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Dreyer RP, Raparelli V, Tsang SW, D'Onofrio G, Lorenze N, Xie CF, Geda M, Pilote L, Murphy TE. Development and Validation of a Risk Prediction Model for 1-Year Readmission Among Young Adults Hospitalized for Acute Myocardial Infarction. J Am Heart Assoc 2021; 10:e021047. [PMID: 34514837 PMCID: PMC8649501 DOI: 10.1161/jaha.121.021047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Readmission over the first year following hospitalization for acute myocardial infarction (AMI) is common among younger adults (≤55 years). Our aim was to develop/validate a risk prediction model that considered a broad range of factors for readmission within 1 year. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which enrolled young adults aged 18 to 55 years hospitalized with AMI across 103 US hospitals (N=2979). The primary outcome was ≥1 all‐cause readmissions within 1 year of hospital discharge. Bayesian model averaging was used to select the risk model. The mean age of participants was 47.1 years, 67.4% were women, and 23.2% were Black. Within 1 year of discharge for AMI, 905 (30.4%) of participants were readmitted and were more likely to be female, Black, and nonmarried. The final risk model consisted of 10 predictors: depressive symptoms (odds ratio [OR], 1.03; 95% CI, 1.01–1.05), better physical health (OR, 0.98; 95% CI, 0.97–0.99), in‐hospital complication of heart failure (OR, 1.44; 95% CI, 0.99–2.08), chronic obstructive pulmomary disease (OR, 1.29; 95% CI, 0.96–1.74), diabetes mellitus (OR, 1.23; 95% CI, 1.00–1.52), female sex (OR, 1.31; 95% CI, 1.05–1.65), low income (OR, 1.13; 95% CI, 0.89–1.42), prior AMI (OR, 1.47; 95% CI, 1.15–1.87), in‐hospital length of stay (OR, 1.13; 95% CI, 1.04–1.23), and being employed (OR, 0.88; 95% CI, 0.69–1.12). The model had excellent calibration and modest discrimination (C statistic=0.67 in development/validation cohorts). Conclusions Women and those with a prior AMI, increased depressive symptoms, longer inpatient length of stay and diabetes may be more likely to be readmitted. Notably, several predictors of readmission were psychosocial characteristics rather than markers of AMI severity. This finding may inform the development of interventions to reduce readmissions in young patients with AMI.
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Raparelli V, Benea D, Nunez Smith M, Behlouli H, Murphy TE, D'Onofrio G, Pilote L, Dreyer RP. Impact of Race on the In-Hospital Quality of Care Among Young Adults With Acute Myocardial Infarction. J Am Heart Assoc 2021; 10:e021408. [PMID: 34431311 PMCID: PMC8649291 DOI: 10.1161/jaha.121.021408] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The extent to which race influences in-hospital quality of care for young adults (≤55 years) with acute myocardial infarction (AMI) is largely unknown. We examined racial disparities in in-hospital quality of AMI care and their impact on 1-year cardiac readmission. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolling young Black and White US adults with AMI (2008-2012). An in-hospital quality of care score (QCS) was computed (standard AMI quality indicators divided by the total a patient is eligible for). Multivariable logistic regression was performed to identify factors associated with the lowest QCS tertile, including interactions between race and social determinants of health. Among 2846 young adults with AMI (median 48 years [interquartile range 44-52], 67.4% women, 18.8% Black race), Black individuals, especially women, exhibited a higher prevalence of cardiac risk factors and social determinants of health and were more likely to experience a non-ST-segment-elevation myocardial infarction than White individuals. Black individuals were more likely in the lowest QCS tertile than White individuals (40.8% versus 34.7%; P=0.003). The association between Black race and low QCS (odds ratio [OR], 1.25; 95% CI, 1.02-1.54) was attenuated by adjustment for confounders. Employment was independently associated with better QCS, especially among Black participants (OR, 0.76; 95% CI, 0.62-0.92; P-interaction=0.02). Black individuals experienced a higher rate of 1-year cardiac readmission (29.9% versus 20.0%; P<0.0001). Conclusions Black individuals with AMI received lower in-hospital quality of care and exhibited a higher rate of cardiac readmissions than White individuals. Black individuals had a lower quality of care if unemployed, highlighting the intersection of race and social determinants of health.
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Doyle MM, Murphy TE, Pisani MA, Yaggi HK, Jeon S, Redeker NS, Knauert MP. A SAS macro for modelling periodic data using cosinor analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 209:106292. [PMID: 34380075 PMCID: PMC8435001 DOI: 10.1016/j.cmpb.2021.106292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 07/12/2021] [Indexed: 05/22/2023]
Abstract
BACKGROUND AND OBJECTIVE Cosinor analysis, developed by Franz Hallberg and colleagues in the 1960s, allows for the fitting of a cosine curve to data of a known period. Cosinor analysis is frequently used in the analysis of biological rhythm data. While software exists to perform these analyses, we are not aware of any published SAS procedures or macros which would facilitate them. METHODS To meet this gap, we herein describe SAS macros which perform cosinor analyses that assume either normally or gamma distributed outcomes and fixed period. The macros can 1) produce datasets with cosinor parameters including acrophase, mesor, amplitude, nadir and test for rhythmicity 2) output datasets with fitted and observed values from the model, and 3) plot the resulting curve and underlying data. RESULTS We demonstrate the use of these macros with data from our research on circadian rhythms of heart rate and sleep in critically ill patients. CONCLUSIONS Cosinor analysis provides a parsimonious and intuitive set of estimates to summarize periodic data. We are hopeful that the publication of our macro will allow a wider spectrum of users to avail themselves of this technique.
