectiveness of a Novel Sleep Telehealth Platform and Remote Monitoring Assessment in the US Military: Pilot Study Providing Evidence-Based Sleep Treatment Recommendations.

BACKGROUND: Sleep problems are common and costly in the US military. Yet, within the military health system, there is a gross shortage of trained specialist providers to address sleep problems. As a result, demand for sleep medicine care far exceeds the available supply. Telehealth including telemedicine, mobile health, and wearables represents promising approaches to increase access to high-quality and cost-effective care. OBJECTIVE: The purpose of this study was to evaluate patient engagement and provider perceived effectiveness of a novel sleep telehealth platform and remote monitoring assessment in the US military. The platform includes a desktop web portal, native mobile app, and integrated wearable sensors (ie, a commercial off-the-shelf sleep tracker [Fitbit]). The goal of the remote monitoring assessment was to provide evidence-based sleep treatment recommendations to patients and providers. METHODS: Patients with sleep problems were recruited from the Internal Medicine clinic at Walter Reed National Military Medical Center. Patients completed intensive remote monitoring assessments over 10 days (including a baseline intake questionnaire, daily sleep diaries, and 2 daily symptom surveys), and wore a Fitbit sleep tracker. Following the remote monitoring period, patients received assessment results and personalized sleep education in the mobile app. In parallel, providers received a provisional patient assessment report in an editable electronic document format. Patient engagement was assessed via behavioral adherence metrics that were determined a priori. Patients also completed a brief survey regarding ease of completion. Provider effectiveness was assessed via an anonymous survey. RESULTS: In total, 35 patients with sleep problems participated in the study. There were no dropouts. Results indicated a high level of engagement with the sleep telehealth platform, with all participants having completed the baseline remote assessment, reviewed their personalized sleep assessment report, and completed the satisfaction survey. Patients completed 95.1% of sleep diaries and 95.3% of symptom surveys over 10 days. Patients reported high levels of satisfaction with most aspects of the remote monitoring assessment. In total, 24 primary care providers also participated and completed the anonymous survey. The results indicate high levels of perceived effectiveness and identified important potential benefits from adopting a sleep telehealth approach throughout the US military health care system. CONCLUSIONS: Military patients with sleep problems and military primary care providers demonstrated high levels of engagement and satisfaction with a novel sleep telehealth platform and remote monitoring assessment. Sleep telehealth approaches represent a potential pathway to increase access to evidence-based sleep medicine care in the US military. Further evaluation is warranted.

Screening for sleep disordered breathing among children hospitalized for asthma exacerbation.

BACKGROUND: Sleep disordered breathing (SDB) may exacerbate asthma and is a treatable comorbidity. OBJECTIVE: To design and implement a screening process for SDB in patients hospitalized for asthma exacerbation using quality improvement (QI) methods. We sought to improve screening for SDB from zero to 60% from July 2019 to December 2020. DESIGN/METHODS: A multidisciplinary team used QI methods to screen for SDB using the Michigan pediatric sleep questionnaire (PSQ) in patients 2-18 years hospitalized for asthma exacerbation. Key interventions included: pairing the PSQ screen with another element of routine care (the asthma risk factor screen), educating staff and physicians, engaging respiratory therapists to complete the PSQ and document scores, and modifying the electronic medical record (asthma order set and flowsheet for PSQ score documentation). A run chart tracked progress and descriptive statistics were generated. RESULTS: There were 2067 patients admitted for asthma exacerbation during this project. The PSQ was completed for 1531 patients (74%) overall. Of screened patients, 360 (24%) had a positive PSQ; the mean age was 8.6 years. Approximately 14 months after the project began, ~90% of children admitted for asthma were being screened; subsequently, >80% of patients were being screened until May 2022. Screening with the PSQ occurred approximately 90% of the time when routine asthma risk screens were completed. CONCLUSION: A screening process for SDB was successfully implemented and appeared feasible and sustainable. The high proportion of positive screens reinforces the importance of evaluating for SDB in the high-risk population of children requiring hospitalization for asthma exacerbation.

Association Between Insomnia and Mental Health and Neurocognitive Outcomes Following Traumatic Brain Injury.

