Self-Reported Delays in Care Do not Predict Increased Mortality in a Cohort of Community-Dwelling Elders

Background: Self-reporting of delayed care is a common measure of access to healthcare. The relationship of such reports to worsened health outcomes is often assumed, but few studies have tested this longitudinal connection. Objective: To determine whether self-reports of delayed care predict increased mortality among community-dwelling elderly. Design: 3-year longitudinal retrospective cohort study. Setting: A five county area of North Carolina. Participants: 4,162 randomly sampled individuals age 65 and older. Measurements: The outcome was the proportional hazard ratio (HR) for death stratified by the factor of interest, baseline self-reports of delayed or foregone care. Control variables included predisposing, enabling, and need factors influencing care seeking and/or mortality. Results: Of 3,964 eligible participants reporting, 61% never, 27% once in awhile, and 12% quite often delayed care. 13% of participants died during the study period. Older age, male gender, lower income, less education, lack of supplemental insurance, less social support, more depression, more severe chronic disease, smoking, and worse self-rated health predict increased mortality (pvalues<.0l). Of these, age, lower income, less education, lack of supplemental insurance, less social support, worse self-rated health, and more depression were significantly associated with more self-reported delays in care. In both an unadjusted and fully adjusted survival model, 3-year mortality rates did not differ among cohorts reporting varying degrees of delayed care. Conclusion: Among community dwelling elders, self-reports of delayed care did not predict increased 3-year mortality rates. These results raise questions about self-reporting of delayed or foregone care as a measure of access to the healthcare system.Master of Public Healt

Rurality or distance to care and the risk of homelessness among Afghanistan and Iraq veterans

INTRODUCTION: To date, no studies have examined the relationship of rurality and distance to nearest VA facility to risk of homelessness. METHODS: We examined differences in the rate of homelessness within a year of a Veteran's first encounter with the VA following last military separation based on rurality and distance to the nearest VA facility using multivariable log-binomial regressions. RESULTS: In our cohort of 708,120 Veterans, 73% were determined to have a forwarding address in urban areas, 59.2% and 86.7% lived within 40 miles of the nearest VA medical center (VAMC), respectively. Veterans living in a rural area and those living between 20+ miles away from the nearest VAMC were at a lower risk for homelessness. CONCLUSIONS: Our unique dataset allowed us to explore the relationship between geography and homelessness. These results are important to policy makers in understanding the risk factors for homelessness among Veterans and planning interventions

Methodological framework to identify possible adverse drug reactions using population-based administrative data [v1; ref status: indexed, http://f1000r.es/3ys]

Purpose: We present a framework for detecting possible adverse drug reactions (ADRs) using the Utah Medicaid administrative data. We examined four classes of ADRs associated with treatment of dementia by acetylcholinesterase inhibitors (AChEIs): known reactions (gastrointestinal, psychological disturbances), potential reactions (respiratory disturbance), novel reactions (hepatic, hematological disturbances), and death. Methods: Our cohort design linked drug utilization data to medical claims from Utah Medicaid recipients. We restricted the analysis to 50 years-old and older beneficiaries diagnosed with dementia-related diseases. We compared patients treated with AChEI to patients untreated with anti-dementia medication therapy. We attempted to remove confounding by establishing propensity-score-matched cohorts for each outcome investigated; we then evaluated the effects of drug treatment by conditional multivariable Cox-proportional-hazard regression. Acute and transient effects were evaluated by a crossover design using conditional logistic regression. Results: Propensity-matched analysis of expected reactions revealed that AChEI treatment was associated with gastrointestinal episodes (Hazard Ratio [HR]: 2.02; 95%CI: 1.28-3.2), but not psychological episodes, respiratory disturbance, or death. Among the unexpected reactions, the risk of hematological episodes was higher (HR: 2.32; 95%CI: 1.47-3.6) in patients exposed to AChEI. AChEI exposure was not associated with an increase in hepatic episodes. We also noted a trend, identified in the case-crossover design, toward increase odds of experiencing acute hematological events during AChEI exposure (Odds Ratio: 3.0; 95% CI: 0.97 - 9.3). Conclusions: We observed an expected association between AChEIs treatment and gastrointestinal disturbances and detected a signal of possible hematological ADR after treatment with AChEIs in this pilot study. Using this analytic framework may raise awareness of potential ADEs and generate hypotheses for future investigations. Early findings, or signal detection, are considered hypothesis generating since confirmatory studies must be designed to determine if the signal represents a true drug safety problem