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Gettel CJ, Venkatesh AK, Leo-Summers LS, Murphy TE, Gahbauer EA, Hwang U, Gill TM. A Longitudinal Analysis of Functional Disability, Recovery, and Nursing Home Utilization After Hospitalization for Ambulatory Care Sensitive Conditions Among Community-Living Older Persons. J Hosp Med 2021; 16:469-475. [PMID: 34328835 PMCID: PMC8340961 DOI: 10.12788/jhm.3669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND/OBJECTIVE Hospitalizations for ambulatory care sensitive conditions (ACSCs) are considered potentially preventable. With little known about the functional outcomes of older persons after ACSC-related hospitalizations, our objectives were to describe: (1) the 6-month course of postdischarge functional disability, (2) the cumulative monthly probability of functional recovery, and (3) the cumulative monthly probability of incident nursing home (NH) admission. METHODS The analytic sample included 251 ACSC-related hospitalizations from a cohort of 754 nondisabled, community-living persons aged 70 years and older who were interviewed monthly for up to 19 years. Patient-reported disability scores in basic, instrumental, and mobility activities ranged from 0 to 13. Functional recovery was defined as returning within 6 months of discharge to a total disability score less than or equal to that immediately preceding hospitalization. RESULTS The mean age was 85.1 years, and the mean disability score was 5.4 in the month prior to the ACSC-related hospitalization. After the ACSC-related hospitalization, total disability scores peaked at month 1 and improved modestly over the next 5 months, but remained greater than the pre-hospitalization score. Functional recovery was achieved by 70% of patients, and incident NH admission was experienced by 50% within 6 months after the 251 ACSC-related hospitalizations. CONCLUSIONS During the 6 months after an ACSC-related hospitalization, older persons exhibited total disability scores that were higher than those immediately preceding hospitalization, with 3 of 10 not achieving functional recovery and half experiencing incident NH admission. These findings provide evidence that older persons experience clinically meaningful adverse patient-reported outcomes after ACSC-related hospitalizations.
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Garg T, Johns A, Young AJ, Nielsen ME, Tan HJ, McMullen CK, Kirchner HL, Cohen HJ, Murphy TE. Geriatric conditions and treatment burden following diagnosis of non-muscle- invasive bladder cancer in older adults: A population-based analysis. J Geriatr Oncol 2021; 12:1022-1030. [PMID: 33972184 DOI: 10.1016/j.jgo.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 03/23/2021] [Accepted: 04/27/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Treatment burden is emerging as an important patient-centered outcome for older adults with cancer who concurrently manage geriatric conditions. Our objective was to evaluate the contribution of geriatric conditions to treatment burden in older adults with non-muscle invasive bladder cancer (NMIBC). METHODS We identified 73,395 Medicare beneficiaries age 66+ diagnosed with NMIBC (Stage <II) in SEER-Medicare (2001-2014). The primary outcome was treatment burden, defined as health system contact days in the year following NMIBC diagnosis. Explanatory variables were the following geriatric conditions: multimorbidity (≥ 2 chronic conditions), functional dependency, falls, depression, cognitive impairment, weight loss, and urinary incontinence. We used negative binomial regression to model the association between individual geriatric conditions and treatment burden while adjusting for covariates. RESULTS At baseline, 64% had multimorbidity and median 3 conditions (IQR 0-5). Prevalence of other geriatric conditions ranged from 5.9%-15.2%. Adjusted mean health system contact was 8.9 days (95% CI 8.6-9.2). Multimorbidity had the largest effect size (adjusted mean 11.8 contact days (95% CI 8.3-8.8)). Each additional chronic condition conferred a 13% increased average number of health system contact (adjusted IRR 1.132, 95% CI 1.129-1.135). Regardless of number of chronic conditions, rural patients consistently had more treatment burden than urban counterparts. DISCUSSION In this population-based cohort of older NMIBC patients, multimorbidity and rurality were strongly associated with treatment burden in the year following NMIBC diagnosis. These findings highlight the need for interventions that reduce treatment burden due to geriatric conditions among the growing population of older adults with cancer, particularly in rural areas.
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Gill TM, Han L, Gahbauer EA, Leo-Summers L, Murphy TE, Becher RD. Functional Effects of Intervening Illnesses and Injuries After Hospitalization for Major Surgery in Community-living Older Persons. Ann Surg 2021; 273:834-841. [PMID: 33074902 PMCID: PMC8370041 DOI: 10.1097/sla.0000000000004438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the functional effects of intervening illnesses and injuries, that is, events, in the year after major surgery. BACKGROUND Intervening events have pronounced deleterious effects on functional status in older persons, but have not been carefully evaluated after major surgery. METHODS From a cohort of 754 community-living persons, aged 70+ years, 317 admissions for major surgery were identified from 244 participants who were discharged from the hospital. Functional status (13 activities) and exposure to intervening hospitalizations, emergency department (ED) visits, and restricted activity were assessed each month. Comprehensive assessments (for covariates) were completed every 18 months. RESULTS In the year after major surgery, exposure rates (95% CI) per 100-person months to hospitalizations, ED visits, and restricted activity were 10.0 (8.0-12.5), 3.9 (2.8-5.4), and 12.3 (10.2-14.8) for functional recovery and 7.2 (6.1-8.5), 2.5 (1.9-3.2), 11.2 (9.8-12.9) for functional decline. Each of the 3 intervening events were independently associated with reduced recovery, with adjusted hazard ratios (95% CI) of 0.20 (0.09-0.47), 0.35 (0.15-0.81), and 0.57 (0.36-0.90) for hospitalizations, ED visits, and restricted activity. For functional decline, the corresponding odds ratios (95% CI) were 5.68 (3.87-8.33), 1.90 (1.13-3.20), and 1.30 (0.96-1.75). The effect sizes for hospitalizations and ED visits were larger than those for the covariates. CONCLUSIONS Intervening illnesses/injuries are common in the year after major surgery, and those leading to hospitalization and ED visit are strongly associated with adverse functional outcomes, with effect sizes larger than those of traditional risk factors.
