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Obayashi K, Kodate N, Ishii Y, Masuyama S. Assistive technologies and aging in place for people with dementia and disabilities: a proof-of-concept study with in-home passive remote monitoring with interactive communication functions. Disabil Rehabil Assist Technol 2024; 19:2341-2354. [PMID: 38143315 DOI: 10.1080/17483107.2023.2287148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/12/2023] [Accepted: 11/19/2023] [Indexed: 12/26/2023]
Abstract
PURPOSE Can assistive technologies (ATs) support aging in place for people with dementia and disability? In seeking to go beyond the persistent institutional care delivery paradigm, this proof-of-concept study tested the feasibility of home care delivery using sensors and remote communication devices. This article reports the collaborative efforts among care professionals, care recipients and family caregivers in their private home environment and the impact of in-home passive remote monitoring (PRM) system on the users. The purpose of this study was to investigate the usability and impact of a PRM system combining in-house passive remote monitoring and an interactive communication function. METHODS In order to realize AT-supported, person-centered aging in place, a new care delivery model was designed, developed and tested for the duration of 12 weeks. The study was conducted with 5 older people (1 with severe disability and 4 with dementia), their primary family carers with 15 care professionals as users. RESULTS The findings indicate that there were some technical issues. However, the overall assessment of the system performance was positive, and the users expressed favorable views regarding its preventive and interactive nature. The importance of team-based care delivery, adjusted to fit the PRM equipment, was also highlighted. Faced with the challenge of meeting the increasing demand for person-centered care with limited resources, there will be a greater need for better integration of improved ATs. The study indicates ATs' potential for enhancing the quality of life for those involved in caregiving, while stressing the significance of stakeholders' engagement, skills and teamwork.
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Affiliation(s)
- Kazuko Obayashi
- Faculty of Healthcare Management, Nihon Fukushi University, Mihama, Aichi, Japan
- Social Welfare Corporation Tokyo Seishin-kai, Nishitokyo, Tokyo, Japan
- Universal Accessibility & Ageing Research Centre, Nishitokyo, Tokyo, Japan
| | - Naonori Kodate
- Universal Accessibility & Ageing Research Centre, Nishitokyo, Tokyo, Japan
- School of Social Policy, Social Work and Social Justice, University College Dublin, Dublin, Ireland
- Public Policy Research Center, Hokkaido University, Sapporo, Hokkaido, Japan
- Fondation France Japon, L'École des hautes études en sciences sociales, Paris, France
- Institute for Future Initiatives, University of Tokyo, Bunkyo, Tokyo, Japan
| | - Yoko Ishii
- Universal Accessibility & Ageing Research Centre, Nishitokyo, Tokyo, Japan
| | - Shigeru Masuyama
- Universal Accessibility & Ageing Research Centre, Nishitokyo, Tokyo, Japan
- Traveler's Medical Center, Tokyo Medical University, Shinjuku, Tokyo, Japan
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Propes C, O'Rourke PP, Morain SR. Recurring and Emerging Ethical Issues in Pragmatic Clinical Trials. Circ Cardiovasc Qual Outcomes 2024; 17:e010847. [PMID: 39012931 PMCID: PMC11254325 DOI: 10.1161/circoutcomes.124.010847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Affiliation(s)
- Caleigh Propes
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health and the Berman Institute of Bioethics, Baltimore, MD (C.P., S.R.M.). Dr O'Rourke is retired
| | | | - Stephanie R Morain
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health and the Berman Institute of Bioethics, Baltimore, MD (C.P., S.R.M.). Dr O'Rourke is retired
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Wang X, Goldfeld KS, Taljaard M, Li F. Sample Size Requirements to Test Subgroup-Specific Treatment Effects in Cluster-Randomized Trials. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:356-370. [PMID: 37816835 PMCID: PMC11004667 DOI: 10.1007/s11121-023-01590-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
Cluster-randomized trials (CRTs) often allocate intact clusters of participants to treatment or control conditions and are increasingly used to evaluate healthcare delivery interventions. While previous studies have developed sample size methods for testing confirmatory hypotheses of treatment effect heterogeneity in CRTs (i.e., targeting the difference between subgroup-specific treatment effects), sample size methods for testing the subgroup-specific treatment effects themselves have not received adequate attention-despite a rising interest in health equity considerations in CRTs. In this article, we develop formal methods for sample size and power analyses for testing subgroup-specific treatment effects in parallel-arm CRTs with a continuous outcome and a binary subgroup variable. We point out that the variances of the subgroup-specific treatment effect estimators and their covariance are given by weighted averages of the variance of the overall average treatment effect estimator and the variance of the heterogeneous treatment effect estimator. This analytical insight facilitates an explicit characterization of the requirements for both the omnibus test and the intersection-union test to achieve the desired level of power. Generalizations to allow for subgroup-specific variance structures are also discussed. We report on a simulation study to validate the proposed sample size methods and demonstrate that the empirical power corresponds well with the predicted power for both tests. The design and setting of the Umea Dementia and Exercise (UMDEX) CRT in older adults are used to illustrate our sample size methods.
