Population-based estimates of major forms of housing insecurity among community-living older Americans.

OBJECTIVES: The number of older adults struggling to maintain adequate housing is growing. Prior studies have used various criteria to measure housing insecurity; however, no standardized definition exists to date. Using a multidimensional approach, our study sought to calculate population-based estimates of various forms of housing insecurity among community-living older Americans and determine how these estimates differ across key characteristics. METHODS: This study utilized data from the 2011 round of the National Health and Aging Trends Study (NHATS), a prospective longitudinal study of Medicare beneficiaries aged 65 years or older. Three key forms of housing insecurity were operationalized: poor housing affordability (PHA), poor housing quality (PHQ), and poor neighborhood quality (PNQ). Population-based estimates of these forms of housing insecurity were calculated using analytic sampling weights and stratified by age, gender, race and ethnicity, frailty status, and dementia status. RESULTS: Totally 6466 participants were included in the analysis, representing 29,848,119 community-living older Americans. The mean (standard deviation) age was 77.3 (7.7) years; by weighted percentages, 56.0% identified as female, 81.3% as White, 8.2% Black, and 7.1% Hispanic. At least one form of housing insecurity was identified in 38.5% of older Americans. Individually, the prevalence of PHA was 14.8%, PHQ 24%, and PNQ 12.5%. The prevalence of at least one form of housing insecurity was higher among persons of color (62.9% Black and 66% Hispanic vs White; p < 0.001), those with frailty (40.9% pre-frail and 49.4% frail vs robust; p < 0.001), and those with cognitive impairment (48.1% possible and 51% probable dementia vs no dementia; p < 0.001). DISCUSSION: Nearly one in three community-living older Americans experience at least one form of housing insecurity. This was most common among vulnerable subgroups. Our multidimensional approach to defining various forms of housing insecurity can be used for future studies focused on improving social determinants of health among high-risk older adults.

Changes in neighborhood disadvantage over the course of 22 years among community-living older persons.

BACKGROUND: Among older persons, neighborhood disadvantage is a granular and increasingly used social determinant of health and functional well-being. The frequency of transitions into or out of a disadvantaged neighborhood over time is not known. These transitions may occur when a person moves from one location to another or when the Neighborhood Atlas, the data source for the area deprivation index (ADI) that is used to identify disadvantaged neighborhoods at the census-block level, is updated. METHODS: From a prospective longitudinal study of community-living persons, aged 70 years or older in South Central Connecticut, neighborhood disadvantage was ascertained every 18 months for 22 years (from March 1998 to March 2020). ADI scores higher than the 80th state percentile were used to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80). RESULTS: At baseline, 205 (29.3%) of the 699 participants were living in a disadvantaged neighborhood. Changes in neighborhood disadvantage during 14 consecutive 18-month intervals were relatively uncommon, ranging from 1.5% to 11.8%. Nearly 80% of participants had no change in neighborhood disadvantage and less than 4% had more than one change over a median follow-up of more than 9 years. Overall, the rate of transitions into or out of neighborhood disadvantage was only 2.7 per 100 person-years. These transitions were most common when the Neighborhood Atlas was updated (2013, 2015, 2018, and 2020). Comparable results were observed when decile changes in ADI scores during the 18-month intervals were evaluated. CONCLUSIONS: In longitudinal studies of older persons with extended follow-up, it may not be necessary to update information on disadvantaged neighborhoods in circumstances when it is possible, and the degree of misclassification of neighborhood disadvantage should be relatively low in circumstances when updated information cannot be obtained.

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

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

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

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

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

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

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

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

Current use of the National Surgical Quality Improvement Program surgical risk calculator in academic surgery: a mixed-methods study.

