Barriers, facilitators and needs to deprescribe benzodiazepines and other sedatives in older adults: a mixed methods study of primary care provider perspectives

BACKGROUND

Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects.

METHODS

We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences.

RESULTS

The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes.

CONCLUSION

The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.

Drug-related readmissions in older hospitalized adults: External validation and updating of OPERAM DRA prediction tool

BACKGROUND

Drug-related readmissions (DRAs) are defined as rehospitalizations with an adverse drug event as their main or significant contributory cause. DRAs represent a major adverse health burden for older patients. A prediction model which identified older hospitalized patients at high risk of a DRA <1 year was previously developed using the OPERAM trial cohort, a European cluster randomized controlled trial including older hospitalized patients with multimorbidity and polypharmacy. This study has performed external validation and updated the prediction model consequently.

METHODS

The MedBridge trial cohort (a multicenter cluster randomized crossover trial performed in Sweden) was used as a validation cohort. It consisted of 2516 hospitalized patients aged ≥65 years. Model performance was assessed by: (1) discriminative power, assessed by the C-statistic with a 95% confidence interval (CI); (2) calibration, assessed by visual examination of the calibration plot and use of the Hosmer-Lemeshow goodness-of-fit test; and (3) overall accuracy, assessed by the scaled Brier score. Several updating methods were carried out to improve model performance.

RESULTS

In total, 2516 older patients were included in the validation cohort, of whom 582 (23.1%) experienced a DRA <1 year. In the validation cohort, the original model showed a good overall accuracy (scaled Brier score 0.03), but discrimination was moderate (C-statistic 0.62 [95% CI 0.59-0.64]), and calibration showed underestimation of risks. In the final updated model, the predictor "cirrhosis with portal hypertension" was removed and "polypharmacy" was added. This improved the model's discriminative capability to a C-statistic of 0.64 (95% CI 0.59-0.70) and enhanced calibration plots. Overall accuracy remained good.

CONCLUSIONS

The updated OPERAM DRA prediction model may be a useful tool in clinical practice to estimate the risk of DRAs in older hospitalized patients subsequent to discharge. Our efforts lay the groundwork for the future development of models with even better performance.

Impact of an INtervention to increase MOBility in older hospitalized medical patients (INTOMOB): Study protocol for a cluster randomized controlled trial

BACKGROUND

Low mobility during an acute hospitalization is frequent and associated with adverse effects, including persistent functional decline, institutionalization and death. However, we lack effective interventions to improve mobility that are scalable in everyday practice. The INTOMOB trial - INtervention to increase MOBility in older hospitalized medical patients - will test the effect of a multilevel intervention to improve mobility of older hospitalized patients on functional mobility.

METHODS

The INTOMOB multicenter superiority parallel cluster randomized controlled trial will enroll in total 274 patients in Swiss hospitals. Community-dwelling adults aged ≥ 60 years, admitted to a general internal medicine ward with an anticipated length of hospital stay of ≥ 3 days, will be eligible for participation. Unit of randomization will be the wards. A multilevel mobility intervention will be compared to standard of care and target the patients (information and exercise booklets, mobility diary, iPad with exercise videos), healthcare professionals (e-learning, oral presentation, mobility checklist), and environment (posters and pictures on the wards). The primary outcome will be life-space level, measured by the University of Alabama at Birmingham Study of Aging Life-Space Assessment (LSA), at 30 days after enrollment. The LSA is a measure of functional mobility, i.e., how far participants move from bedroom to outside town. Secondary outcomes include, among others, LSA at 180 days, mobility and falls during hospitalization, muscle strength at discharge, and falls, emergency room visits, readmissions, and death within 180 days.

DISCUSSION

This study has the potential to improve outcomes of older hospitalized patients through an intervention that should be scalable in clinical practice because it fosters patient empowerment and does not require additional resources. The tools provided to the patients can help them implement better mobility practices after discharge, which can contribute to better functional outcomes. The choice of a functional patient-reported outcome measure as primary outcome (rather than a "simple" objective mobility measure) reinforces the patient-centeredness of the study.

TRIAL REGISTRATION

clinicaltrials.gov (NCT05639231, released on December 19 2022); Swiss National Clinical Trial Portal (SNCTP000005259, released on November 28 2022).