We previously described five trajectories of insomnia (each defined by a distinct pattern of insomnia severity over 12 months following traumatic brain injury [TBI]). Our objective in the present study was to estimate the association between insomnia trajectory status and trajectories of mental health and neurocognitive outcomes during the 12 months after TBI. In this study, participants included N = 2022 adults from the Federal Inter-agency Traumatic Brain Injury Repository database and Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. The following outcome measures were assessed serially at 2 weeks, and 3, 6, and 12 months post-injury: Insomnia Severity Index, Patient Health Questionnaire, Post-Traumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Patient Reported Outcomes Measurement Information System-Pain, and Quality of Life After Brain Injury-Overall Scale. Neurocognitive performance was assessed at 2 weeks, and 6 and 12 months using the Wechsler Adult Intelligence Scales Processing Speed Index and the Trails Making Test Parts A and B. Results indicated that greater insomnia severity was associated with greater abnormality in mental health, quality of life, and neuropsychological testing outcomes. The pattern of insomnia over time tracked the temporal pattern of all these outcomes for all but a very small number of participants. Notably, severe insomnia at 3 or 6 months post-TBI was a risk factor for poor recovery at 12 months post-injury. In conclusion, in this well-characterized sample of individuals with TBI, insomnia severity generally tracked severity of depression, pain, PTSD, quality of life, and neurocognitive outcomes over 12 months post-injury. More intensive sleep assessment is needed to elucidate the nature of these relationships and to help inform best strategies for intervention.

Occult, undiagnosed obstructive sleep apnea increases risk of depression among a national sample of older adult Medicare beneficiaries.

STUDY OBJECTIVES: To determine the association between occult, undiagnosed obstructive sleep apnea and incident depression among a nationally representative sample of older adult Medicare beneficiaries. METHODS: Our data source was a random 5% sample of Medicare administrative claims data for the years 2006-2013. Occult, undiagnosed obstructive sleep apnea was defined as the 12-month period preceding receipt of one or more International Classification of Disease, Version 9, Clinical Modification diagnostic codes for obstructive sleep apnea. To determine the effect of obstructive sleep apnea on incident depression, beneficiaries with undiagnosed obstructive sleep apnea were matched on index date to a random sample of nonsleep disordered controls (ie, individuals without evidence of sleep-related testing, diagnosis, or treatment). After excluding beneficiaries with preexisting depression, the risk of depression was modeled as a function of occult, undiagnosed obstructive sleep apnea status over the 12months prior to obstructive sleep apnea diagnosis using log-binomial regression. Covariates were balanced between groups using inverse probability of treatment weights. RESULTS: The final sample included 21,116 beneficiaries with occult, undiagnosed obstructive sleep apnea and 237,375 nonsleep disordered controls. In adjusted models, beneficiaries with occult, undiagnosed obstructive sleep apnea demonstrated a significantly higher risk of depression during the year prior to obstructive sleep apnea diagnosis (risk ratio 3.19; 95% confidence interval 3.00, 3.39). CONCLUSIONS: In this national study of Medicare beneficiaries and relative to nonsleep disordered controls, occult, undiagnosed obstructive sleep apnea was associated with a significantly higher risk for incident depression.

Undiagnosed obstructive sleep apnea increases risk of hospitalization among a racially diverse group of older adults with comorbid cardiovascular disease.

STUDY OBJECTIVES: Undiagnosed obstructive sleep apnea (OSA) is associated with increased risk for subsequent cardiovascular events, hospitalizations, and mortality. The primary objective of this study was to determine the association between undiagnosed OSA and subsequent hospitalizations among older adults with preexisting cardiovascular disease (CVD). A secondary objective was to determine the risk of 30-day hospital readmission associated with undiagnosed OSA among older adults with CVD. METHODS: This was a retrospective cohort study of a 5% sample of Medicare administrative claims data for years 2006-2013. Beneficiaries aged 65 years and older diagnosed with CVD were included. Undiagnosed OSA was defined as the 12-month period prior to OSA diagnosis. A similar 12-month period among beneficiaries not diagnosed with OSA was used for the comparison group (no OSA). Our primary outcome was the first all-cause hospital admission. Among beneficiaries with a hospital admission, 30-day readmission was assessed for the first hospital admission only. RESULTS: Among 142,893 beneficiaries diagnosed with CVD, 19,390 had undiagnosed OSA. Among beneficiaries with undiagnosed OSA, 9,047 (46.7%) experienced at least 1 hospitalization whereas 27,027 (21.9%) of those without OSA experienced at least 1 hospitalization. Following adjustment, undiagnosed OSA was associated with increased risk of hospitalization (odds ratio 1.82; 95% confidence interval 1.77, 1.87) relative to no OSA. Among beneficiaries with ≥ 1 hospitalization, undiagnosed OSA was associated with a smaller but significant effect in weighted models (odds ratio 1.18; 95% confidence interval 1.09, 1.27). CONCLUSIONS: Undiagnosed OSA was associated with significantly increased risk of hospitalization and 30-day readmissions among older adults with preexisting CVD. CITATION: Kirk J, Wickwire EM, Somers VK, Johnson DA, Albrecht JS. Undiagnosed obstructive sleep apnea increases risk of hospitalization among a racially diverse group of older adults with comorbid cardiovascular disease. J Clin Sleep Med. 2023;19(7):1175-1181.

Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries.

Importance: Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI. Objective: To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI. Design, Setting, and Participants: This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022. Exposures: Black or White race. Main Outcomes and Measures: Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors. Results: Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32). Conclusions and Relevance: This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.

Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data.

Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.

Adherence to continuous positive airway pressure reduces the risk of 30-day hospital readmission among older adults with comorbid obstructive sleep apnea and cardiovascular disease.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is underdiagnosed and undertreated among patients hospitalized with comorbid cardiovascular disease (CVD). Treatment of OSA may reduce health care utilization, but benefits of continuous positive airway pressure (CPAP) therapy are related to adherence. Benefits of CPAP among hospitalized individuals with OSA and CVD have not been well studied. We evaluated the effect of CPAP adherence on 30-day hospital readmission among Medicare beneficiaries hospitalized with OSA and CVD. METHODS: We conducted a retrospective cohort study of Medicare beneficiaries aged ≥ 65 years with pre-existing CVD who were newly diagnosed with OSA between 2009 and 2013, initiated CPAP, and were hospitalized. CPAP adherence was defined as nonadherent, partially adherent, or highly adherent based on the number of machine charges (< 4, 4-12, and > 12, respectively) over 25 months of follow-up. The primary outcome was 30-day hospital readmission. RESULTS: Among 1,301 beneficiaries meeting study criteria, the 30-day readmission rate was 10.2%. In adjusted models and compared to patients with low CPAP adherence, those with high adherence had lower odds of 30-day readmission (odds ratio 0.41; 95% confidence interval 0.24-0.70). The protective effect of high CPAP adherence on 30-day readmission was significant among beneficiaries with heart failure (odds ratio 0.50; 95% confidence interval 0.16, 0.79), but not among those with other CVD. CONCLUSIONS: In this nationally representative sample of older adults with CVD and comorbid OSA, high CPAP adherence was associated with lower odds of 30-day readmission. These results highlight the importance of screening for and treating OSA among individuals with CVD. CITATION: Bailey MD, Wickwire EM, Somers VK, Albrecht JS. Adherence to continuous positive airway pressure reduces the risk of 30-day hospital readmission among older adults with comorbid obstructive sleep apnea and cardiovascular disease. J Clin Sleep Med. 2022;18(12):2739-2744.

Comparison Groups Matter in Traumatic Brain Injury Research: An Example with Dementia.

The association between traumatic brain injury (TBI) and risk for Alzheimer disease and related dementias (ADRD) has been investigated in multiple studies, yet reported effect sizes have varied widely. Large differences in comorbid and demographic characteristics between individuals with and without TBI could result in spurious associations between TBI and poor outcomes, even when control for confounding is attempted. Yet, inadvertent control for post-TBI exposures (e.g., psychological and physical trauma) could result in an underestimate of the effect of TBI. Choice of the unexposed or comparison group is critical to estimating total associated risk. The objective of this study was to highlight how selection of the comparison group impacts estimates of the effect of TBI on risk for ADRD. Using data on Veterans aged ≥55 years obtained from the Veterans Health Administration (VA) for years 1999-2019, we compared risk of ADRD between Veterans with incident TBI (n = 9440) and (1) the general population of Veterans who receive care at the VA (All VA) (n = 119,003); (2) Veterans who received care at a VA emergency department (VA ED) (n = 111,342); and (3) Veterans who received care at a VA ED for non-TBI trauma (VA ED NTT) (n = 65,710). In inverse probability of treatment weighted models, TBI was associated with increased risk of ADRD compared with All VA (hazard ratio [HR] 1.94; 95% confidence interval [CI] 1.84, 2.04), VA ED (HR 1.42; 95% CI 1.35, 1.50), and VA ED NTT (HR 1.12; 95% CI 1.06, 1.18). The estimated effect of TBI on incident ADRD was strongly impacted by choice of the comparison group.

