Frailty and cardiovascular mortality in more than 3 million US Veterans.

AIMS: Frailty is associated with an increased risk of all-cause mortality and cardiovascular (CV) events. Limited data exist from the modern era of CV prevention on the relationship between frailty and CV mortality. We hypothesized that frailty is associated with an increased risk of CV mortality. METHODS AND RESULTS: All US Veterans aged ≥65 years who were regular users of Veteran Affairs care from 2002 to 2017 were included. Frailty was defined using a 31-item previously validated frailty index, ranging from 0 to 1. The primary outcome was CV mortality with secondary analyses examining the relationship between frailty and CV events (myocardial infarction, stroke, revascularization). Survival analysis models were adjusted for age, sex, ethnicity, geographic region, smoking, hyperlipidaemia, statin use, and blood pressure medication use. There were 3 068 439 US Veterans included in the analysis. Mean age was 74.1 ± 5.8 years in 2002, 76.0 ± 8.3 years in 2014, 98% male, and 87.5% White. In 2002, the median (interquartile range) frailty score was 0.16 (0.10-0.23). This increased and stabilized to 0.19 (0.10-0.32) for 2006-14. The presence of frailty was associated with an increased risk of CV mortality at every stage of frailty. Frailty was associated with an increased risk of myocardial infarction and stroke, but not revascularization. CONCLUSION: In this population, both the presence and severity of frailty are tightly correlated with CV death, independent of underlying CV disease. This study is the largest and most contemporary evaluation of the relationship between frailty and CV mortality to date. Further work is needed to understand how this risk can be diminished. KEY QUESTION: Can an electronic frailty index identify adults aged 65 and older who are at risk of CV mortality and major CV events? KEY FINDING: Among 3 068 439 US Veterans aged 65 and older, frailty was associated with an increased risk of CV mortality at every level of frailty. Frailty was also associated with an increased risk of myocardial infarction and stroke, but not revascularization. TAKE HOME MESSAGE: Both the presence and severity of frailty are associated with CV mortality and major CV events, independent of underlying CV disease.

Defining Employment Specialist Competencies: Results of a Participatory Research Study.

The preponderance of research conducted on supported employment has focused on the structure of interventions with little empirical investigation into the contribution of employment specialists to work outcomes. Using a participatory approach, we identified competencies essential to the role of the employment specialists, operationalized and refined those competencies using the perspectives of experts, service recipients, and employment specialists themselves. We conducted an online survey with 34 candidate items and n = 142 respondents. Results suggested good psychometric properties, stability and coherence of the Vocational Practices and Relationship Scale. A total of n = 23 final items tapping the working alliance coalesced into a strong factor, as did strategies for promoting vocational recovery, suggesting that the scale warrants wide-scale testing for predictive validity. We consider these constructs and competencies to be a potential blueprint for training employment specialists, not only in technical skills and strategies, but also to increase the hope for vocational recovery among those they serve.

Peer Support Specialist Work and Experiences During the COVID-19 Pandemic: A National Longitudinal Study.

OBJECTIVE: The study followed up with peer support specialists (PSSs) responding to an earlier survey to assess the pandemic's continued employment and personal effects. METHODS: A December 2020 online survey was conducted with respondents to a May 2020 survey. Items on employment status, work tasks, challenges, support, and benefits were included. Responses were analyzed with descriptive and inferential statistics. RESULTS: A total of 496 PSSs completed both surveys. Unemployment remained at 7%. The proportion with full-time employment increased by December, but financial instability also increased. Tasks involving individual support and group facilitation, which had decreased significantly, rebounded somewhat by December, when nearly all PSSs (86%) reported having some new tasks. Job satisfaction remained stable and high. In both surveys, about 75% reported pandemic-related benefits. Symptoms and housing instability among clients increased. CONCLUSIONS: Pandemic-related PSS unemployment was relatively stable, and work tasks evolved. Respondents reported increasing needs among clients, as well as pandemic-related work benefits.

Impact of COVID-19 on Peer Support Specialists in the United States: Findings From a Cross-Sectional Online Survey.