Perspectives of patients and clinicians on older patient mobility on acute medical wards: a qualitative study

BACKGROUND

Low mobility during an acute care medical hospitalization is frequent and associated with adverse outcomes, particularly among older patients. Better understanding barriers and facilitators to improve mobility during hospitalization could help develop effective interventions. The goal of this study was to assess barriers and facilitators to older medical patients' hospital mobility, from the point of view of patients and clinicians, to develop a framework applicable in clinical practice.

METHODS

We conducted a qualitative study in one university and two non-university hospitals of two different language and cultural regions of Switzerland, including 13 focus groups (FGs; five with patients, eight with clinicians). We included 24 adults aged 60 years or older hospitalized on an acute general internal medicine ward of one of the three participating hospitals during the previous years, and 34 clinicians (15 physicians, nine nurses/nursing assistants, 10 physiotherapists) working on those wards. The FG guides included open-ended questions exploring mobility experiences, expectations, barriers and facilitators to mobility, consequences of low mobility and knowledge on mobility. We applied an inductive thematic analysis.

RESULTS

We identified four themes of barriers and facilitators to mobility: 1) patient-related factors; 2) clinician-related factors; 3) social interactions; and 4) non-human factors. Clinician-related factors were only mentioned in clinician FGs. Otherwise, subthemes identified from patient and clinician FGs were similar and codes broadly overlapped. Subthemes included motivation, knowledge, expectations, mental and physical state (theme 1); process, knowledge - skills, mental state - motivation (theme 2); interpersonal relationships, support (theme 3); hospital setting - organization (theme 4).

CONCLUSIONS

From patients' and clinicians' perspectives, a broad spectrum of human and structural factors influences mobility of older patients hospitalized on an acute general internal medicine ward. New factors included privacy issues and role perception. Many of those factors are potentially actionable without additional staff resources. This study is a first step in participatory research to improve mobility of older medical inpatients.

Overtreatment and associated risk factors among multimorbid older patients with diabetes

BACKGROUND

In multimorbid older patients with type 2 diabetes mellitus (T2DM), the intensity of glucose-lowering medication (GLM) should be focused on attaining a suitable level of glycated hemoglobin (HbA1c ) while avoiding side effects. We aimed at identifying patients with overtreatment of T2DM as well as associated risk factors.

METHODS

In a secondary analysis of a multicenter study of multimorbid older patients, we evaluated HbA1c levels among patients with T2DM. Patients were aged ≥70 years, with multimorbidity (≥3 chronic diagnoses) and polypharmacy (≥5 chronic medications), enrolled in four university medical centers across Europe (Belgium, Ireland, Netherlands, and Switzerland). We defined overtreatment as HbA1c  < 7.5% with ≥1 GLM other than metformin, as suggested by Choosing Wisely and used prevalence ratios (PRs) to evaluate risk factors of overtreatment in age- and sex-adjusted analyses.

RESULTS

Among the 564 patients with T2DM (median age 78 years, 39% women), mean ± standard deviation HbA1c was 7.2 ± 1.2%. Metformin (prevalence 51%) was the most frequently prescribed GLM and 199 (35%) patients were overtreated. The presence of severe renal impairment (PR 1.36, 1.21-1.53) and outpatient physician (other than general practitioner [GP], i.e. specialist) or emergency department visits (PR 1.22, 1.03-1.46 for 1-2 visits, and PR 1.35, 1.19-1.54 for ≥3 visits versus no visits) were associated with overtreatment. These factors remained associated with overtreatment in multivariable analyses.

CONCLUSIONS

In this multicountry study of multimorbid older patients with T2DM, more than one third were overtreated, highlighting the high prevalence of this problem. Careful balancing of benefits and risks in the choice of GLM may improve patient care, especially in the context of comorbidities such as severe renal impairment, and frequent non-GP healthcare contacts.

Feasibility and Acceptability of an INtervention TO Increase MOBility in Older Hospitalized Medical Patients (INTOMOB): A Mixed-Methods Pilot Study

Background: To reduce adverse outcomes of low hospital mobility, we need interventions that are scalable in everyday practice. This study assessed the feasibility and acceptability of the INTOMOB multilevel intervention addressing barriers to hospital mobility without requiring unavailable resources. Methods: The INTOMOB intervention, targeting older patients, healthcare professionals (HCPs) and the hospital environment, was implemented on acute general internal medicine wards of three hospitals (12/2022-03/2023). Feasibility and acceptability of the intervention were assessed and two types of accelerometers compared in a mixed methods study (patient and HCP surveys and interviews). Quantitative data were analyzed descriptively and qualitative data using a deductive approach. Results were integrated through meta-inferences. Results: Of 20 patients (mean age 74.1 years), 90% found the intervention helpful and 82% said the environment intervention (posters) stimulated mobility. The majority of 44 HCPs described the intervention as clear and helpful. There was no major implementation or technical issue. About 60% of patients and HCPs preferred a wrist-worn over an ankle-worn accelerometer. Conclusions: The INTOMOB intervention is feasible and well accepted. Patients' and HCPs' feedback allowed to further improve the intervention that will be tested in a cluster randomized trial and provides useful information for future mobility-fostering interventions.