Rurality or distance to care and the risk of homelessness among Afghanistan and Iraq veterans

INTRODUCTION: To date, no studies have examined the relationship of rurality and distance to nearest VA facility to risk of homelessness. METHODS: We examined differences in the rate of homelessness within a year of a Veteran's first encounter with the VA following last military separation based on rurality and distance to the nearest VA facility using multivariable log-binomial regressions. RESULTS: In our cohort of 708,120 Veterans, 73% were determined to have a forwarding address in urban areas, 59.2% and 86.7% lived within 40 miles of the nearest VA medical center (VAMC), respectively. Veterans living in a rural area and those living between 20+ miles away from the nearest VAMC were at a lower risk for homelessness. CONCLUSIONS: Our unique dataset allowed us to explore the relationship between geography and homelessness. These results are important to policy makers in understanding the risk factors for homelessness among Veterans and planning interventions

Association between specific unmet functional needs and desire to institutionalize among caregivers of older veterans

ObjectivesTo evaluate the associations between specific functional needs of older Veterans and the desire to institutionalize (DTI) among their caregivers. MethodsCross-sectional multivariable logistic regression analysis of 3579 Hero Care survey responses from caregivers of Veterans at five US sites from July to December 2021. Unmet needs were areas in which the caregiver reported the Veteran needed a little more or a lot more help. Caregiver DTI was defined as the caregiver reporting that they had discussed, considered, or taken steps toward a nursing home or assisted living placement for the Veteran or that they felt the Veteran would be better off in such a setting or they were likely to move the Veteran to another living arrangement. ResultsCaregivers were largely white, retired, females with an average age of 71 and with some college education who spent an average of 8-9 h per day 6 days a week caring for a Veteran spouse. There was evidence of associations between the following needs and a DTI: managing incontinence, using the telephone, transportation, and arranging services in the home such as visiting nurses, home care aides, or meals on wheels. Unmet functional needs in other selected domains were not associated with the DTI. ConclusionAmong caregivers of older Veterans, a need for more assistance managing incontinence, telephone use, transportation, and arranging in-home services were associated with the DTI. These may represent functional markers of important clinical determinants for institutionalization as well as potential targets for intervention to reduce caregiver DTI, such as programs that provide more caregiver or Veteran support in the home to meet these needs and reduce caregiver burden

Protocol for an embedded pragmatic clinical trial to test the effectiveness of Aliviado Dementia Care in improving quality of life for persons living with dementia and their informal caregivers

Introduction: Persons living with Alzheimer's disease and related dementias (ADRD) frequently experience pain and behavioral and psychological symptoms of dementia (BPSD) which decrease quality of life (QOL) and influence caregiver burden. Home healthcare professionals however may underrecognize or lack the ability to manage BPSD. Intervention: This protocol describes an ADRD palliative quality assurance performance improvement program for home healthcare, Aliviado Dementia Care-Home Health Edition. It includes training, mentoring, and a toolbox containing intervention strategies. Methods: This embedded pragmatic clinical trial will utilize a multi-site, cluster randomized control design. Recruitment will occur from three home healthcare agencies located in New Jersey, Utah, and Florida. At each agency, care teams will be randomized as clusters and assigned to either the Aliviado Dementia Care program or usual care. We plan to enroll 345 persons living with ADRD and their informal caregiver dyads. The primary outcome will be to measure QOL in both the person living with ADRD and their informal caregiver, and emergency department visits and hospital admissions. Secondary outcomes in the person living with ADRD will include the examination of pain, BPSD, antipsychotic and analgesic use. Secondary outcomes in caregivers include burden, depressive symptoms, functional health and wellbeing, and healthcare utilization. Conclusion: This study will be the first large-scale embedded pragmatic clinical trial in home healthcare focused on care quality and outcomes in addressing QOL in ADRD. If proven successful, the intervention can then be disseminated to agencies throughout the country to improve the quality of care for this vulnerable, underserved population