Background: This study aims to quantitatively assess use of the NSQIP surgical risk calculator (NSRC) in contemporary surgical practice and to identify barriers to use and potential interventions that might increase use. Materials and methods: We performed a cross-sectional study of surgeons at seven institutions. The primary outcomes were self-reported application of the calculator in general clinical practice and specific clinical scenarios as well as reported barriers to use. Results: In our sample of 99 surgeons (49.7% response rate), 73.7% reported use of the NSRC in the past month. Approximately half (51.9%) of respondents reported infrequent NSRC use (<20% of preoperative discussions), while 14.3% used it in ≥40% of preoperative assessments. Reported use was higher in nonelective cases (30.2% vs 11.1%) and in patients who were ≥65 years old (37.1% vs 13.0%), functionally dependent (41.2% vs 6.6%), or with surrogate consent (39.9% vs 20.4%). NSRC use was not associated with training status or years in practice. Respondents identified a lack of influence on the decision to pursue surgery as well as concerns regarding the calculator's accuracy as barriers to use. Surgeons suggested improving integration to workflow and better education as strategies to increase NSRC use. Conclusions: Many surgeons reported use of the NSRC, but few used it frequently. Surgeons reported more frequent use in nonelective cases and frail patients, suggesting the calculator is of greater utility for high-risk patients. Surgeons raised concerns about perceived accuracy and suggested additional education as well as integration of the calculator into the electronic health record.

Routine post-operative labs and healthcare system burden in acute appendicitis.

BACKGROUND: Data from the National Health Expenditure Accounts have shown a steady increase in healthcare cost paralleled by availability of laboratory tests. Resource utilization is a top priority for reducing health care costs. We hypothesized that routine post-operative laboratory utilization unnecessarily increases costs and healthcare system burden in acute appendicitis (AA) management. METHODS: A retrospective cohort of patients with uncomplicated AA 2016-2020 were identified. Clinical variables, demographics, lab usage, interventions, and costs were collected. RESULTS: A total of 3711 patients with uncomplicated AA were identified. Total costs of labs ($289,505, 99.56%) and repletions ($1287.63, 0.44%) were $290,792.63. Increased LOS was associated with lab utilization in multivariable modeling, increasing costs by $837,602 or 472.12 per patient. CONCLUSIONS: In our patient population, post-operative labs resulted in increased costs without discernible impact on clinical course. Routine post-operative laboratory testing should be re-evaluated in patients with minimal comorbidities as this likely increases cost without adding value.

Alcohol withdrawal syndrome in trauma patients: a study using the Trauma Quality Program Participant User File.

Objective: To identify the rates and possible predictors of alcohol withdrawal syndrome (AWS) among adult trauma patients. Methods: This is a retrospective review of all adult patients (18 years or older) included in the 2017 and 2018 American College of Surgeons Trauma Quality Program Participant User File (PUF). The main outcomes were rates and predictors of AWS. Results: 1 677 351 adult patients were included in the analysis. AWS was reported in 11 056 (0.7%). The rate increased to 0.9% in patients admitted for more than 2 days and 1.1% in those admitted for more than 3 days. Patients with AWS were more likely to be male (82.7% vs. 60.7%, p<0.001), have a history of alcohol use disorder (AUD) (70.3% vs. 5.6%, p<0.001) and have a positive blood alcohol concentration (BAC) on admission (68.2% vs. 28.6%, p<0.001). In a multivariable logistic regression, history of AUD (OR 12.9, 95% CI 12.1 to 13.7), cirrhosis (OR 2.1, 95% CI 1.9 to 2.3), positive toxicology screen for barbiturates (OR 2.1, 95% CI 1.6 to 2.7), tricyclic antidepressants (OR 2.2, 95% CI 1.5 to 3.1) or alcohol (OR 2.5, 95% CI 2.4 to 2.7), and Abbreviated Injury Scale head score of ≥3 (OR 1.7, 95% CI 1.6 to 1.8) were the strongest predictors for AWS. Conversely, only 2.7% of patients with a positive BAC on admission, 7.6% with a history of AUD and 4.9% with cirrhosis developed AWS. Conclusion: AWS after trauma was an uncommon occurrence in the patients in the PUF, even in higher-risk patient populations. Level of evidence: IV: retrospective study with more than one negative criterion.