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Yu L, Zhao Y, Wang H, Sun TL, Murphy TE, Tsui KL. Assessing elderly's functional balance and mobility via analyzing data from waist-mounted tri-axial wearable accelerometers in timed up and go tests. BMC Med Inform Decis Mak 2021; 21:108. [PMID: 33766011 PMCID: PMC7995592 DOI: 10.1186/s12911-021-01463-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 03/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background Poor balance has been cited as one of the key causal factors of falls. Timely detection of balance impairment can help identify the elderly prone to falls and also trigger early interventions to prevent them. The goal of this study was to develop a surrogate approach for assessing elderly’s functional balance based on Short Form Berg Balance Scale (SFBBS) score. Methods Data were collected from a waist-mounted tri-axial accelerometer while participants performed a timed up and go test. Clinically relevant variables were extracted from the segmented accelerometer signals for fitting SFBBS predictive models. Regularized regression together with random-shuffle-split cross-validation was used to facilitate the development of the predictive models for automatic balance estimation. Results Eighty-five community-dwelling older adults (72.12 ± 6.99 year) participated in our study. Our results demonstrated that combined clinical and sensor-based variables, together with regularized regression and cross-validation, achieved moderate-high predictive accuracy of SFBBS scores (mean MAE = 2.01 and mean RMSE = 2.55). Step length, gender, gait speed and linear acceleration variables describe the motor coordination were identified as significantly contributed variables of balance estimation. The predictive model also showed moderate-high discriminations in classifying the risk levels in the performance of three balance assessment motions in terms of AUC values of 0.72, 0.79 and 0.76 respectively. Conclusions The study presented a feasible option for quantitatively accurate, objectively measured, and unobtrusively collected functional balance assessment at the point-of-care or home environment. It also provided clinicians and elderly with stable and sensitive biomarkers for long-term monitoring of functional balance.
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Monin JK, Laws H, Gahbauer E, Murphy TE, Gill TM. Spousal Influences on Monthly Disability in Late-Life Marriage in the Precipitating Events Project. J Gerontol B Psychol Sci Soc Sci 2021; 76:283-288. [PMID: 31956899 DOI: 10.1093/geronb/gbaa006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Few studies have examined spousal influences on disability in late-life marriage, and no prior study has examined these associations using monthly data. Drawing from interdependence theory, we hypothesized that one spouse currently having higher disability would be positively associated with their partner having higher disability in the next month. We also examined whether participants were at risk for increased disability when both spouses had higher prior disability. In addition, we examined gender differences in spousal associations. METHOD Data were from 37 married couples in the Precipitating Events Project, an ongoing longitudinal study of 754 initially nondisabled adults aged 70 years and older. Assessments included monthly disability (13 basic, instrumental, and mobility activities of daily living) and demographics. RESULTS As hypothesized, higher disability in one spouse was positively associated with higher subsequent disability in their partner. Also, wives with higher disability were especially vulnerable to subsequent increased disability when husbands had higher disability. DISCUSSION Incorporating a spouse's current disability level in modeling older adults' subsequent disability provides additional predictive information. Wives with greater disability may be at a particularly high risk of accelerated decline when their husbands have greater disability.
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Dodson JA, Hajduk AM, Murphy TE, Geda M, Krumholz HM, Tsang S, Nanna MG, Tinetti ME, Ouellet G, Sybrant D, Gill TM, Chaudhry SI. 180-day readmission risk model for older adults with acute myocardial infarction: the SILVER-AMI study. Open Heart 2021; 8:openhrt-2020-001442. [PMID: 33452007 PMCID: PMC7813425 DOI: 10.1136/openhrt-2020-001442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/11/2020] [Accepted: 12/13/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To develop a 180-day readmission risk model for older adults with acute myocardial infarction (AMI) that considered a broad range of clinical, demographic and age-related functional domains. METHODS We used data from ComprehenSIVe Evaluation of Risk in Older Adults with AMI (SILVER-AMI), a prospective cohort study that enrolled participants aged ≥75 years with AMI from 94 US hospitals. Participants underwent an in-hospital assessment of functional impairments, including cognition, vision, hearing and mobility. Clinical variables previously shown to be associated with readmission risk were also evaluated. The outcome was 180-day readmission. From an initial list of 72 variables, we used backward selection and Bayesian model averaging to derive a risk model (N=2004) that was subsequently internally validated (N=1002). RESULTS Of the 3006 SILVER-AMI participants discharged alive, mean age was 81.5 years, 44.4% were women and 10.5% were non-white. Within 180 days, 1222 participants (40.7%) were readmitted. The final risk model included 10 variables: history of chronic obstructive pulmonary disease, history of heart failure, initial heart rate, first diastolic blood pressure, ischaemic ECG changes, initial haemoglobin, ejection fraction, length of stay, self-reported health status and functional mobility. Model discrimination was moderate (0.68 derivation cohort, 0.65 validation cohort), with good calibration. The predicted readmission rate (derivation cohort) was 23.0% in the lowest quintile and 65.4% in the highest quintile. CONCLUSIONS Over 40% of participants in our sample experienced hospital readmission within 180 days of AMI. Our final readmission risk model included a broad range of characteristics, including functional mobility and self-reported health status, neither of which have been previously considered in 180-day risk models.
