Olfactory Impairment and the Risk of Major Adverse Cardiovascular Outcomes in Older Adults.

BACKGROUND: Olfactory impairment is common in older adults and may be associated with adverse cardiovascular health; however, empirical evidence is sparse. We examined olfaction in relation to the risk of coronary heart disease (CHD), stroke, and congestive heart failure (CHF). METHODS AND RESULTS: This study included 2537 older adults (aged 75.6±2.8 years) from the Health ABC (Health, Aging, and Body Composition) study with olfaction assessed by the 12-item Brief Smell Identification Test in 1999 to 2000, defined as poor (score ≤8), moderate (9-10), or good (11-12). The outcomes were incident CHD, stroke, and CHF. During up to a 12-year follow-up, 353 incident CHD, 258 stroke, and 477 CHF events were identified. Olfaction was statistically significantly associated with incident CHF, but not with CHD or stroke. After adjusting for demographics, risk factors, and biomarkers of CHF, the cause-specific hazard ratio (HR) of CHF was 1.32 (95% CI, 1.05-1.66) for moderate and 1.28 (95% CI, 1.01-1.64) for poor olfaction. These associations were robust in preplanned subgroup analyses by age, sex, race, and prevalent CHD/stroke. While the subgroup results were not statistically significantly different, the association of olfaction with CHF appeared to be evident among participants who reported very good to excellent health (HR, 1.47 [95% CI, 1.01-2.14] for moderate; and 1.76 [95% CI, 1.20-2.58] for poor olfaction), but not among those with fair to poor self-reported health (HR, 1.04 [95% CI, 0.64-1.70] for moderate; and 0.92 [95% CI, 0.58-1.47] for poor olfaction). CONCLUSIONS: In community-dwelling older adults, a single olfaction test was associated with a long-term risk for incident CHF, particularly among those reporting very good to excellent health.

Olfaction and Mobility in Older Adults.

Importance: Decreased mobility is a hallmark of aging. Olfactory dysfunction is common in older adults and may be associated with declines in mobility. Objective: To determine whether poor olfaction was associated with faster declines in mobility in older adults. Design, Setting, and Participants: This cohort study included 2500 participants from the Health, Aging, and Body Composition Study. Participants completed the Brief Smell Identification Test during the year 3 clinical visit (1999-2000) and were followed for up to 7 years. A data analysis was conducted between January and July 2023. Exposures: Olfaction was defined as good (test score, 11-12), moderate (9-10), hyposmia (7-8), or anosmia (0-6). Main Outcomes and Measures: Mobility was measured using the 20-m usual and fast walking tests in clinical visit years 3 to 6, 8, and 10 and the 400-m fast walking test in years 4, 6, 8, and 10. Results: The primary analyses included 2500 participants (1292 women [51.7%]; 1208 men [48.3%]; 960 Black [38.4%] and 1540 White [61.6%] individuals; mean [SD] age, 75.6 [2.8] years). Multivariate-adjusted analyses showed that poor olfaction was associated with slower walking speed at baseline and a faster decline over time. Taking the 20-m usual walking test as an example, compared with participants with good olfaction, the speed at baseline was 0.027 (95% CI, 0-0.053) m/s slower for those with hyposmia and 0.034 (95% CI, 0.005-0.062) m/s slower for those with anosmia. Longitudinally, the annual decline was 0.004 (95% CI, 0.002-0.007) m/s/year faster for those with hyposmia and 0.01 (95% CI, 0.007-0.013) m/s/year faster for those with anosmia. Similar results were obtained for the 20-m and 400-m fast walking tests. Further, compared with participants with good olfaction, the odds of being unable to do the 400-m test were 2.02 (95% CI, 1.17-3.48) times higher for those with anosmia at the year 8 visit and 2.73 (95% CI, 1.40-5.35) times higher at year 10. Multiple sensitivity and subgroup analyses supported the robustness and generalizability of the findings. Conclusion and Relevance: The results of this cohort study suggest that poor olfaction is associated with a faster decline in mobility in older adults. Future studies should investigate underlying mechanisms and potential health implications.

Air Pollutants and Risk of Parkinson's Disease among Women in the Sister Study.