OBJECTIVE: Peer support specialists (PSS) are an integral part of the mental health workforce. The purpose of this study was to better understand how the COVID-19 pandemic affected their employment status and day-to-day work. METHODS: A cross-sectional, online survey was conducted (May-June 2020). Recruitment occurred through the National Association of Peer Specialists and additional snowball sampling. Closed- and open-ended questions sought information about employment status, work tasks, challenges faced by PSS and by individuals they supported, and positive impacts they experienced. RESULTS: A total of 1,280 surveys were analyzed. Nine percent of respondents reported having lost their job as a result of COVID-19. Of these, 65% reported a length of employment of 2 or more years, and 61% reported working 35 hours or less per week. Job tasks changed dramatically, with 73% reporting engagement in new tasks, including increased reliance on technology (N=717), increased coordination of resources (N=123), and COVID-19-related tasks (N=142). Engagement in some support tasks decreased significantly from prepandemic levels, including individual support provision (p<0.001) and group facilitation (p<0.001). Respondents reported significant challenges among individuals they supported, including increased isolation (92%), substance use (67%), housing instability (38%), and food insecurity (64%). Although respondents also reported challenges, satisfaction with organizational and supervisory support was high. Most respondents (73%) reported positive impacts or benefits from the pandemic. CONCLUSIONS: The changing roles and tasks identified in this study have implications for hiring, training, supervising, and supporting peer staff. The peer workforce demonstrated flexibility and commitment to meeting increasing needs.

Development of a comprehensive inventory of community participation for individuals with psychiatric disabilities.

OBJECTIVE: The social lives of individuals with psychiatric conditions are often characterized by isolation and a lack of meaningful engagement in communities of their choice. The purpose of this study was to develop and test a comprehensive and multidimensional measure of community participation for use in research, evaluation, and service provision. METHOD: We conducted this study in phases beginning with conceptual activities and culminating in the psychometric testing of the reliability and validity of the Inventory of Community Participation for individuals with Mental Health conditions (ICP-MH). Data were collected from a total of 301 participants using a variety of legacy and newly constructed items as well as a subscale using narrative vignettes, all designed to assess levels of community participation. Data were analyzed using both classical test and item response theory approaches. RESULTS: Statistical analyses suggest excellent internal consistency, convergent and divergent validity. The novel approach of vignettes to depict community participation was well-received and suggests a subscale with excellent psychometric properties. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: We conceptualized, operationalized and assessed tested a multidimensional scale of community participation utilizing both traditional and novel assessment methods. The ICP-MH assesses essential objective and subjective factors of community participation and can provide valuable data to test the effectiveness of community-oriented interventions, as well as information which can be used to guide treatment and services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Racial and Ethnic Disparities in U.S. Veteran Health Characteristics.

Racial/ethnic health disparities persist among veterans despite comparable access and quality of care. We describe racial/ethnic differences in self-reported health characteristics among 437,413 men and women (mean age (SD) = 64.5 (12.6), 91% men, 79% White) within the Million Veteran Program. The Cochran-Mantel-Haenszel test and linear mixed models were used to compare age-standardized frequencies and means across race/ethnicity groups, stratified by gender. Black, Hispanic, and Other race men and women reported worse self-rated health, greater VA healthcare utilization, and more combat exposure than Whites. Compared to White men, Black and Other men reported more circulatory, musculoskeletal, mental health, and infectious disease conditions while Hispanic men reported fewer circulatory and more mental health, infectious disease, kidney, and neurological conditions. Compared to White women, Black women reported more circulatory and infectious disease conditions and Other women reported more infectious disease conditions. Smoking rates were higher among Black men, but lower for other minority groups compared to Whites. Minority groups were less likely to drink alcohol and had lower physical fitness than Whites. By identifying differences in burden of various health conditions and risk factors across different racial/ethnic groups, our findings can inform future studies and ultimately interventions addressing disparities.

Phenome-wide association of 1809 phenotypes and COVID-19 disease progression in the Veterans Health Administration Million Veteran Program.