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Gill TM, Gahbauer EA, Leo-Summers L, Murphy TE. Trends in Restricting Symptoms at the End of Life from 1998 to 2019: A Cohort Study of Older Persons. J Am Geriatr Soc 2020; 69:450-458. [PMID: 33145752 DOI: 10.1111/jgs.16871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe changes in the occurrence of restricting symptoms at the end of life from 1998 to 2019 and compare these changes according to the condition leading to death. DESIGN Prospective longitudinal study. SETTING Greater New Haven, CT. PARTICIPANTS A total of 665 decedents from a cohort of 754 community-living persons, 70 years or older. MEASUREMENTS The occurrence of 16 restricting symptoms was ascertained during monthly interviews. Information on the conditions leading to death was obtained from death certificates and comprehensive assessments that were completed every 18-months. For each restricting symptom, adjusted rates (per 100 person-months) were calculated separately for six multiyear time intervals. RESULTS From 1998 to 2019, rates decreased for five (31.3%) restricting symptoms (difficulty sleeping; chest pain or tightness; shortness of breath; cold or flu symptoms; and nausea, vomiting, or diarrhea), increased for three (18.8%: arm or leg weakness; urinary incontinence; and memory or thinking problem), and changed little for the other eight (50.0%: poor eyesight; anxiety; depression; musculoskeletal pain; fatigue; dizziness or unsteadiness; frequent or painful urination; and swelling in feet or ankles). The decrease in rates was most pronounced for shortness of breath, with a reduction from 15.0 (95% credible interval = 11.7-18.6) in 1998 to 2001 to 8.2 (95% credible interval = 5.9-10.5) in 2014 to 2019, yielding a rate ratio (95% credible interval) of 0.92 (0.86-0.98). When evaluated according to the condition leading to death, the results were similar, with 10 of the 13 statistically significant rate ratios representing decreases in rates over time and only 3 representing increases. CONCLUSION The occurrence of most restricting symptoms at the end of life has been decreasing or stable over the past two decades. These results suggest that end-of-life care has been improving, although additional efforts will be needed to further reduce symptom burden at the end of life.
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Hajduk AM, Dodson JA, Murphy TE, Tsang S, Geda M, Ouellet GM, Gill TM, Brush JE, Chaudhry SI. Risk Model for Decline in Activities of Daily Living Among Older Adults Hospitalized With Acute Myocardial Infarction: The SILVER-AMI Study. J Am Heart Assoc 2020; 9:e015555. [PMID: 33000681 PMCID: PMC7792390 DOI: 10.1161/jaha.119.015555] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Functional decline (ie, a decrement in ability to perform everyday activities necessary to live independently) is common after acute myocardial infarction (AMI) and associated with poor long‐term outcomes; yet, we do not have a tool to identify older AMI survivors at risk for this important patient‐centered outcome. Methods and Results We used data from the prospective SILVER‐AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction) study of 3041 patients with AMI, aged ≥75 years, recruited from 94 US hospitals. Participants were assessed during hospitalization and at 6 months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living. Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (ie, bathing, dressing, transferring, and ambulation) from baseline to 6 months postdischarge. The mean age of the sample was 82±5 years; 57% were men, 90% were White, and 13% reported activity of daily living decline at 6 months postdischarge. The model identified older age, longer hospital stay, mobility impairment during hospitalization, preadmission physical activity, and depression as risk factors for decline. Revascularization during AMI hospitalization and ability to walk a quarter mile before AMI were associated with decreased risk. Model discrimination (c=0.78) and calibration were good. Conclusions We identified a parsimonious model that predicts risk of activity of daily living decline among older patients with AMI. This tool may aid in identifying older patients with AMI who may benefit from restorative therapies to optimize function after AMI.
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Gill TM, Murphy TE, Gahbauer EA, Leo-Summers L, Han L. Factors Associated With Insidious and Noninsidious Disability. J Gerontol A Biol Sci Med Sci 2020; 75:2125-2129. [PMID: 31907523 PMCID: PMC7566549 DOI: 10.1093/gerona/glaa002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Although disability is often precipitated by an illness/injury, it may arise insidiously. Our objectives were to identify the factors associated with the development of insidious and noninsidious disability and to determine whether these risk factors differ between the two types of disability. METHODS We prospectively evaluated 754 community-living persons, 70+ years, from 1998 to 2016. The unit of analysis was an 18-month person-interval, with risk factors assessed at the start of each interval. Disability in four activities of daily living and exposure to intervening events, defined as illnesses/injuries leading to hospitalization, emergency department visits, or restricted activity, were assessed each month. Insidious and noninsidious disability were defined based on the absence and presence of an intervening event. RESULTS The rate of noninsidious disability (21.7%) was twice that of insidious disability (10.8%). In multivariable recurrent-event Cox analyses, six factors were associated with both disability outcomes: non-Hispanic white race, lower extremity muscle weakness, poor manual dexterity, and (most strongly) frailty, cognitive impairment, and low functional self-efficacy. Three factors were associated with only noninsidious disability (older age, number of chronic conditions, and depressive symptoms), whereas four were associated with only insidious disability (female sex, lives with others, low SPPB score, and upper extremity weakness). The modest differences in risk factors identified for the two outcomes in multivariable analyses were less apparent in the bivariate analyses. CONCLUSIONS Although arising from different mechanisms, insidious and noninsidious disability share a similar set of risk factors. Interventions to prevent disability should prioritize this shared set of risk factors.