BACKGROUND: Air pollutants may contribute to the development of Parkinson's disease (PD), but empirical evidence is limited and inconsistent. OBJECTIVES: This study aimed to prospectively investigate the associations of PD with ambient exposures to fine particulate matter with aerodynamic diameter ≤2.5µm (PM2.5) and nitrogen dioxide (NO2). METHODS: We analyzed data from 47,108 US women from the Sister Study, enrolled from 2003-2009 (35-80 years of age) and followed through 2018. Exposures of interest included address-level ambient PM2.5 and NO2 in 2009 and their cumulative averages from 2009 to PD diagnosis with varying lag-years. The primary outcome was PD diagnosis between 2009 and 2018 (n=163). We used multivariable Cox proportional hazards and time-varying Cox models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: NO2 exposure in 2009 was associated with PD risk in a dose-response manner. The HR and 95% CI were 1.22 (95% CI: 1.03, 1.46) for one interquartile [4.8 parts per billion (ppb)] increment in NO2, adjusting for age, race and ethnicity, education, smoking status, alcohol drinking, caffeine intake, body mass index, physical activity, census region, residential area type, area deprivation index (ADI), and self-reported health status. The association was confirmed in secondary analyses with time-varying averaged cumulative exposures. For example, the multivariable adjusted HR for PD per 4.8 ppb increment in NO2 was 1.25 (95% CI: 1.05, 1.50) in the 2-year lag analysis using cumulative average exposure. Post hoc subgroup analyses overall confirmed the association. However, statistical interaction analyses found that the positive association of NO2 with PD risk was limited to women in urban, rural, and small town areas and women with ≥50th percentile ADI but not among women from suburban areas or areas with <50th percentile ADI. In contrast, PM2.5 exposure was not associated with PD risk with the possible exception for women from the Midwest region of the US (HRinterquartile-range=2.49, 95% CI: 1.20, 5.14) but not in other census regions. DISCUSSION: In this nationwide cohort of US women, higher level exposure to ambient NO2 is associated with a greater risk of PD. This finding needs to be independently confirmed and the underlying mechanisms warrant further investigation. https://doi.org/10.1289/EHP13009.

Use of nonsteroidal anti-inflammatory drugs and poor olfaction in women.

BACKGROUND: It is unclear whether regular use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with poor olfaction in older adults. METHODS: We selected 4020 participants, aged 50 to 79 years in 2018, from 36,492 eligible participants in the National Institute of Environmental Health Sciences Sister Study, according to their self-reported olfaction status. Of these, 3406 women completed the 12-item Brief Smell Identification Test. We defined poor olfaction as a test score ≤9 in the primary analysis. We then estimated odds ratios (ORs) and 95% confidence intervals (CIs) from weighted logistic models, accounting for the study design, missing exposures/outcomes, and covariates. RESULTS: Overall, NSAID use was not associated with poor olfaction. However, we found evidence for potential multiplicative interactions. Specifically, the OR comparing regular versus never use of aspirin was 1.8 (95% CI, 1.1-3.2) among women who had not regularly used nonaspirin NSAIDs, while the corresponding OR was 0.8 (95% CI, 0.5-1.2) among nonaspirin NSAID users (P for interaction = 0.016). Similar results were seen for ibuprofen alone versus ibuprofen with other NSAID use (P for interaction = 0.010). Among women using either drug alone, associations with poor olfaction increased with increasing duration and cumulative dose. Post hoc analyses showed that the interactions could not be readily explained by potential biases. Other NSAIDs were not associated with olfaction. CONCLUSION: Long-term regular use of aspirin or ibuprofen was associated with poor olfaction among women who never regularly used other types of NSAIDs. These preliminary findings warrant independent confirmation.

Emergency Medical Services Compliance With Prehospital Stroke Quality Metrics Is Associated With Faster Stroke Evaluation and Treatment.