BACKGROUND: The risk factors associated with the stages of Coronavirus Disease-2019 (COVID-19) disease progression are not well known. We aim to identify risk factors specific to each state of COVID-19 progression from SARS-CoV-2 infection through death. METHODS AND RESULTS: We included 648,202 participants from the Veteran Affairs Million Veteran Program (2011-). We identified characteristics and 1,809 ICD code-based phenotypes from the electronic health record. We used logistic regression to examine the association of age, sex, body mass index (BMI), race, and prevalent phenotypes to the stages of COVID-19 disease progression: infection, hospitalization, intensive care unit (ICU) admission, and 30-day mortality (separate models for each). Models were adjusted for age, sex, race, ethnicity, number of visit months and ICD codes, state infection rate and controlled for multiple testing using false discovery rate (≤0.1). As of August 10, 2020, 5,929 individuals were SARS-CoV-2 positive and among those, 1,463 (25%) were hospitalized, 579 (10%) were in ICU, and 398 (7%) died. We observed a lower risk in women vs. men for ICU and mortality (Odds Ratio (95% CI): 0.48 (0.30-0.76) and 0.59 (0.31-1.15), respectively) and a higher risk in Black vs. Other race patients for hospitalization and ICU (OR (95%CI): 1.53 (1.32-1.77) and 1.63 (1.32-2.02), respectively). We observed an increased risk of all COVID-19 disease states with older age and BMI ≥35 vs. 20-24 kg/m2. Renal failure, respiratory failure, morbid obesity, acid-base balance disorder, white blood cell diseases, hydronephrosis and bacterial infections were associated with an increased risk of ICU admissions; sepsis, chronic skin ulcers, acid-base balance disorder and acidosis were associated with mortality. CONCLUSIONS: Older age, higher BMI, males and patients with a history of respiratory, kidney, bacterial or metabolic comorbidities experienced greater COVID-19 severity. Future studies to investigate the underlying mechanisms associated with these phenotype clusters and COVID-19 are warranted.

Caregiving Status and Health of Heterosexual, Sexual Minority, and Transgender Adults: Results From Select U.S. Regions in the Behavioral Risk Factor Surveillance System 2015 and 2016.

BACKGROUND AND OBJECTIVES: Insufficient research attention has been paid to the diversity of informal caregivers, including sexual and gender minority caregivers. This study examined health effects of caregiving separately from sexual orientation or gender identity status, while stratifying by gender among cisgender adults. We hypothesized that compared with heterosexual cisgender noncaregivers, heterosexual caregivers and lesbian/gay/bisexual (LGB), and transgender (T) noncaregivers would report poorer health outcomes (i.e., self-reported health, and poor mental health days and poor physical health days), and LGBT caregivers would report the worst health outcomes. RESEARCH DESIGN AND METHODS: This is a secondary data analysis of the 2015 and 2016 Behavioral Risk Factor Surveillance System data from 19 U.S. states. RESULTS: After adjusting for covariates and stratifying by gender among the cisgender sample, heterosexual caregivers, LGB noncaregivers and LGB caregivers had significantly higher odds of self-reported fair or poor health (adjusted odds ratios [aORs] 1.3-2.0 for women and 1.2 for men), poor physical health days (aORs 1.2-2.8 for women and 1.3-2.8 for men), and poor mental health days (aORs 1.4-4.7 for women and 1.5-5.6 for men) compared with heterosexual noncaregivers (reference group). By contrast, transgender caregivers did not have significantly poorer health than cisgender noncaregivers. DISCUSSION AND IMPLICATIONS: LGB caregivers reported the worst health compared with other groups on multiple measures, signifying they are an at-risk population. These results suggest the necessity to develop LGB appropriate services and programs to prevent poor health in LGB caregivers. Existing policies should also be inclusive of LGBT individuals who are caregivers.

Design analysis indicates Potential overestimation of treatment effects in randomized controlled trials supporting Food and Drug Administration cancer drug approvals.

OBJECTIVE: Statistical significance drives interpretation of randomized controlled trials (RCTs). We examined the type S error risk-claiming a new drug is falsely beneficial-and exaggeration ratio-how estimated effects differ from true effects-to re-emphasize direction and magnitude of treatment effects. STUDY DESIGN AND SETTING: We systematically reviewed RCTs supporting Food and Drug Administration (FDA) approval of cancer drugs between 2007 and 2016. We extracted data for overall survival (OS), progression-free survival (PFS), and response outcomes from FDA reviews. We estimated type S error risks and exaggeration ratios by considering replicated RCTs of equal size and a range of true effects. RESULTS: We analyzed 42 RCTs for 39 approved drugs. Across 38 RCTs reporting OS, the median type S error risk was 0.00% (Q1-Q3, 0.00-0.01%) and 3.56% (0.40-6.74%), for true hazard ratios of 0.7 and 0.9, respectively, indicating confidence in effect direction. The corresponding exaggeration ratios were 1.09 (1.01-1.11) and 1.30 (1.13-1.42), indicating median overestimations of 9% and 30%. Similar results held for PFS and response outcomes. CONCLUSIONS: The type S error risk and exaggeration ratio provide additional insights into the replicability of RCTs. Our analyses also quantify the winner's curse, in which pivotal RCTs tend toward overoptimism.