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Affiliation(s)
- Xueqi Wang
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Keith S Goldfeld
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA.
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, Suite 200, Room 229, 135 College Street, New Haven, CT, 06510, USA.
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Blette BS, Halpern SD, Li F, Harhay MO. Assessing treatment effect heterogeneity in the presence of missing effect modifier data in cluster-randomized trials. Stat Methods Med Res 2024; 33:909-927. [PMID: 38567439 PMCID: PMC11041086 DOI: 10.1177/09622802241242323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Understanding whether and how treatment effects vary across subgroups is crucial to inform clinical practice and recommendations. Accordingly, the assessment of heterogeneous treatment effects based on pre-specified potential effect modifiers has become a common goal in modern randomized trials. However, when one or more potential effect modifiers are missing, complete-case analysis may lead to bias and under-coverage. While statistical methods for handling missing data have been proposed and compared for individually randomized trials with missing effect modifier data, few guidelines exist for the cluster-randomized setting, where intracluster correlations in the effect modifiers, outcomes, or even missingness mechanisms may introduce further threats to accurate assessment of heterogeneous treatment effect. In this article, the performance of several missing data methods are compared through a simulation study of cluster-randomized trials with continuous outcome and missing binary effect modifier data, and further illustrated using real data from the Work, Family, and Health Study. Our results suggest that multilevel multiple imputation and Bayesian multilevel multiple imputation have better performance than other available methods, and that Bayesian multilevel multiple imputation has lower bias and closer to nominal coverage than standard multilevel multiple imputation when there are model specification or compatibility issues.
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Affiliation(s)
- Bryan S Blette
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott D Halpern
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Tan ZS, Qureshi N, Spivack E, Rhinehart D, Gatmaitan D, Guinto A, Kremen S, Sicotte NL. Pragmatic implementation of comprehensive dementia care management: The Cedars-Sinai C.A.R.E.S. Program preliminary data. J Am Geriatr Soc 2024. [PMID: 38526042 DOI: 10.1111/jgs.18891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/15/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The United States faces a growing challenge with over 6.5 million people living with dementia (PLwD). PLwD and their caregivers struggle with cognitive, functional, behavioral, and psychosocial issues. As dementia care shifts to home settings, caregivers receive inadequate support but bear increasing responsibilities, leading to higher healthcare costs. In response, the Centers for Medicare & Medicaid Services (CMS) introduced the Guiding an Improving Dementia Experience (GUIDE) Model. The study explores the real-world implementation of the Cedars-Sinai C.A.R.E.S. Program, a pragmatic dementia care model, detailing its recruitment process and initial outcomes. METHODS The Cedars-Sinai C.A.R.E.S. Program was integrated into the Epic electronic health record system and focused on proactive patient identification, engagement, interdisciplinary collaboration, care transitions, and ongoing care management. Eligible patients with a dementia diagnosis were identified through electronic health record and invited to join the program. Nurse practitioners with specialized training in dementia care performed comprehensive assessments using the CEDARS-6 tool, leading to personalized care plans developed in consultation with primary care providers. Patients benefited from a multidisciplinary team and support from care navigators. RESULTS Of the 781 eligible patients identified, 431 were enrolled in the C.A.R.E.S. PROGRAM Enrollees were racially diverse, with lower caregiver strain and patient behavioral and psychological symptoms of dementia (BPSD) severity compared to other programs dementia care programs. Healthcare utilization, including hospitalizations, emergency department (ED) admissions, and urgent care visits showed a downward trend over time. Completion of advanced directives and Physician Order of Life-Sustaining Treatment (POLST) increased after enrollment. CONCLUSION The Cedars-Sinai C.A.R.E.S. Program offers a promising approach to dementia care. Its real-world implementation demonstrates the feasibility of enrolling a diverse population and achieving positive outcomes for PLwD and their caregivers, supporting the goals of national dementia care initiatives.
