Examining Rural vs. Urban Disparities in Community-Based Helper Support and Residential Care Transitions among Medicare Beneficiaries with Dementia and Functional Limitations

Strategies to afford elders with dementia the opportunity to remain in their homes or other community dwelling places are often desirable among various stakeholders. Informal care in the community has been shown to delay nursing home entry. Rural elders in general are particularly vulnerable for institutionalization due to reduced access to adequate community-based support. Less is known regarding geographic disparities in community-based helper support networks over time for people with dementia and functional difficulties and the direct impact of such support on residential care transitions from community dwellings to nursing facilities (i.e., skilled nursing facilities (SNFs), nursing homes, and assisted living facilities). Using a retrospective cohort of community-dwelling Medicare beneficiaries in the Medicare Current Beneficiary Survey (MCBS), this study aimed to examine the presence, magnitude, and sources of community-based helper support over time for Medicare beneficiaries age 65 and older with dementia and ADL/IADL limitations living in rural and urban residences, as well as to determine whether and how such support impacts residential care transitions. Gaps in support for functional limitations (i.e., the absence of reported help for a reported functional difficulty) were found among the full sample; however, the presence of the support gaps for functional limitations did not statistically differ across geographic areas. Compared to persons living in an urban area, persons with dementia and functional limitations who lived in a rural area adjacent to a metropolitan or micropolitan area were, on average, less likely to transition to both short- and long-term care nursing facilities. Rural-urban residence and community-based support were not associated with time-to-transition. Age and number of co-morbidities were significantly associated with time-to-first nursing facility transition. In conclusion, this study did not find evidence of geographic disparities in residential care transitions. However, differences in the composition of support networks of older persons in the community with dementia who are managing functional limitations across rural and urban communities were found. Widespread access to well-supported community living for persons with dementia or their family members who desire this option should remain a policy priority given the perpetual impact of this disease.Doctor of Philosoph

Associations of Social Support and 8-Year Follow-Up Depressive Symptoms: Differences in African American and White Caregivers

The present study used data from the Alzheimer’s Study of Emotions in Caregivers (ASEC) to evaluate perceptions of social support assessed at baseline, as well as changes in social support assessed at a follow-up eight-years later, as predictors of symptoms of change in depression, with a focus on race as a potential moderator of these relationships. Specifically, multiple regression analyses adjusted for age, sex, income, education, race, living arrangement of care recipient at baseline, death of care recipient, the cultural justification for caregiving scale (CJCS), and baseline depressive symptoms were conducted to assess baseline social support ratings, as well as the change in social support over time as a predictor of depression at follow-up—with a focus on moderation by race. Baseline social support (F(1,77) = 7.60, p=.008) was associated with fewer depressive symptoms at follow-up for all participants. The change in social support over time was also related to depressive symptoms, with effects moderated by race (F(1,77) = 7.97, p = .007), such that when support decreased over time depressive symptoms at follow-up were higher for Whites, as compared with African Americans, whereas, when social support increased over time depressive symptoms tended to be similar for both groups. These findings indicate that research designed to plan interventions in caregivers must not ignore potential racial differences with regard to the effects of caregiving on mental health

Influence of Clinical and Demographic Variables on Mycophenolic Acid Pharmacokinetics in Antineutrophil Cytoplasmic Antibody–Associated Vasculitis

Mycophenolic acid (MPA) is used off-label to treat many forms of glomerulonephritis

Pharmacokinetics of Mycophenolic Acid in Patients with Lupus Nephritis

Lupus nephritis is associated with urinary protein excretion, hypoalbuminemia, and renal function declines, which may impact the pharmacokinetics (PK) of mycophenolic acid (MPA)

CYP2C9 genotype and pharmacodynamic responses to losartan in patients with primary and secondary kidney diseases

