Potential Overtreatment of Hyperglycemia in Older Adults: A Factorial Vignette Study of Primary Care Clinicians

University of Minnesota Ph.D. dissertation. July 2016. Major: Health Services Research, Policy and Administration. Advisor: Robert Kane. 1 computer file (PDF); ix, 108 pages.Background Diabetes is characterized by high blood sugar, or hyperglycemia. In addition to diet and exercise, several classes of medications are commonly used to treat hyperglycemia in type 2 diabetes in an attempt to reduce the downstream vascular complications of the disease. Four large trials showed few benefits and significant harms from attempting to achieve near normal glycemic control in middle aged people with type 2 diabetes. Benefits of aggressive glycemic control are further reduced for older adults with longstanding disease, those who have accumulated many of the complications of diabetes, and people with other comorbid conditions that limit life expectancy. This more complex older adult population is also at greater risk of iatrogenic hypoglycemia, a harm associated with treatment. For these reasons the American Diabetes Association and the American Geriatric Society have published guidelines recommending less stringent glycemic control for older adults with multiple comorbid conditions and limited life expectancies. However, little is known about how these guidelines are being implemented by primary care clinicians who provide most of the chronic disease management in the US. Methods A factorial vignette study was used to determine the effect of the patient characteristics mentioned in the existing guidelines on a clinician’s decision to prescribe a second-line treatment to achieve tighter glycemic control. The factors varied were patient age / disease duration (65 with short disease duration, 80 with long disease duration), cardiovascular disease (no heart disease, coronary artery disease with previous bypass), and cognitive impairment (no impairment, cognitive impairment that restricted ability to drive). Two policy-relevant glycated hemoglobin (HbA1c) levels were varied in the vignettes: 7.5% or 8.5%. Independent and combined effects of patient factors (patient complexity) were considered. Primary care clinicians from around the US were asked to participate via email. Clinician information was collected, including: years in practice, familiarity with treating older adults, and clinician type (family, internal, nurse practitioner). Clinicians were also asked to predict how likely the hypothetical patient was to adhere to their medication choices. Mixed effect models were used to account for the panel nature of the data (clinicians viewing multiple vignettes). Results 366 primary care clinicians from 36 states participated, with the majority of respondents practicing in Minnesota (35% of sample) or Florida (26% of sample). While we found some sensitivity to the patient factors mentioned in the existing guidelines, we also found evidence of overtreatment of the most complex hypothetical patients. For example, an 80-year-old with longstanding diabetes, cognitive impairment, and coronary artery disease requiring bypass had a second-line treatment added 35% of the time at a HbA1c level of 7.5%, and 75% of the time at a HbA1c of 8.5%. The same patient was recommended a sulfonylurea or insulin (agents known to increase the risk of iatrogenic hypoglycemia) 36% of the time at a HbA1c level of 7.5% and 44% of the time at a HbA1c level of 8.5%. Family practice physicians were less likely to add an additional medication than internal medicine physicians or nurse practitioners. Clinicians did not incorporate their adherence predictions into their decisions to intensify medication therapy. Conclusions This work is part of a larger discussion around balancing the risks and benefits of aggressively treating hyperglycemia in older adults with type 2 diabetes for whom tight glycemic control produces few benefits and significantly increases risk for iatrogenic hypoglycemia. Clinicians may treat more aggressively than guidelines recommend because they are unfamiliar with the geriatric-specific guidelines or they may work in settings where performance incentives are tied to achieving HbA1c levels recommended for average or healthier patients. As few benefits and serious harms are associated with overtreatment, policy recommendations include: 1. creating performance incentives to reduce anti-glycemic medication therapy when appropriate; and 2. developing tools to help primary care clinicians evaluate and address complexity and life expectancy in their older patients with multiple chronic conditions

Using Healthcare Data in Embedded Pragmatic Clinical Trials among People Living with Dementia and Their Caregivers: State of the Art

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/156003/1/jgs16617_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/156003/2/jgs16617.pd

Occurrence of Typhoid Fever Complications and Their Relation to Duration of Illness Preceding Hospitalization: A Systematic Literature Review and Meta-analysis.

BACKGROUND:Complications from typhoid fever disease have been estimated to occur in 10%-15% of hospitalized patients, with evidence of a higher risk in children and when delaying the implementation of effective antimicrobial treatment. We estimated the prevalence of complications in hospitalized patients with culture-confirmed typhoid fever and the effects of delaying the implementation of effective antimicrobial treatment and age on the prevalence and risk of complications. METHODS:A systematic review and meta-analysis were performed using studies in the PubMed database. We rated risk of bias and conducted random-effects meta-analyses. Days of disease at hospitalization (DDA) was used as a surrogate for delaying the implementation of effective antimicrobial treatment. Analyses were stratified by DDA (DDA <10 versus ≥10 mean/median days of disease) and by age (children versus adults). Differences in risk were assessed using odds ratios (ORs) and 95% confidence intervals (CIs). Heterogeneity and publication bias were evaluated with the I2 value and funnel plot analysis, respectively. RESULTS:The pooled prevalence of complications estimated among hospitalized typhoid fever patients was 27% (95% CI, 21%-32%; I2 = 90.9%, P < .0001). Patients with a DDA ≥ 10 days presented higher prevalence (36% [95% CI, 29%-43%]) and three times greater risk of severe disease (OR, 3.00 [95% CI, 2.14-4.17]; P < .0001) than patients arriving earlier (16% [95% CI, 13%- 18%]). Difference in prevalence and risk by age groups were not significant. CONCLUSIONS:This meta-analysis identified a higher overall prevalence of complications than previously reported and a strong association between duration of symptoms prior to hospitalization and risk of serious complications

Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD

BackgroundPrevious research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents after the Centers for Medicare & Medicaid Services National Partnership to Improve Dementia Care. Given known health and healthcare disparities among Black NH residents, we examined how race and Alzheimer’s and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among NH residents following the partnership.MethodsWe used a quasi- experimental difference- in- differences design to study the quarterly prevalence of schizophrenia among US long- stay NH residents aged 65- years and older, by Black race and ADRD status. Using 2011- 2015 Minimum Data Set 3.0 assessments, our analysis controlled for age, sex, measures of function and frailty (activities of daily living [ADL] and Changes in Health, End- stage disease and Symptoms and Signs scores) and behavioral expressions.ResultsThere were over 1.2 million older long- stay NH residents, annually. Schizophrenia diagnoses were highest among residents with ADRD. Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the partnership. Following the partnership, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to nonblack residents with ADRD who had a decrease of 1.7% (p = 0.007).ConclusionsFollowing the partnership, Black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their MDS assessments, and schizophrenia rates increased for Black NH residents with ADRD only. Further work is needed to examine the impact of - colorblind- policies such as the partnership and to determine if schizophrenia diagnoses are appropriately applied in NH practice, particularly for black Americans with ADRD.See related editorial by Rhodes.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/171195/1/jgs17464.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/171195/2/jgs17464_am.pd

Using structured observations to evaluate the effects of a personalized music intervention on agitated behaviors and mood in nursing home residents with dementia: Results from an embedded, pragmatic randomized controlled trial

OBJECTIVE: The objective of this research was to determine if a personalized music intervention reduced the frequency of agitated behaviors as measured by structured observations of nursing home (NH) residents with dementia. DESIGN: The design was a parallel, cluster-randomized, controlled trial. SETTING: The setting was 54 NH (27 intervention, 27 control) from four geographically-diverse, multifacility NH corporations. PARTICIPANTS: The participants were 976 NH residents (483 intervention, 493 control) with Alzheimer\u27s disease or related dementias (66% with moderate to severe symptoms); average age 80.3 years (SD: 12.3) and 25.1% were Black. INTERVENTION: The intervention was individuals’ preferred music delivered via a personalized music device. MEASUREMENT: The measurement tool was the Agitated Behavior Mapping Instrument, which captures the frequency of 13 agitated behaviors and five mood states during 3-minute observations. RESULTS: The results show that no verbally agitated behaviors were reported in a higher proportion of observations among residents in NHs randomized to receive the intervention compared to similar residents in NHs randomized to usual care (marginal interaction effect (MIE): 0.061, 95% CI: 0.028–0.061). Residents in NHs randomized to receive the intervention were also more likely to be observed experiencing pleasure compared to residents in usual care NHs (MIE: 0.038; 95% CI: 0.008–0.073)). There was no significant effect of the intervention on physically agitated behaviors, anger, fear, alertness, or sadness. CONCLUSIONS: The conclusions are that personalized music may be effective at reducing verbally-agitated behaviors. Using structured observations to measure behaviors may avoid biases of staff-reported measures. (PsycInfo Database Record (c) 2023 APA, all rights reserved

Measuring Effects of Nondrug Interventions on Behaviors: Music & Memory Pilot Study

BACKGROUND/OBJECTIVES: Most people with Alzheimer disease and related dementias will experience agitated and/or aggressive behaviors during the later stages of the disease. These behaviors cause significant stress for people living with dementia and their caregivers, including nursing home (NH) staff. Addressing these behaviors without the use of chemical restraints is a growing focus of policy makers and professional organizations. Unfortunately, evidence for nonpharmacological strategies for addressing dementia-related behaviors is lacking. DESIGN: Six-month, preintervention-postintervention pilot study. SETTING: US NHs (n = 4). PARTICIPANTS: Residents with advanced dementia (n = 45). INTERVENTION: Music & Memory, an individualized music program in which the music a resident preferred when she/he was young is delivered at early signs of agitation, using a personal music player. MEASUREMENTS: Dementia-related behaviors for the same residents were measured three ways: (1) observationally using the Agitation Behavior Mapping Instrument (ABMI); (2) staff report using the Cohen-Mansfield Agitation Inventory (CMAI); and (3) administratively using the Minimum Data Set-Aggressive Behavior Scale (MDS-ABS). RESULTS: ABMI score was 4.1 (SD = 3.0) preintervention while not listening to the music, 4.4 (SD = 2.3) postintervention while not listening to the music, and 1.6 (SD = 1.5) postintervention while listening to music (P \u3c .01). CMAI score was 61.2 (SD = 16.3) preintervention and 51.2 (SD = 16.1) postintervention (P \u3c .01). MDS-ABS score was 0.8 (SD = 1.6) preintervention and 0.7 (SD = 1.4) postintervention (P = .59). CONCLUSION: Direct observations were most likely to capture behavioral responses, followed by staff interviews. Nursing-home based, pragmatic trials that rely solely on available administrative data may fail to detect effects of nonpharmaceutical interventions on behaviors. Findings are relevant to evaluations of nonpharmaceutical strategies for addressing behaviors in NHs, and will inform a large, National Institute on Aging-funded pragmatic trial beginning spring 2019. J Am Geriatr Soc 67:2134-2138, 2019