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Womack JA, Murphy TE, Bathulapalli H, Smith A, Bates J, Jarad S, Redeker NS, Luther SL, Gill TM, Brandt CA, Justice AC. Serious Falls in Middle-Aged Veterans: Development and Validation of a Predictive Risk Model. J Am Geriatr Soc 2020; 68:2847-2854. [PMID: 32860222 DOI: 10.1111/jgs.16773] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND/OBJECTIVES Due to high rates of multimorbidity, polypharmacy, and hazardous alcohol and opioid use, middle-aged Veterans are at risk for serious falls (those prompting a visit with a healthcare provider), posing significant risk to their forthcoming geriatric health and quality of life. We developed and validated a predictive model of the 6-month risk of serious falls among middle-aged Veterans. DESIGN Cohort study. SETTING Veterans Health Administration (VA). PARTICIPANTS Veterans, aged 45 to 65 years, who presented for care within the VA between 2012 and 2015 (N = 275,940). EXPOSURES The exposures of primary interest were substance use (including alcohol and prescription opioid use), multimorbidity, and polypharmacy. Hazardous alcohol use was defined as an Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) score of 3 or greater for women and 4 or greater for men. We used International Classification of Diseases, Ninth Revision (ICD-9), codes to identify alcohol and illicit substance use disorders and identified prescription opioid use from pharmacy fill-refill data. We included counts of chronic medications and of physical and mental health comorbidities. MEASUREMENTS We identified serious falls using external cause of injury codes and a machine-learning algorithm that identified serious falls in radiology reports. We used multivariable logistic regression with general estimating equations to calculate risk. We used an integrated predictiveness curve to identify intervention thresholds. RESULTS Most of our sample (54%) was aged 60 years or younger. Duration of follow-up was up to 4 years. Veterans who fell were more likely to be female (11% vs 7%) and White (72% vs 68%). They experienced 43,641 serious falls during follow-up. We identified 16 key predictors of serious falls and five interaction terms. Model performance was enhanced by addition of opioid use, as evidenced by overall category-free net reclassification improvement of 0.32 (P < .001). Discrimination (C-statistic = 0.76) and calibration were excellent for both development and validation data sets. CONCLUSION We developed and internally validated a model to predict 6-month risk of serious falls among middle-aged Veterans with excellent discrimination and calibration.
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Knauert MP, Murphy TE, Doyle MM, Pisani MA, Redeker NS, Yaggi HK. Pilot Observational Study to Detect Diurnal Variation and Misalignment in Heart Rate Among Critically Ill Patients. Front Neurol 2020; 11:637. [PMID: 32760341 PMCID: PMC7373742 DOI: 10.3389/fneur.2020.00637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/28/2020] [Indexed: 11/21/2022] Open
Abstract
Circadian disruption is common in critically ill patients admitted to the intensive care unit (ICU). Understanding and treating circadian disruption in critical illness has significant potential to improve critical illness outcomes through improved cognitive, immune, cardiovascular, and metabolic function. Measurement of circadian alignment (i.e., circadian phase) can be resource-intensive as it requires frequent blood or urine sampling over 24 or more hours. Less cumbersome methods of assessing circadian alignment would advance investigations in this field. Thus, the objective of this study is to examine the feasibility of using continuous telemetry to assess diurnal variation in heart rate (HR) among medical ICU patients as a proxy for circadian alignment. In exploratory analyses, we tested for associations between misalignment of diurnal variation in HR and death during hospital admission. This was a prospective observational cohort study embedded within a prospective medical ICU biorepository. HR data were continuously collected (every 5 s) via telemetry systems for the duration of the medical ICU admission; the first 24 h of this data was analyzed. Patients were extensively characterized via medical record chart abstraction and patient interviews. Of the 56 patients with complete HR data, 48 (86%) had a detectable diurnal variation. Of these patients with diurnal variation, 39 (81%) were characterized as having the nadir of their HR outside of the normal range of 02:00–06:00 (“misalignment”). Interestingly, no deaths occurred in the patients with normally aligned diurnal variation; in contrast, there were seven deaths (out of 39 patients) in patients who had misaligned diurnal variation in HR. In an exploratory analysis, we found that the odds ratio of death for misaligned vs. aligned patients was increased at 4.38; however, this difference was not statistically significant (95% confidence interval 0.20–97.63). We conclude that diurnal variation in HR can be detected via continuous telemetric monitoring of critically ill patients. A majority of these patients with diurnal variation exhibited misalignment in their first 24 h of medical ICU admission. Exploratory analyses suggest possible associations between misalignment and death.