Hepatopancreatobiliary malignancies: time to treatment matters.

Background: Initiation of oncologic care is often delayed, yet little is known about delays in hepatopancreatobiliary (HPB) cancers or their impact. This retrospective cohort study describes trends in time to treatment initiation (TTI), assesses the association between TTI and survival, and identifies predictors of TTI in HPB cancers. Methods: The National Cancer Database was queried for patients with cancers of the pancreas, liver, and bile ducts between 2004 and 2017. Kaplan-Meier survival analysis and Cox regression were used to investigate the association between TTI and overall survival for each cancer type and stage. Multivariable regression identified factors associated with longer TTI. Results: Of 318,931 patients with HPB cancers, median TTI was 31 days. Longer TTI was associated with increased mortality in patients with stages I-III extrahepatic bile duct (EHBD) cancer and stages I-II pancreatic adenocarcinoma. Patients treated within 3-30, 31-60, and 61-90 days had median survivals of 51.5, 34.9, and 25.4 months (log-rank P<0.001), respectively, for stage I EHBD cancer, and 18.8, 16.6, and 15.2 months for stage I pancreatic cancer, respectively (P<0.001). Factors associated with increased TTI included stage I disease (+13.7 days vs. stage IV, P<0.001), treatment with radiation only (ß=+13.9 days, P<0.001), Black race (+4.6 days, P<0.001) and Hispanic ethnicity (+4.3 days, P<0.001). Conclusions: Some HPB cancer patients with longer time to definitive care experienced higher mortality than patients treated expeditiously, particularly in non-metastatic EHBD cancer. Black and Hispanic patients are at risk for delayed treatment. Further research into these associations is needed.

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

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

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

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

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

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

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

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

Population-Based Estimates of 1-Year Mortality After Major Surgery Among Community-Living Older US Adults.

Importance: Despite their importance to guiding public health decision-making and policies and to establishing programs aimed at improving surgical care, contemporary nationally representative mortality data for geriatric surgery are lacking. Objective: To calculate population-based estimates of mortality after major surgery in community-living older US adults and to determine how these estimates differ according to key demographic, surgical, and geriatric characteristics. Design, Setting, and Participants: Prospective longitudinal cohort study with 1 year of follow-up in the continental US from 2011 to 2018. Participants included 5590 community-living fee-for-service Medicare beneficiaries, aged 65 years or older, from the National Health and Aging Trends Study (NHATS). Data analysis was conducted from February 22, 2021, to March 16, 2022. Main Outcomes and Measures: Major surgeries and mortality over 1 year were identified through linkages with data from the Centers for Medicare & Medicaid Services. Data on frailty and dementia were obtained from the annual NHATS assessments. Results: From 2011 to 2017, of the 1193 major surgeries (from 992 community-living participants), the mean (SD) age was 79.2 (7.1) years; 665 were women (55.7%), and 30 were Hispanic (2.5%), 198 non-Hispanic Black (16.6%), and 915 non-Hispanic White (76.7%). Over the 1-year follow-up period, there were 206 deaths representing 872 096 survey-weighted deaths and 13.4% (95% CI, 10.9%-15.9%) mortality. Mortality rates were 7.4% (95% CI, 4.9%-9.9%) for elective surgeries and 22.3% (95% CI, 17.4%-27.1%) for nonelective surgeries. For geriatric subgroups, 1-year mortality was 6.0% (95% CI, 2.6%-9.4%) for persons who were nonfrail, 27.8% (95% CI, 21.2%-34.3%) for those who were frail, 11.6% (95% CI, 8.8%-14.4%) for persons without dementia, and 32.7% (95% CI, 24.3%-41.0%) for those with probable dementia. The age- and sex-adjusted hazard ratios for 1-year mortality were 4.41 (95% CI, 2.53-7.69) for frailty with a reduction in restricted mean survival time of 48.8 days and 2.18 (95% CI, 1.40-3.40) for probable dementia with a reduction in restricted mean survival time of 44.9 days. Conclusions and Relevance: In this study, the population-based estimate of 1-year mortality after major surgery among community-living older adults in the US was 13.4% but was 3-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery.