Traumatic Brain Injury in Older Adults: Characteristics, Outcomes, and Considerations. Results From the American Association for the Surgery of Trauma Geriatric Traumatic Brain Injury (GERI-TBI) Multicenter Trial.

OBJECTIVES: Describe the epidemiology of a large cohort of older adults with isolated traumatic brain injury (TBI) and identify predictors of mortality, palliative interventions, and discharge to preinjury residence in those presenting with moderate/severe TBI. DESIGN: Prospective observational study of geriatric patients with TBI enrolled across 45 trauma centers. SETTING AND PARTICIPANTS: Inclusion criteria were age ≥40 years, and computed tomography (CT)-verified TBI. Exclusion criteria were any other body region abbreviated injury scale score >2 and presentation at enrolling center >24 hours after injury. METHODS: The analysis was restricted to individuals aged ≥65 and stratified into 3 age groups: young-old (65-74), middle-old (75-84), and oldest-old (≥85). Demographic, clinical, and injury data were collected. Predictors of mortality, palliative interventions, and discharge to preinjury residence in the moderate/severe TBI group were identified using Classification and Regression Tree and Generalized Linear Mixed Models. RESULTS: Of the 3081 subjects enrolled in the study, 2028 were ≥65 years old. Overall, 339 (16.7%) presented with a moderate/severe TBI and experienced a 64% mortality rate. A Glasgow Coma Scale (GCS) score <9 was the main predictor of mortality, CT worsening (odds ratio [OR] = 1.7, P < .04), cerebral edema (OR = 2.4, P < .04), GCS <9, and age ≥75 (OR = 2.1, P = .007) were predictors for palliative interventions, and an injury severity score ≤24 (OR = 0.087, P = .002) was associated with increased likelihood of discharge to preinjury residence in the moderate/severe TBI group. CONCLUSION AND IMPLICATIONS: In this prospective study of a large cohort of older adults with isolated TBI, comparisons across the older age groups with moderate/severe TBI revealed that survival and favorable discharge disposition were influenced more by severity of injury rather than age itself. Indicating that chronological age alone maybe insufficient to accurately predict outcomes, and increased representation of older adults in TBI research to develop better diagnostic and prognostic tools is warranted.

Active Duty Service Members, Primary Managers, and Administrators' Perspectives on a Novel Sleep Telehealth Management Platform in the U.S. Military Healthcare System.

INTRODUCTION: Sleep disorders are common in the military, and there is a gross shortage of sleep specialists in the military health system. The purposes of the present study were to (1) understand perceptions and expectations surrounding sleep telehealth approaches and (2) solicit feedback to optimize and refine a proposed novel sleep telehealth management platform. To accomplish these objectives, we investigated the perceptions, expectations, and preferences of active duty service members (ADSMs) with sleep disorders, primary care managers (PCMs), and administrative stakeholders regarding sleep telehealth management. MATERIALS AND METHODS: Using convenience sampling, we conducted five focus groups with 26 ADSMs and 11 individual interviews with PCMs from two military treatment facilities in the U.S National Capital Region and 11 individual interviews with administrative sleep stakeholders (9 military and 2 civilian). RESULTS: Active duty service members, PCMs, and administrative stakeholders provided insight regarding expectations for sleep telehealth as well as suggestions to optimize the novel sleep telehealth platform. In terms of outcomes, ADSMs expected sleep telehealth to improve sleep and convenience. Primary care managers expected improved sleep and other comorbidities, enhanced operational readiness, and reduced mortalities among their patients. Administrators expected increased access to care, optimized utilization of health services, realized cost savings, reduced accidents and errors, and improved military performance. In terms of the platform, for ADSMs, desired characteristics included delivery of timely clinical reports, improved patient-provider communication, and enhanced continuity of care. For PCMs and administrators,an ideal sleep telehealth solution will improve the diagnosis and triage of sleep patients, save PCM time, be easy to use, and integrate with the electronic health record system. CONCLUSION: The proposed sleep telehealth platform appealed to nearly all participants as a significant force multiplier to enhance sleep disorder management in the military. Stakeholders offered valuable recommendations to optimize the platform to ensure its successful real-world implementation.