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Gill TM, Gahbauer EA, Leo-Summers L, Murphy TE. Recovery from Severe Disability that Develops Progressively Versus Catastrophically: Incidence, Risk Factors, and Intervening Events. J Am Geriatr Soc 2020; 68:2067-2073. [PMID: 32495396 DOI: 10.1111/jgs.16567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few prior studies have evaluated recovery after the onset of severe disability or have distinguished between the two subtypes of severe disability. OBJECTIVES To identify the risk factors and intervening illnesses and injuries (i.e., events) that are associated with reduced recovery after episodes of progressive and catastrophic severe disability. DESIGN Prospective longitudinal study of 754 nondisabled community-living persons, aged 70 years or older. SETTING Greater New Haven, CT, March 1998 to December 2016. PARTICIPANTS A total of 431 episodes of severe disability were evaluated from 385 participants: 116 progressive (115 participants) and 315 catastrophic (270 participants). MEASUREMENTS Candidate risk factors were assessed every 18 months. Functional status and exposure to intervening events leading to hospitalization, emergency department visit, or restricted activity were assessed each month. Severe disability was defined as the need for personal assistance with three or more of four essential activities of daily living. Recovery was defined as return to independent function (no disability) within 6 months of developing severe disability. RESULTS Recovery occurred among 35.3% (95% confidence interval [CI] = 26.0%-48.0%) and 61.6% (95% CI = 53.5%-70.9%) of the 116 progressive and 315 catastrophic severe disability episodes, respectively. In the multivariable analyses, lives alone, frailty, and intervening hospitalization were each independently associated with reduced recovery from progressive disability, with adjusted hazard ratios (95% CIs) of 0.31 (0.15-0.64), 0.23 (0.12-0.45), and 0.27 (0.08-0.95), respectively, whereas low functional self-efficacy, intervening restricted activity, and intervening hospitalization were each independently associated with reduced recovery from catastrophic disability, with adjusted hazard ratios (95% CIs) of 0.56 (0.40-0.81), 0.55 (0.35-0.85), and 0.45 (0.31-0.66), respectively. CONCLUSIONS Recovery of independent function is considerably more likely after the onset of catastrophic than progressive severe disability, the risk factors for reduced recovery differ between progressive and catastrophic severe disability, and subsequent exposure to intervening illnesses and injuries considerably diminishes the likelihood of recovery from both subtypes of severe disability.
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Gill TM, Han L, Gahbauer EA, Leo-Summers L, Murphy TE. Risk Factors and Precipitants of Severe Disability Among Community-Living Older Persons. JAMA Netw Open 2020; 3:e206021. [PMID: 32484551 PMCID: PMC7267844 DOI: 10.1001/jamanetworkopen.2020.6021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Severe disability greatly diminishes quality of life and often leads to a protracted period of long-term care or death, yet the processes underlying severe disability have not been fully evaluated. OBJECTIVE To evaluate potential risk factors and precipitants associated with severe disability that develops progressively (during ≥2 months) vs catastrophically (from 1 month to the next). DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study conducted in greater New Haven, Connecticut, from March 1998 to December 2016, with 754 nondisabled community-living persons aged 70 years or older. Data analysis was conducted from November 2018 to May 2019. MAIN OUTCOMES AND MEASURES Candidate risk factors were assessed every 18 months. Functional status and potential precipitants, including illnesses or injuries leading to hospitalization, emergency department visit, or restricted activity, were assessed each month. Severe disability was defined as the need for personal assistance with at least 3 of 4 essential activities of daily living. The analysis was based on person-months within 18-month intervals. RESULTS The mean (SD) age for the 754 participants was 78.4 (5.3) years, 487 (64.6%) were women, and 683 (90.5%) were non-Hispanic white participants. The incidence of progressive and catastrophic severe disability was 3.5% and 9.7%, respectively, based on 3550 intervals. In multivariable analysis, 6 risk factors were independently associated with progressive disability (≥85 years: hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; hearing impairment: HR, 1.7; 95% CI, 1.0-2.8; frailty: HR, 2.4; 95% CI, 1.6-3.7; cognitive impairment: HR, 2.0; 95% CI, 1.3-3.1; low functional self-efficacy: HR, 1.8; 95% CI, 1.2-2.8; low peak flow: HR, 1.7; 95% CI, 1.2-2.4), and 4 were independently associated with catastrophic disability (visual impairment: HR, 1.4; 95% CI, 1.1-1.8; hearing impairment: HR, 1.3; 95% CI, 1.0-1.7; poor physical performance: HR, 1.8; 95% CI, 1.3-2.5; low peak flow: HR, 1.3; 95% CI, 1.0-1.7). The associations of the precipitants were much more pronounced than those of the risk factors, with HRs as high as 321.4 (95% CI, 194.5-531.0) for hospitalization and catastrophic disability and 48.3 (95% CI, 31.0%-75.4%) for hospitalization and progressive disability. Elimination of an intervening hospitalization was associated with a decrease in the risk of progressive and catastrophic severe disability of 3.0% (95% CI, 3.0%-3.1%) and 12.3% (95% CI, 12.1%-12.5%), respectively. Risk differences were 0.6% (95% CI, 0.6%-0.6%) and 1.3% (95% CI, 1.3%-1.4%) for emergency department visit and 0.1% (95% CI, 0.1%-0.2%) and 0.4% (95% CI, 0.4%-0.4%) for restricted activity, and ranged from 0.1% (95% CI, 0.1%-0.1%) to 0.3% (95% CI, 0.3%-0.3%) for the independent risk factors, for progressive and catastrophic disability, respectively. CONCLUSIONS AND RELEVANCE The findings of this study suggest that whether it develops progressively or catastrophically, severe disability among older community-living adults arises most commonly in the setting of an intervening illness or injury. To reduce the burden of severe disability, more aggressive efforts will be needed to prevent and manage intervening illnesses or injuries and to facilitate recovery after these debilitating events.