BACKGROUND: Emergency medical services (EMS) is an important link in the stroke chain of recovery. Various prehospital quality metrics have been proposed for prehospital stroke care, but their individual impact is uncertain. We sought to measure associations between EMS quality metrics and downstream stroke care. METHODS: This is a retrospective analysis of a cohort of EMS-transported stroke patients assembled through a linkage between Michigan's EMS and stroke registries. We used multivariable regression to quantify the independent associations between EMS quality metric compliance (dispatch within 90 seconds of 911 call, prehospital stroke screen documentation [Prehospital stroke scale], glucose check, last known well time, maintenance of scene times ≤15 minutes, hospital prenotification, and intravenous line placement) and shorter door-to-CT times (door-to-CT ≤25), accounting for EMS recognition, age, sex, race, stroke subtype, severity, and duration of symptoms. We then developed a simple EMS quality score based on metrics associated with early CT and examined its associations with hospital stroke evaluation times, treatment, and patient outcomes. RESULTS: Five thousand seven hundred seven EMS-transported stroke cases were linked to prehospital records from January 2018 through June 2019. In multivariable analysis, prehospital stroke scale documentation (adjusted odds ratio, 1.4 [1.2-1.6]), glucose check (1.3 [1.1-1.6]), on-scene time ≤15 minutes (1.6 [1.4-1.9]), hospital prenotification ([2.0 [1.4-2.9]), and intravenous line placement (1.8 [1.5-2.1]) were independently associated with a door-to-CT ≤25 minutes. A 5-point quality score (1 point for each element) was therefore developed. In multivariable analysis, a 1-point higher EMS quality score was associated with a shorter time from EMS contact to CT (-9.2 [-10.6 to -7.8] minutes; P<0.001) and thrombolysis (-4.3 [-6.4 to -2.2] minutes; P<0.001), and higher odds of discharge to home (adjusted odds ratio, 1.1 [1.0-1.2]; P=0.002). CONCLUSIONS: Five EMS actions recommended by national guidelines were associated with rapid CT imaging. A simple quality score derived from these measures was also associated with faster stroke evaluation, greater odds of reperfusion treatment, and discharge to home.

Olfactory impairment and the risk of major adverse cardiovascular outcomes in older adults.

Background: Olfactory impairment is common in older adults and may be associated with adverse cardiovascular health; however, empirical evidence is sparse. Objective: To examine olfaction and the risk of coronary heart disease (CHD), stroke, and congestive heart failure (CHF). Methods: This study included 2,537 older adults (aged 75.6±2.8 years) from the Health ABC Study with olfaction assessed by the 12-item Brief Smell Identification Test in 1999-2000, defined as poor (score ≤8), moderate (9-10), or good (11-12). The outcomes were incident CHD, stroke, and CHF. Results: During up to 12-year follow-up, 353 incident CHD, 258 stroke, and 477 CHF events were identified. Olfaction was associated with incident CHF, but not with CHD or stroke. After adjusting for demographics, the cause-specific hazard ratio (HR) of CHF was 1.35 (95% confidence interval (CI): 1.08, 1.70) for moderate and 1.39 (95%CI: 1.09, 1.76) for poor olfaction. With additional adjustment for lifestyle, chronic diseases, and biomarkers of CHF, the HR was modestly attenuated to 1.32 (95%CI: 1.05, 1.66) for moderate and 1.28 (95%CI: 1.01, 1.64) for poor olfaction. These associations were robust in pre-planned subgroup analyses by age, sex, race, and prevalent CHD/stroke. However, the associations appeared to be evident among participants who reported very-good-to-excellent health (HR=1.47 (95%CI: 1.02, 2.13) for moderate and 1.76, (95%CI: 1.20, 2.57) for poor olfaction). In contrast, null association with CHF was found among those with fair-to-poor self-reported health. Conclusions: In community-dwelling older adults, a single olfaction test was associated with a long-term risk for incident CHF, particularly among those reporting very-good-to-excellent health.

Polygenic risk score for Parkinson's disease and olfaction among middle-aged to older women.

INTRODUCTION: Olfactory impairment and Parkinson's disease (PD) may share common genetic and environmental risk factors. This study investigates the association of a PD polygenic risk score (PRS) with olfaction, and whether the associations are modified by environmental exposures of PM2.5, NO2, or smoking. METHODS: This analysis included 3358 women (aged 50-80) from the Sister Study with genetic data and results from the Brief Smell Identification Test (B-SIT) administered in 2018-2019. PD PRS was calculated using 90 single nucleotide polymorphisms. Olfactory impairment was defined with different B-SIT cutoffs, and PD diagnosis was adjudicated via expert review. We report odds ratios (ORs) and 95% confidence intervals (CIs) from multivariable logistic regression. RESULTS: As expected, PD PRS was strongly associated with the odds of having PD (OR highest vs. lowest quartile = 3.79 (1.64, 8.73)). The highest PRS quartile was also associated with olfactory impairment, with OR ranging from 1.24 (0.98, 1.56) for a B-SIT cutoff of 9 to 1.42 (1.04, 1.92) for a cutoff of 6. For individual B-SIT items, the highest PRS quartile was generally associated with lower odds of correctly identifying the odorant, albeit only statistically significant for pineapple (0.72 (0.56, 0.94), soap (0.76 (0.58, 0.99)) and rose (0.70 (0.54, 0.92)). The association of PD PRS with olfactory impairment was not modified by airborne environmental exposures or smoking. CONCLUSION: These preliminary data suggest that high PD genetic susceptibility is associated with olfactory impairment in middle-aged and older women.