Neuropsychiatric symptoms in people living with dementia receiving home health services

BackgroundWe sought to describe neuropsychiatric symptoms (NPS) among people living with dementia (PLWD) from diverse racial and ethnic groups receiving home health services while accounting for dementia severity, individual symptom prevalence, and neighborhood disadvantage. MethodsA prospective study using cross-sectional data from n = 192 PLWD receiving skilled home healthcare in New Jersey enrolled in the Dementia Symptom Management at Home Program trial. We prospectively measured symptom prevalence with the Neuropsychiatric Inventory Questionnaire and dementia severity using the Quick Dementia Rating System. A one-way ANOVA determined NPS prevalence by dementia severity (mild, moderate, severe). Fisher's exact tests were used to assess the association of individual symptom prevalence with race and ethnicity and cross tabs to descriptively stratify individual symptom prevalence by dementia severity among groups. A Pearson correlation was performed to determine if a correlation existed among neighborhood disadvantages measured by the Area Deprivation Index (ADI) state decile scores and NPS prevalence and severity. ResultsParticipants identified as non-Hispanic White (50%), non-Hispanic Black (30%), or Hispanic (13%). NPS were prevalent in 97% of participants who experienced 5.4 & PLUSMN; 2.6 symptoms with increased severity (10.8 & PLUSMN; 6.6) and care partner distress (13.8 & PLUSMN; 10.8). NPS increased with dementia severity (p = 0.004) with the greatest difference seen between individuals with mild dementia (4.3 & PLUSMN; 2.3) versus severe dementia (5.9 & PLUSMN; 2.3; p = 0.002). Few differences were found in symptom prevalence by racial and ethnic sub-groups. Nighttime behaviors were higher in non-Hispanic Black (78%), compared with non-Hispanic Whites (46%) with moderate dementia, p = 0.042. State ADI scores were not correlated with the number of NPS reported, or severity. ConclusionsNPS were prevalent and increased with dementia severity with commonalities among racial and ethnic groups with varying levels of neighborhood disadvantage. There is a need for effective methods for improving NPS identification, assessment, and management broadly for homebound PLWD

Data_Sheet_1_Identifying clinical phenotypes of frontotemporal dementia in post-9/11 era veterans using natural language processing.pdf

IntroductionFrontotemporal dementia (FTD) encompasses a clinically and pathologically diverse group of neurodegenerative disorders, yet little work has quantified the unique phenotypic clinical presentations of FTD among post-9/11 era veterans. To identify phenotypes of FTD using natural language processing (NLP) aided medical chart reviews of post-9/11 era U.S. military Veterans diagnosed with FTD in Veterans Health Administration care.MethodsA medical record chart review of clinician/provider notes was conducted using a Natural Language Processing (NLP) tool, which extracted features related to cognitive dysfunction. NLP features were further organized into seven Research Domain Criteria Initiative (RDoC) domains, which were clustered to identify distinct phenotypes.ResultsVeterans with FTD were more likely to have notes that reflected the RDoC domains, with cognitive and positive valence domains showing the greatest difference across groups. Clustering of domains identified three symptom phenotypes agnostic to time of an individual having FTD, categorized as Low (16.4%), Moderate (69.2%), and High (14.5%) distress. Comparison across distress groups showed significant differences in physical and psychological characteristics, particularly prior history of head injury, insomnia, cardiac issues, anxiety, and alcohol misuse. The clustering result within the FTD group demonstrated a phenotype variant that exhibited a combination of language and behavioral symptoms. This phenotype presented with manifestations indicative of both language-related impairments and behavioral changes, showcasing the coexistence of features from both domains within the same individual.DiscussionThis study suggests FTD also presents across a continuum of severity and symptom distress, both within and across variants. The intensity of distress evident in clinical notes tends to cluster with more co-occurring conditions. This examination of phenotypic heterogeneity in clinical notes indicates that sensitivity to FTD diagnosis may be correlated to overall symptom distress, and future work incorporating NLP and phenotyping may help promote strategies for early detection of FTD.</p