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Dodson JA, Hajduk AM, Murphy TE, Geda M, Krumholz HM, Tsang S, Nanna MG, Tinetti ME, Goldstein D, Forman DE, Alexander KP, Gill TM, Chaudhry SI. Thirty-Day Readmission Risk Model for Older Adults Hospitalized With Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020; 12:e005320. [PMID: 31010300 DOI: 10.1161/circoutcomes.118.005320] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early readmissions among older adults hospitalized for acute myocardial infarction (AMI) are costly and difficult to predict. Aging-related functional impairments may inform risk prediction but are unavailable in most studies. Our objective was to, therefore, develop and validate an AMI readmission risk model for older patients who considered functional impairments and was suitable for use before hospital discharge. METHODS AND RESULTS SILVER-AMI (Comprehensive Evaluation of Risk in Older Adults with AMI) is a prospective cohort study of 3006 patients of age ≥75 years hospitalized with AMI at 94 US hospitals. Participants underwent in-hospital assessment of functional impairments including cognition, vision, hearing, and mobility. Other variables plausibly associated with readmissions were also collected. The outcome was all-cause readmission at 30 days. We used backward selection and Bayesian model averaging to derive (N=2004) a risk model that was subsequently validated (N=1002). Mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. Within 30 days, 547 participants (18.2%) were readmitted. Readmitted participants were older, had more comorbidities, and had a higher prevalence of functional impairments, including activities of daily living disability (17.0% versus 13.0%; P=0.013) and impaired functional mobility (72.5% versus 53.6%; P<0.001). The final risk model included 8 variables: functional mobility, ejection fraction, chronic obstructive pulmonary disease, arrhythmia, acute kidney injury, first diastolic blood pressure, P2Y12 inhibitor use, and general health status. Functional mobility was the only functional impairment variable retained but was the strongest predictor. The model was well calibrated (Hosmer-Lemeshow P value >0.05) with moderate discrimination (C statistics: 0.65 derivation cohort and 0.63 validation cohort). Functional mobility significantly improved performance of the risk model (net reclassification improvement index =20%; P<0.001). CONCLUSIONS In our final risk model, functional mobility, previously not included in readmission risk models, was the strongest predictor of 30-day readmission among older adults after AMI. The modest discrimination indicates that much of the variability in readmission risk among this population remains unexplained by patient-level factors. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01755052.
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Garg T, Young AJ, O'Keeffe-Rosetti M, McMullen CK, Nielsen ME, Murphy TE, Kirchner HL. Association between metabolic syndrome and recurrence of nonmuscle-invasive bladder cancer in older adults. Urol Oncol 2020; 38:737.e17-737.e23. [PMID: 32409197 DOI: 10.1016/j.urolonc.2020.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 04/06/2020] [Accepted: 04/10/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Nonmuscle-invasive bladder cancer (NMIBC) disproportionately affects older adults who often have coexisting chronic conditions such as metabolic syndrome (MetS). Although prior research suggests that MetS is a risk factor for NMIBC, limited data exists on whether MetS is associated with NMIBC recurrence. Our objective was to evaluate the association between MetS and recurrence in older adults treated for NMIBC. METHODS We identified 1,485 older (age ≥60 years) NMIBC patients (American Joint Committee on Cancer Stage ≤1) from 2community-based health systems. Using data from the health systems' electronic medical record, MetS was defined as the presence of three of the following: diagnosis codes indicating hypertension, hyperlipidemia, diabetes, or body mass index >30. Follow up time was determined by date of the last follow up in the tumor registry and censored at 10 years. Cox proportional hazards regression of time to recurrence that accounts for the competing risk of death included adjustment for age, sex, smoking status, health system, NMIBC stage/grade, tumor size, and number of specimens with cancer. RESULTS Overall, 341 patients (23%) met MetS criteria. Median follow up was 5.9 years and 582 patients (39.2%) died. Patients with MetS were more frequently male (84.2%), and mostly current/former smokers (82.6%). By 10 years, 34.1% of the cohort had experienced a recurrence. After accounting for the competing risk of death, there was no association between MetS and time to recurrence (adjusted hazard ratio, 0.88, 95% confidence interval 0.70-1.11, P = 0.28). Patients without MetS had more 0a/low grade recurrences (49.1% vs. 41.4%), though differences were not significant. CONCLUSION We found no association between MetS and risk of NMIBC recurrence in this large, multisite cohort of older adults with NMIBC. In order to design personalized care for older NMIBC patients, future research is needed to evaluate associations between common chronic conditions and a variety of oncologic outcomes.
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Nanna MG, Sullivan AE, Bazylevska V, L Wong R, Murphy TE, Bellumkonda L, McNamara RL. Weight change in heart failure inpatients not associated with 30-day readmission. Future Cardiol 2020; 16:289-296. [PMID: 32286858 DOI: 10.2217/fca-2019-0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The association of weight change and short-term readmission in patients hospitalized for heart failure (HF) has not been well studied. Methods: We collected clinical and weight data from patients admitted with decompensated HF to a single center (2012-2013). We performed logistic regression to determine the association between weight change and two outcomes: a total of 30-day HF-specific readmission and 30-day all-cause readmission. Results: Admission and discharge weights were documented in 479/658 patients (73%). Weight loss >2 kg was not associated with 30-day all-cause or HF-specific readmission when compared with more modest inpatient weight change (-2 kg to +2 kg; all-cause readmission odds ratio: 0.86; CI: 0.56-1.37; HF-specific readmission odds ratio: 1.15; CI: 0.61-2.16). Conclusion: Among HF inpatients, in-hospital weight loss was not associated with 30-day all-cause or HF-specific readmission.