Ambient Air Pollutants and Olfaction among Women 50-79 Years of Age from the Sister Study.

BACKGROUND: Poor olfaction is common in older adults and may have profound adverse implications on their health. However, little is known about the potential environmental contributors to poor olfaction. OBJECTIVE: We investigated ambient fine particulate matter [PM ≤2.5µm in aerodynamic diameter (PM2.5)] and nitrogen dioxide (NO2) in relation to poor olfaction in middle-aged to older women. METHODS: The Sister Study is a nationwide cohort of 50,884 women in the United States with annual average air pollutant exposures estimated based on participants' residences from enrollment (2003-2009) through 2017. This analysis was limited to 3,345 women, 50-79 years of age as of January 2018, who completed the Brief Smell Identification Test (B-SIT) in 2018-2019. Poor olfaction was defined as a B-SIT score of ≤9 in the primary analysis. We conducted multivariable logistic regressions, accounting for covariates and study sampling design. RESULTS: Overall, we found little evidence for associations of air pollutants with poor olfaction. The odds ratio (OR) and 95% confidence interval (CI) of poor olfaction for each interquartile range (IQR) increment of air pollutants in 2006 were 1.03 (95% CI: 0.91, 1.17) for PM2.5 (per 3.3 µg/m3) and 1.08 (95% CI: 0.96, 1.22) for NO2 (per 5.7 ppb). Results were similar in the analyses using the most recent (2017) or the cumulative average (2006-2017) air pollutant exposure data. Secondary analyses suggested potential association in certain subgroups. The OR per IQR was 1.35 (95% CI: 1.11, 1.65) for PM2.5 among younger participants (<54.2 years of age) and 1.87 (95% CI: 1.29, 2.71) for NO2 among current smokers. DISCUSSION: This study did not find convincing evidence that air pollutants have lasting detrimental effects on the sense of smell of women 50-79 years of age. The subgroup analyses are exploratory, and the findings need independent confirmation. https://doi.org/10.1289/EHP12066.

The impact of place-based contextual social and environmental determinants on preterm birth: A systematic review of the empirical evidence.

The objective of this study was to systematically review the available empirical evidence examining associations between preterm birth (PTB) and five domains of place-based contextual social and environmental determinants, including (1) physical environment, (2) residential greenness, (3) neighborhood violence/crime, (4) food accessibility and availability, and (5) health services accessibility, among adult mothers in high-income countries. The evidence in this review suggests an adverse association between damaged physical environment, neighborhood violence/crime, lack of health services accessibility, and PTB. The existing evidence also suggests a beneficial effect of residential greenness on PTB. Further studies are needed to investigate these associations for more understanding of the direction and magnitude of these association and for potential heterogeneity by factors such as race/ethnicity, urban vs rural residence, immigration status, and social class.

Community Health Worker Home Visiting, Birth Outcomes, Maternal Care, and Disparities Among Birthing Individuals With Medicaid Insurance.