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Affiliation(s)
- Zaldy S Tan
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nabeel Qureshi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
- RAND Corporation, Santa Monica, California, USA
| | - Erica Spivack
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deana Rhinehart
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Dyane Gatmaitan
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Augustine Guinto
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sarah Kremen
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nancy L Sicotte
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Stephens N, Evans S, Russell C, Brooker D. Understanding 'value' in the context of community-based interventions for people affected by dementia: A concept analysis. J Adv Nurs 2024; 80:935-947. [PMID: 37828689 DOI: 10.1111/jan.15886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 10/14/2023]
Abstract
AIM This study aimed to conduct a concept analysis of value in the context of community-based interventions for people affected by dementia. BACKGROUND Concepts of value play a critical role in shaping the delivery and distribution of community-based health interventions through related concepts. However, the use and meaning of 'value' is rarely clarified limiting the term's utility in practice and research. Increasing need for community healthcare and scarce public resources means developing understanding of value in community-based interventions for people affected by dementia is timely, and may support more informed approaches to exploring, explaining and delivering value. DESIGN Evolutionary Concept Analysis was used to systematically determine the characteristics of value. DATA SOURCES Peer-reviewed and grey literature databases were searched between April and July 2021, with 32 pieces of literature from different disciplines included in the final sample. No limits were set for the years of literature retrieved. METHODS Literature was thematically analysed for information on the antecedents, attributes and consequences of value. RESULTS AND DISCUSSION The analysis uncovered a need and/or desire to understand the experience of people affected by or that affect interventions; and to demonstrate, prove/disprove the (best) quality and nature of results of interventions as antecedents of value. Attributes of value were stakeholder/person centred, measurable, time and context dependent and multidimensional. Consequences of the concept included shared decision-making, valuation of interventions and internal/external investment and development of interventions. CONCLUSION Through concept analysis value can now be better understood and applied. The development of a conceptual model to illustrate the constituent elements and relationships of the concept adds transparency to where, why and how concepts of value are enabled that supports future concept development. PATIENT AND PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Nathan Stephens
- Association for Dementia Studies, University of Worcester, Worcester, UK
| | - Shirley Evans
- Association for Dementia Studies, University of Worcester, Worcester, UK
| | - Chris Russell
- Association for Dementia Studies, University of Worcester, Worcester, UK
| | - Dawn Brooker
- Association for Dementia Studies, University of Worcester, Worcester, UK
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Gabbard J, Sadarangani TR, Datta R, Fabius CD, Gettel CJ, Douglas NF, Juckett LA, Kiselica AM, Murali KP, McCarthy EP, Torke AM, Callahan CM. Career development in pragmatic clinical trials to improve care for people living with dementia. J Am Geriatr Soc 2023; 71:3554-3565. [PMID: 37736669 PMCID: PMC10810339 DOI: 10.1111/jgs.18599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 09/23/2023]
Abstract
The growing number of people living with dementia (PLWD) requires a coordinated clinical response to deliver pragmatic, evidence-based interventions in frontline care settings. However, infrastructure to support such a response is lacking. Moreover, there are too few researchers conducting rigorous embedded pragmatic clinical trials (ePCTs) to make the vision of high quality, widely accessible dementia care a reality. National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease and Related Dementias Clinical Trials (IMPACT) Collaboratory seeks to improve the pipeline of early career researchers qualified to lead ePCTs by funding career development awards. Even with support from the Collaboratory, awardees face practical and methodological challenges to success, recently exacerbated by the COVID-19 pandemic. We first describe the training opportunities and support network for the IMPACT CDA recipients. This report then describes the unique career development challenges faced by early-career researchers involved in ePCTs for dementia care. Topics addressed include challenges in establishing a laboratory, academic promotion, mentoring and professional development, and work-life balance. Concrete suggestions to address these challenges are offered for early-career investigators, their mentors, and their supporting institutions. While some of these challenges are faced by researchers in other fields, this report seeks to provide a roadmap for expanding the work of the IMPACT Collaboratory and initiating future efforts to recruit, train, and retain talented early-career researchers involved in ePCTs for dementia care.