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

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

Geriatric vulnerability and the burden of disability after major surgery.

BACKGROUND: Strong epidemiologic evidence linking indicators of geriatric vulnerability to long-term functional outcomes after major surgery is lacking. The objective of this study was to evaluate the association between geriatric vulnerability and the burden of disability after hospital discharge for major surgery. METHODS: From a prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older, 327 admissions for major surgery were identified from 247 participants who were discharged from the hospital from March 1997 to December 2017. The indicators of geriatric vulnerability were ascertained immediately prior to the major surgery or during the prior comprehensive assessment, which was completed every 18 months. Disability in 13 essential, instrumental and mobility activities was assessed each month. RESULTS: The burden of disability over the 6 months after major surgery was considerably greater for non-elective than elective surgery. In multivariable analysis, 10 factors were independently associated with disability burden: age 85 years or older, female sex, Black race or Hispanic ethnicity, neighborhood disadvantage, multimorbidity, frailty, one or more disabilities, low functional self-efficacy, smoking, and obesity. The burden of disability increased with each additional vulnerability factor, with mean values (credible intervals) increasing from 1.6 (1.4-1.9) disabilities for 0-1 vulnerability factors to 6.6 (6.0-7.2) disabilities for 7 or more vulnerability factors. The corresponding values were 1.2 (0.9-1.5) and 5.9 (5.0-6.7) disabilities for elective surgery and 2.6 (2.1-3.1) and 8.2 (7.3-9.2) disabilities for non-elective surgery. CONCLUSIONS: The burden of disability after hospital discharge for major surgery increases progressively as the number of geriatric vulnerability factors increases. These factors can be used to identify older persons who are particularly susceptible to poor functional outcomes after major surgery, and a subset may be amenable to intervention, including frailty, low functional self-efficacy, smoking, and obesity.

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

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

Evaluation of mild cognitive impairment and dementia in patients with metastatic renal cell carcinoma.

BACKGROUND: Dementia and cancer are both more common in adults as they age. As new cancer treatments become more popular, it is important to consider how these treatments might affect older patients. This study evaluates metastatic renal cell carcinoma (mRCC) as a risk factor for older adults developing mild cognitive impairment or dementia (MCI/D) and the impact of mRCC-directed therapies on the development of MCI/D. METHODS: We identified patients diagnosed with mRCC in a Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset from 2007 to 2015 and matched them to non-cancer controls. Exclusion criteria included age < 65 years at mRCC diagnosis and diagnosis of MCI/D within the year preceding mRCC diagnosis. The main outcome was time to incident MCI/D within one year of mRCC diagnosis for cases or cohort entry for non-cancer controls. Cox proportional hazards models were used to measure associations between mRCC and incident MCI/D as well as associations of oral anticancer agent (OAA) use with MCI/D development within the mRCC group. RESULTS: Patients with mRCC (n = 2533) were matched to non-cancer controls (n = 7027). mRCC (hazard ratio [HR] 8.52, p < .001), being older (HR 1.05 per 1-year age increase, p < .001), and identifying as Black (HR 1.92, p = .047) were predictive of developing MCI/D. In addition, neither those initiating treatment with OAAs nor those who underwent nephrectomy were more likely to develop MCI/D. CONCLUSIONS: Patients with mRCC were more likely to develop MCI/D than those without mRCC. The medical and surgical therapies evaluated were not associated with increased incidence of MCI/D. The increased incidence of MCI/D in older adults with mRCC may be the result of the pathology itself or risk factors common to the two disease processes.