Importance: Home visiting is recommended to address maternal and infant health disparities but is underused with mixed impacts on birth outcomes. Community health workers, working with nurses and social workers in a combined model, may be a strategy to reach high-risk individuals, improve care and outcomes, and address inequities. Objective: To assess the association of participation in a home visiting program provided by community health workers working with nurses and social workers (Strong Beginnings) with adverse birth outcomes and maternal care vs usual care among birthing individuals with Medicaid. Design, Setting, and Participants: This retrospective, population-based, propensity score matching cohort study used an administrative linked database, including birth records and Medicaid claims, linked to program participation. The Strong Beginnings program exposure took place in 1 county that includes the second largest metropolitan area in Michigan. Study participants included primarily non-Hispanic Black and Hispanic Strong Beginnings participants and all mother-infant dyads with a Medicaid-insured birth in the other Michigan counties (2016 through 2019) as potential matching nonparticipants. The data were analyzed between 2021 and 2023. Exposure: Participation in Strong Beginnings or usual care. Main Outcomes and Measures: Preterm birth (less than 37 weeks' gestation at birth), very preterm birth (less than 32 weeks' gestation), low birth weight (less than 2500 g at birth), very low birth weight (less than 1500 g), adequate prenatal care, and postnatal care (3 weeks and 60 days). Results: A total of 125 252 linked Medicaid-eligible mother-infant dyads (mean age [SD], 26.6 [5.6] years; 27.1% non-Hispanic Black) were included in the analytical sample (1086 in Strong Beginnings [mean age (SD), 25.5 (5.8) years]; 124 166 in usual prenatal care [mean age (SD), 26.6 (5.5) years]). Of the participants, 144 of 1086 (13.3%) in the SB group and 14 984 of 124 166 (12.1%) in the usual care group had a preterm birth. Compared with usual prenatal care, participation in the Strong Beginnings program was significantly associated with reduced risk of preterm birth (-2.2%; 95% CI, -4.1 to -0.3), very preterm birth (-1.2%; 95% CI, -2.0 to -0.4), very low birth weight (-0.8%; 95% CI, -1.3 to -0.3), and more prevalent adequate prenatal care (3.1%; 95% CI, 0.6-5.6), postpartum care in the first 3 weeks after birth (21%; 95% CI, 8.5-33.5]), and the first 60 days after birth (23.8%; 95% CI, 9.7-37.9]). Conclusions and Relevance: Participation in a home visiting program provided by community health workers working with nurses and social workers, compared with usual care, was associated with reduced risk for adverse birth outcomes, improved prenatal and postnatal care, and reductions in disparities, among birthing individuals with Medicaid. The risk reductions in adverse birth outcomes were greater among Black individuals.

A National Study of Marital Status Differences in Early Uptake of COVID-19 Vaccine among Older Americans.

We provide one of the first nationally representative studies to examine COVID-19 vaccine uptake differences by marital status within the first year after the vaccine was recommended among older Americans. Data were drawn from the National Health and Aging Trends Study (2021). The study sample included 3180 participants aged 65 and older with 1846 women and 1334 men. Results from logistic regression models suggest that divorced/separated older adults were less likely to receive at least one dose of the COVID-19 vaccine in 2021 than their married counterparts, especially among women and individuals with higher education. Widowed and never married respondents were generally not significantly different from married respondents in COVID-19 vaccination status, with only one exception: less-educated never-married respondents were more likely to receive COVID-19 vaccination than their less-educated married counterparts. Our study highlights divorce/separation as a significant social factor associated with COVID-19 vaccine uptake among older adults in the U.S. These findings suggest that divorced/separated older adults are the most vulnerable population segment at risk of low COVID-19 vaccine uptake. Future efforts to improve vaccine equity and uptake should target this group specifically, with tailored interventions to increase their access and uptake of the vaccine.

Models for Delivering Weight Management in Primary Care: Qualitative Results from the MOST Obesity Study.

BACKGROUND: Obesity is a leading cause of morbidity and mortality in the United States (US). Primary care medical practices can educate patients about the health effects of obesity and help patients with obesity lose and manage their weight. However, implementation of weight management in primary care is challenging. We sought to examine how practices that implement weight management services do so feasibly. METHODS: Multiple methods including site visits, observations, interviews, and document reviews were utilized to identify and learn from primary care practices located across the US. A qualitative multidimensional classification of empirical cases was performed to identify unique delivery features that were feasible to implement in primary care. RESULTS: Across 21 practices, 4 delivery models were identified: group, integrated into standard primary care, hiring an "other" professional, and using a specific program. Model characteristics included who delivered the weight management services, whether delivered to an individual or group, the types of approaches used, and how the care was reimbursed or paid. Most practices integrated weight management services and primary care delivery, although some created specific carve-out programs. CONCLUSION: This study identified 4 models that may serve to overcome challenges in delivering weight management services in primary care. Based on practice characteristics, preferences, and resources, primary care practices can identify a model for successfully implementing weight management services that best fits their context and needs. It is time for primary care to truly address obesity care as the health issue it is and make it a standard of care for all patients with obesity.