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Affiliation(s)
- Jennifer Gabbard
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | | | - Rupak Datta
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Chanee D. Fabius
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Natalie F. Douglas
- Department of Communication Sciences and Disorders, The Herbert H. and Grace A. Dow College of Health Professions, Central Michigan University, Mt. Pleasant, Michigan
| | - Lisa A Juckett
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Andrew M. Kiselica
- Department of Health Psychology, School of Health Professions, University of Missouri, Columbia, Missouri
| | | | - Ellen P. McCarthy
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexia M. Torke
- Division of General Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Christopher M. Callahan
- Division of General Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
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Britton GB, Okonkwo OC. A fresh look at the multi-level social determinants of disparities in Alzheimer's disease and related dementias. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2023; 15:e12481. [PMID: 37719283 PMCID: PMC10504580 DOI: 10.1002/dad2.12481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Gabrielle B. Britton
- Centro de NeurocienciasInstituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP)Panamá CityPanamá
| | - Ozioma C. Okonkwo
- Department of Medicine and Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
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Samper-Ternent R, Silveira SL, Stevens A, Volpi E, Naik AD. Considerations When Designing and Implementing Pragmatic Clinical Trials That Include Older Hispanics. Ethn Dis 2023; 33:76-83. [PMID: 38845738 PMCID: PMC11145730 DOI: 10.18865/ed.33.2-3.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Introduction Pragmatic clinical trials (PCTs) are designed to connect researchers with clinicians to assess the real-world effectiveness and feasibility of interventions, treatments, or health care delivery strategies in routine practice. Within PCTs larger, more representative sampling is possible to improve the external validity of the research. Older adults from underrepresented groups can benefit from PCTs given their historically lower engagement in clinical research. The current article focuses on older Hispanic adults with Alzheimer disease and related dementias (ADRDs). Older Hispanic adults represent 19% of the US population and have a higher prevalence of ADRDs than Whites. We provide data from 2 PCTs about the recruitment of older Hispanics with ADRDs and discuss unique challenges associated with conducting PCTs and propose strategies to overcome challenges. Data and Methods The first PCT outlined is the Patient Priorities Care for Hispanics with Dementia (PPC-HD) trial. PPC-HD is testing the feasibility of implementing a culturally adapted version of the Patient Priorities Care approach for older Hispanic adults with multiple chronic conditions and dementia. The second PCT is the Dementia Care (D-CARE) Study, which is a multisite pragmatic study comparing the effectiveness of a health care system-based approach and a community-based approach to dementia care to usual care in patients with ADRDs and their family caregivers. Lessons Learned and Recommendations for Future Studies The lessons learned are summarized according to the various stakeholders that need to work together to effectively recruit diverse participants for PCTs: individuals, health care systems, research teams, and communities. Individual-level considerations include communication, priorities, and flexibility. Health care system-level considerations are grounded in 4 principles of Community-Based Participatory Research and include collaboration/partnership, available resources, priorities of the health care system, and sustainability. Research team-level considerations include team members, intentionality, and communication. Community-level considerations highlight the importance of partnerships, community members, and appropriate incentives. Discussion PCTs provide a unique and potentially impactful opportunity to test interventions in real-world settings that must be culturally appropriate to reach underrepresented groups. Collectively, considering variables at multiple levels to address the needs of older adults with ADRDs is crucial, and the examples and suggestions provided in this report are a foundation for future research.
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Affiliation(s)
- Rafael Samper-Ternent
- Department of Management, Population, and Community Health, School
of Public Health, UTHealth Houston, Houston, TX
| | - Stephanie L. Silveira
- Department of Management, Population, and Community Health, School
of Public Health, UTHealth Houston, Houston, TX
| | - Alan Stevens
- Baylor Scott and White Research Institute, Texas A&M Health
Sciences Center, Temple, TX
| | - Elena Volpi
- Sealy Center on Aging, The University of Texas Medical Branch,
Galveston, TX
| | - Aanand D. Naik
- Department of Management, Population, and Community Health, School
of Public Health, UTHealth Houston, Houston, TX
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