Losartan is used for anti-proteinuric as well as blood pressure effects in chronic kidney disease (CKD). It is metabolized by cytochrome P450 2C9 to active E-3174. Single nucleotide polymorphisms in CYP2C9 that reduce catalytic activity could reduce clinical benefits. The study aims were to determine whether CYP2C9 variant alleles (*2 and *3) altered urinary protein excretion, glomerular filtration rate, and blood pressure in Caucasians prescribed losartan. Differences between baseline and six-month follow-up outcomes were compared by CYP2C9 genotypes in 59 patients using unpaired T-test or Mann Whitney U test. Primary renal disease patients had a trend toward less favorable antiproteinuric response (−31.7±156 vs −125±323%; p=0.123) when carrying variant alleles. Patients with secondary renal diseases had less favorable diastolic blood pressure (9.8±16.0 mm Hg vs −3.2±10.6 mm Hg; p=0.043) and systolic blood pressure (16.2±27.1 mm Hg vs −5.5±17.5 mm Hg; p=0.044) with CYP2C9 variants. Preliminary results suggest a possible influence of CYP2C9 genotype on proteinuria and blood pressure in Caucasian CKD patients treated with losartan

Examining how study teams manage different viewpoints and priorities in patient‐centered outcomes research: Results of an embedded multiple case study

Abstract Introduction Limited evidence exists about which patient and stakeholder engagement practices support or hinder study teams as they negotiate different viewpoints in decisions about the design and conduct of patient‐centered outcomes research. Methods We applied a multiple‐embedded descriptive case study design for six studies funded by the Patient‐Centered Outcomes Research Institute (PCORI). We interviewed 32 researchers and stakeholder partners, including patients, caregivers and clinicians, and reviewed documents related to each study (e.g., publications, and progress reports submitted to PCORI). Findings Overall, researchers reported that incorporating different viewpoints was a strength or opportunity to learn rather than something to be avoided or dreaded. Across cases, different viewpoints and priorities, often related to ethical or pragmatic considerations, emerged between researchers and stakeholders, between stakeholder groups (e.g., patients and clinicians) or within groups (e.g., amongst researchers). Examples of navigating different viewpoints arose across study phases. The length of time to resolve issues depended on how strongly people disagreed and the perceived importance or impact of decisions on the study. All cases used collaborative decision‐making approaches, often described as consensus, throughout the study. Interviewees described consensus as using negotiation, compromise or working towards an agreeable decision. To encourage consensus, cases actively facilitated group discussions with an openness to diverse opinions, remained flexible and open to trying new things, referenced a ground rule or common goal and delegated decisions to partners or smaller workgroups. When viewpoints were not easily resolved, cases used different approaches to reach final decisions while maintaining relationships with partners, such as elevating decisions to leadership or agreeing to test out an approach. No one engagement structure (e.g., advisory group, coinvestigator) stood out as better able to manage different viewpoints. Teams adjusted engagement structures and behaviours to facilitate an overall culture of inclusion and respect. Partners acknowledged the intentional efforts of researchers to incorporate their perspectives, navigate challenges and communicate the value of partner input. Conclusion By using collaborative decision‐making in the early stages and throughout the study, researchers built trust with partners so that when decisions were difficult to resolve, partners still felt listened to and that their input mattered. Patient or Public Contribution Members of the PCORI Patient Engagement Advisory Panel in 2019–2020 provided input into the design of the study, including the research questions and approaches to data collection and analysis

Social Justice, Health Disparities, and Culture in the Care of the Elderly

Abstract available at publisher's web site

Organizational Readiness to Implement the Chronic Disease Self-Management Program in Dialysis Facilities

A gap exists between the development and uptake of evidence-based health promotion programs in health care settings. One reason for this gap is lack of attention to organizational readiness. The objective of this study was to assess organizational readiness to implement the Chronic Disease Self-Management Program in dialysis facilities. Survey data were collected from dialysis staff using a semi-structured Organizational Readiness for Implementing Change questionnaire. Change efficacy and change commitment scale ratings were all above 3.0, indicating a moderate level of readiness among staff. Profession and level of education were significantly associated with mean change efficacy scale ratings. Textual data revealed benefits to patients, implementation barriers and facilitators, and the influence of facility environment and culture. The findings of the current study suggest that additional efforts to advance the implementation of evidence-based health promotion programs in dialysis facilities are needed