Parkinson's Disease Case Ascertainment in the Sister Study: A Cohort for Environmental Health Research.

BACKGROUND: Large prospective studies are essential for investigating the environmental causes of Parkinson's disease (PD), but PD diagnosis via clinical exams is often infeasible in such studies. OBJECTIVE: To present case ascertainment strategy and data collection in a US cohort of women. METHODS: In the Sister Study (n = 50,884, baseline ages 55.6±9.0), physician-made PD diagnoses were first reported by participants or their proxies. Cohort-wide follow-up surveys collected data on subsequent diagnoses, medication usage and PD-relevant motor and nonmotor symptoms. We contacted self-reported PD cases and their treating physicians to obtain relevant diagnostic and treatment history. Diagnostic adjudication was made via expert review of all available data, except nonmotor symptoms. We examined associations of nonmotor symptoms with incident PD, using multivariable logistic regression models and reported odds ratio (OR) and 95% confidence intervals (CI). RESULTS: Of the 371 potential PD cases identified, 242 diagnoses were confirmed. Compared with unconfirmed cases, confirmed cases were more likely to report PD diagnosis from multiple sources, medication usage, and motor and nonmotor features consistently during the follow-up. PD polygenic risk score was associated with confirmed PD (ORinter-quartile range = 1.74, 95% CI: 1.45-2.10), but not with unconfirmed cases (corresponding OR = 1.05). Hyposmia, dream-enacting behaviors, constipation, depression, unexplained weight loss, dry eyes, dry mouth, and fatigue were significantly related to PD risk, with ORs from 1.71 to 4.88. Only one of the eight negative control symptoms was associated with incident PD. CONCLUSION: Findings support our PD case ascertainment approach in this large cohort of women. PD prodromal presentation is likely beyond its well-documented profile.

Primary care provider uptake of intensive behavioral therapy for obesity in Medicare patients, 2013-2019.

BACKGROUND: The delivery of Intensive Behavioral Therapy (IBT) for obesity by primary care providers (PCPs) has been covered by Medicare to support elderly individuals with obesity (BMI > 30 kg/m2) in managing their weight since 2011 for individual therapy and 2015 for group therapy. We conducted a cohort study of PCPs in an attempt to understand patterns of uptake of IBT for obesity services among PCPs serving the Medicare population across the U.S. METHODS: We used the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data from 2013 to 2019 to identify all PCPs who served more than 10 Medicare beneficiaries in each of the seven-year period to form a longitudinal panel. The procedure codes G0447 and G0473 were used to identify PCPs who provided IBT; and the characteristics of these providers were compared by the IBT-uptake status. RESULTS: Of the 537,754 eligible PCPs who served Medicare patients in any of the seven years, only 1.2% were found to be IBT service providers in at least one year from 2013 through 2019 (246 always users, 1,358 early adopters, and 4,563 late adopters). IBT providers shared a few common characteristics: they were more likely to be male, internal medicine providers, saw a higher number of Medicare beneficiaries, and practiced in the South and Northeast regions. Having higher proportion of patients with hyperlipidemia was associated with higher likelihood of a provider being an IBT-user. CONCLUSIONS: Very few PCPs continuously billed IBT services for Medicare patients with obesity. Further investigation is needed to mitigate barriers to the uptake of IBT services among PCPs.

Emergency Medical Services Stroke Care Performance Variability in Michigan: Analysis of a Statewide Linked Stroke Registry.