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Falvey JR, Murphy TE, Gill TM, Stevens-Lapsley JE, Ferrante LE. Home Health Rehabilitation Utilization Among Medicare Beneficiaries Following Critical Illness. J Am Geriatr Soc 2020; 68:1512-1519. [PMID: 32187664 DOI: 10.1111/jgs.16412] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/03/2020] [Accepted: 02/12/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Medicare beneficiaries recovering from a critical illness are increasingly being discharged home instead of to post-acute care facilities. Rehabilitation services are commonly recommended for intensive care unit (ICU) survivors; however, little is known about the frequency and dose of home-based rehabilitation in this population. DESIGN Retrospective analysis of 2012 Medicare hospital and home health (HH) claims data, linked with assessment data from the Medicare Outcomes and Assessment Information Set. SETTING Participant homes. PARTICIPANTS Medicare beneficiaries recovering from an ICU stay longer than 24 hours, who were discharged directly home with HH services within 7 days of discharge and survived without readmission or hospice transfer for at least 30 days (n = 3,176). MEASUREMENTS Count of rehabilitation visits received during HH care episode. RESULTS A total of 19,564 rehabilitation visits were delivered to ICU survivors over 118,145 person-days in HH settings, a rate of 1.16 visits per week. One-third of ICU survivors received no rehabilitation visits during HH care. In adjusted models, those with the highest baseline disability received 30% more visits (rate ratio [RR] = 1.30; 95% confidence interval [CI] = 1.17-1.45) than those with the least disability. Conversely, an inverse relationship was found between multimorbidity (Elixhauser scores) and count of rehabilitation visits received; those with the highest tertile of Elixhauser scores received 11% fewer visits (RR = .89; 95% CI = .81-.99) than those in the lowest tertile. Participants living in a rural setting (vs urban) received 6% fewer visits (RR = .94; 95% CI = .91-.98); those who lived alone received 11% fewer visits (RR = .89; 95% CI = .82-.96) than those who lived with others. CONCLUSION On average, Medicare beneficiaries discharged home after a critical illness receive few rehabilitation visits in the early post-hospitalization period. Those who had more comorbidities, who lived alone, or who lived in rural settings received even fewer visits, suggesting a need for their consideration during discharge planning. J Am Geriatr Soc 68:1512-1519, 2020.
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McAvay GJ, Murphy TE, Agogo GO, Allore H. CRcoder: An Interactive Web Application and SAS Macro to Support Personalized Clinical Decisions. Perm J 2020; 24:19.078. [DOI: 10.7812/tpp/19.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ray AS, Li C, Murphy TE, Cai G, Araujo KL, Bramley K, DeBiasi EM, Pisani MA, Cortopassi IO, Puchalski JT. Improved Diagnostic Yield and Specimen Quality With Endobronchial Ultrasound-Guided Forceps Biopsies: A Retrospective Analysis. Ann Thorac Surg 2020; 109:894-901. [DOI: 10.1016/j.athoracsur.2019.08.106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/22/2019] [Accepted: 08/30/2019] [Indexed: 12/25/2022]
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Ferrante LE, Murphy TE, Leo-Summers LS, Gahbauer EA, Pisani MA, Gill TM. The Combined Effects of Frailty and Cognitive Impairment on Post-ICU Disability among Older ICU Survivors. Am J Respir Crit Care Med 2020; 200:107-110. [PMID: 30883191 DOI: 10.1164/rccm.201806-1144le] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Dodson JA, Hajduk AM, Geda M, Krumholz HM, Murphy TE, Tsang S, Tinetti ME, Nanna MG, McNamara R, Gill TM, Chaudhry SI. Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study. Ann Intern Med 2020; 172:12-21. [PMID: 31816630 PMCID: PMC7695040 DOI: 10.7326/m19-0974] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts. OBJECTIVE To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments. DESIGN Prospective cohort study. (ClinicalTrials.gov: NCT01755052). SETTING 94 hospitals throughout the United States. PARTICIPANTS 3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive. MEASUREMENTS Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality. RESULTS Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment. LIMITATION The model was not externally validated. CONCLUSION A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute of the National Institutes of Health.
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Gill TM, Han L, Gahbauer EA, Leo-Summers L, Murphy TE. Cohort Profile: The Precipitating Events Project (PEP Study). J Nutr Health Aging 2020; 24:438-444. [PMID: 32242212 PMCID: PMC7322244 DOI: 10.1007/s12603-020-1341-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The Precipitating Events Project (PEP Study) is an ongoing longitudinal study of 754 nondisabled community-living persons age 70 years or older who were members of a large health plan in greater New Haven, Connecticut, USA. The study was established to rigorously evaluate the epidemiology of disability in older persons and to elucidate the role of intervening illnesses and injuries on the disabling process. Of the eligible members, 75.2% agreed to participate and were enrolled between March 1998 and October 1999. Participants have completed comprehensive home-based assessments at 18-month intervals and have been interviewed monthly over the phone with a completion rate of 99%. Detailed participant-level data on health care utilization are obtained annually through linkages with Medicare claims. Through June 2019, 702 (93.1%) participants have died after a median of 109 months, while 43 (5.7%) have dropped out of the study after a median of 27 months. Death certificates are available for all decedents. To date, 117 original reports have been published using data from the PEP Study, including many focusing on other high priority areas such as end of life, frailty, depressive symptoms, aging stereotypes, pain, sleep, and methodologic research. The PEP Study welcomes proposals to access data for meritorious analyses from qualified investigators.
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