Background Emergency medical services (EMS) compliance with recommended prehospital care for patients with acute stroke is inconsistent; however, sources of variability in compliance are not well understood. The current analysis utilizes a linkage between a statewide stroke registry and EMS information system data to explore patient and EMS agency-level contributions to variability in prehospital care. Methods and Results This is a retrospective analysis of a cohort of confirmed stroke cases transported by EMS to hospitals participating in a statewide stroke registry. Using EMS information system data, the authors quantified EMS compliance with 6 performance measures derived from national guidelines for prehospital stroke care: prehospital stroke scale performance, glucose check, stroke recognition, on-scene time ≤15 minutes, time last known well documentation, and hospital prenotification. Multilevel multivariable logistic regression analysis was then used to examine associations between patient-level demographic and clinical characteristics and EMS compliance while accounting for and quantifying the variation attributable to agency of transport and recipient hospital. Over an 18-month period, EMS and stroke registry records were linked for 5707 EMS-transported stroke cases. Compliance ranged from 24% of cases for last known well documentation to 82% for documentation of a glucose check. The other measures were documented in approximately half of cases. Older age, higher National Institutes of Health Stroke Scale, and earlier presentation were associated with more compliant prehospital care. EMS agencies accounted for more than half of the variation in EMS prehospital stroke scale documentation and last known well documentation and 27% of variation in glucose check but <10% of stroke recognition and prenotification variability. Conclusions EMS stroke care remains highly variable across different performance measures and EMS agencies. EMS agency and electronic medical record type are important sources of variability in compliance with key prehospital performance metrics for stroke.

Prevention of 90-day inpatient detoxification readmission for opioid use disorder by a community-based life-changing individualized medically assisted evidence-based treatment (C.L.I.M.B.) program: A quasi-experimental study.

BACKGROUND: Evidence for community-based strategies to reduce inpatient detoxification readmission for opioid use disorder (OUD) is scant. A pilot program was designed to provide individualized structured treatment plans, including addressing prolonged withdrawal symptoms, family/systems assessment, and contingency management, to reduce readmission after the index inpatient detoxification. METHODS: A non-randomized quasi-experimental design was used to compare the pilot facilities (treatment) and comparison facilities before and after the program started, i.e., a simple difference-in-differences (DID) strategy. Adults 18 years and older who met the Diagnostic and Statistical Manual of Mental Disorders version 5 criteria for OUD and had an inpatient detoxification admission at any OUD treatment facility in two study periods between 7/2016 and 3/2020 were included. Readmission for inpatient detoxification in 90-days after the index stay was the primary outcome, and partial hospitalization, intensive outpatient care, outpatient services, and medications for OUD were the secondary outcomes. Six statistical estimation methods were used to triangulate evidence and adjust for potential confounding factors between treatment and comparison groups. RESULTS: A total of 2,320 unique patients in the pilot and comparison facilities with 2,443 index inpatient detoxification admissions in the pre- and post-periods were included. Compared with patients in comparison facilities, patients in the C.L.I.M.B. facilities had higher readmission in the pre-period (unadjusted readmission 17.0% vs. 10.6%), but similar rates in the post-period (12.3% vs. 10.6%) after the implementation of the pilot program. For 90-day readmission, all DID estimates were not statistically significant (adjusted estimates ranged from 6 to 9 percentage points difference favoring the C.L.I.M.B. program). There was no significant improvement in the secondary outcomes of utilizations in lower level of care and medications for OUD in C.L.I.M.B. facilities. CONCLUSIONS: We found a reduction in readmission in the pilot facilities between the two periods, but the results were not statistically significant compared with the comparison facilities and the utilization of lower level of care services remained low. Even though providers in the pilot OUD treatment facilities actively worked with health plans to standardize care for patients with OUD, more strategies are needed to improve treatment engagement and retention after an inpatient detoxification.

Study protocol: The Maternal Health Multilevel Intervention for Racial Equity (Maternal Health MIRACLE) Project.

PURPOSE: To test the effectiveness and cost-effectiveness of a multilevel intervention for population-level African American (AA) severe maternal morbidity and mortality. BACKGROUND: Severe maternal morbidity and mortality in the U.S. disproportionately affect AA women. Inequities occur at many levels, including community, provider, and health system levels. DESIGN: Intervention. Throughout the two intervention counties, we will expand access to enhanced prenatal care services using telehealth and flexible scheduling (community level), provide actionable maternal health-focused anti-racism training (provider level), and implement equity-focused community care maternal safety bundles (health system level). Partnership. Interventions were developed/co-developed by intervention county partners, including AA women, enhanced prenatal care staff, and health providers. For equity, 46% of project direct cost dollars go to our partners. Most study investigators are female (75%) and/or AA (38%). Partners are overwhelmingly AA women. Sample, measures, analyses. We use a quasi-experimental difference-in-differences with propensity scores approach to compare pre (2016-2019) to post (2022-2025) changes in outcomes for Medicaid-insured women in intervention counties to similar women in the other Michigan, USA, counties. The sample includes all Medicaid-insured deliveries in Michigan during these years (n ~ 540,000), with women observed during pregnancy, at birth, and up to 1 year postpartum. Measures are taken from a linked dataset that includes Medicaid claims and vital records. CONCLUSION: This study is among the first to examine effects of any multilevel intervention on AA severe maternal morbidity and mortality. It features a rigorous quasi-experimental design, multilevel multi-partner county-wide interventions developed by community partners, and assessment of intervention effects using population-level data.

Improving diabetic patients' adherence to treatment and prevention of cardiovascular disease (Office Guidelines Applied to Practice-IMPACT Study)-a cluster randomized controlled effectiveness trial.

BACKGROUND: Despite nationwide improvements in cardiovascular disease (CVD) mortality and morbidity, CVD deaths in adults with type 2 diabetes (T2DM) are 2-4 times higher than among those without T2DM. A key contributor to these poor health outcomes is medication non-adherence. Twenty-one to 42% of T2DM patients do not take blood sugar, blood pressure (BP), or statin medications as prescribed. Interventions that foster and reinforce patient-centered communication show promise in improving health outcomes. However, they have not been widely implemented, in part due to a lack of compelling evidence for their effectiveness in real-life primary care settings. METHODS: This pragmatic cluster-randomized trial randomizes 17 teams in 12 Federally Qualified Healthcare Centers (FQHCs) to two experimental groups: intervention (group 1): Office-Gap + Texting vs. control (group 2): Texting only. Office-GAP (Office-Guidelines Applied to Practice) is a patient activation intervention to improve communication and patient-provider partnerships through brief patient and provider training in shared decision-making (SDM) and use of a guideline-based checklist. The texting intervention (Way2Health) is a cell phone messaging service that informs and encourages patients to adhere to goals, adhere to medication use and improve communication. After recruitment, patients in groups 1 and 2 will both attend (1) one scheduled group visit, (90-120 min) conducted by trained research assistants, and (2) follow-up visits with their providers after group visit at 0-1, 3, 6, 9, and 12 months. Data will be collected over 12-month intervention period. Our primary outcome is medication adherence measured using eCAP electronic monitoring and self-report. Secondary outcomes are (a) diabetes-specific 5-year CVD risk as measured with the UK Prospective Diabetes Study (UKPDS) Engine score, (b) provider engagement as measured by the CollaboRATE Shared-Decision Making measure, and (c) patient activation measures (PAM). DISCUSSION: This study will provide a rigorous pragmatic evaluation of the effectiveness of combined mHealth, and patient activation interventions compared to mHealth alone, targeting patients and healthcare providers in safety net health centers, in improving medication adherence and decreasing CVD risk. Given that 20-50% of adults with chronic illness demonstrate medication non-adherence, increasing adherence is essential to improve CVD outcomes as well as healthcare cost savings. TRIAL REGISTRATION: The ClinicalTrials.gov registration number is NCT04874116.

Depressive symptoms before and after Parkinson's diagnosis-A longitudinal analysis.

BACKGROUND: Depression is common in Parkinson's disease (PD). It is however unclear when and how depressive symptoms develop and progress in the course of PD development. OBJECTIVE: To assess how depressive symptoms evolve in PD, using repeated measures. METHODS: In 2994 older adults, ages 70-79 years, depressive symptoms were assessed 8 times over 11 years using the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10). For each PD patient at each time point, we calculated the difference between CESD-10 score and its expected value estimated based on data from individuals without PD, and then realigned the time scale in reference to the year of PD diagnosis. We examined longitudinal changes in CESD-10 scores before and after PD diagnosis using a joint modeling approach to account for competing risks of non-participation and death. RESULTS: A total of 79 PD patients were identified at enrollment or during the follow-up, with repeatedly assessed depressive symptom data up to 9 years before and after PD diagnosis. We found a monotonic trend of increasing CESD-10 score in PD patients throughout the observational period (p = 0.002). The observed scores became higher than expected approximately 7 years before PD diagnosis and significantly different 1 year before PD diagnosis. CONCLUSIONS: Increasing depressive symptomatology appears to precede PD diagnosis by a few years.