Prescribing, deprescribing and potential adverse effects of proton pump inhibitors in older patients with multimorbidity: an observational study

BACKGROUND

Proton pump inhibitors (PPIs) contribute to polypharmacy and are associated with adverse effects. As prospective data on longitudinal patterns of PPI prescribing in older patients with multimorbidity are lacking, we sought to assess patterns of PPI prescribing and deprescribing, as well as the association of PPI use with hospital admissions over 1 year in this population.

METHODS

We conducted a prospective, longitudinal cohort study using data from the Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM) trial, a randomized controlled trial testing an intervention to reduce inappropriate prescribing (2016-2018). This trial included adults aged 70 years and older with at least 3 chronic conditions and prescribed at least 5 chronic medications. We assessed prevalence of PPI use at time of hospital admission, and new prescriptions and deprescribing at discharge, and at 2 months and 1 year after discharge, by intervention group. We used a regression with competing risk for death to assess the association of PPI use with readmissions related to their potential adverse effects, and all-cause readmission.

RESULTS

Overall, 1080 (57.4%) of 1879 patients (mean age 79 yr) had PPI prescriptions at admission, including 496 (45.9%) patients with a potentially inappropriate indication. At discharge, 133 (24.9%) of 534 patients in the intervention group and 92 (16.8%) of 546 patients in the control group who were using PPIs at admission had deprescribing. Among 680 patients who were not using PPIs at discharge, 47 (14.6%) of 321 patients in the intervention group and 40 (11.1%) of 359 patients in the control group had a PPI started within 2 months. Use of PPIs was associated with all-cause readmission (n = 770, subdistribution hazard ratio 1.31, 95% confidence interval 1.12-1.53).

INTERPRETATION

Potentially inappropriate use of PPI, new PPI prescriptions and PPI deprescribing were frequent among older adults with multimorbidity and polypharmacy. These data suggest that persistent PPI use may be associated with clinically important adverse effects in this population.

Multimorbidity and long-term disability and physical functioning decline in middle-aged and older Americans: an observational study

BACKGROUND

Multimorbidity is highly prevalent and associated with several adverse health outcomes, including functional limitations. While maintaining physical functioning is relevant for all adults, identifying those with multimorbidity at risk for faster rates of physical functioning decline may help to target interventions to delay the onset and progression of disability. We quantified the association of multimorbidity with rates of long-term disability and objective physical functioning decline.

METHODS

In the Health and Retirement Study, we computed the Multimorbidity-Weighted Index (MWI) by assigning previously validated weights (based on physical functioning) to each chronic condition. We used an adjusted negative binomial regression to assess the association of MWI with disability (measured by basic and instrumental activities of daily living [ADLs, IADLs]) over 16 years, and linear mixed effects models to assess the association of MWI with gait speed and grip strength over 8 years.

RESULTS

Among 16,616 participants (mean age 67.3, SD 9.7 years; 57.8% women), each additional MWI point was associated with a 10% increase in incidence rate of disability (IRR: 1.10; 95%CI: 1.09, 1.10). In 2,748 participants with data on gait speed and grip strength, each additional MWI point was associated with a decline in gait speed of 0.004 m/s (95%CI: -0.006, -0.001). The association with grip strength was not statistically significant (-0.01 kg, 95%CI: -0.73, 0.04). The rate of decline increased with time for all outcomes, with a significant interaction between time and MWI for disability progression only.

CONCLUSION

Multimorbidity, as weighted on physical functioning, was associated with long-term disability, including faster rates of disability progression, and decline in gait speed. Given the importance of maintaining physical functioning and preserving functional independence, MWI is a readily available tool that can help identify adults to target early on for interventions.

Incidence of and predictors for antiseizure medication gaps in Medicare beneficiaries with epilepsy: a retrospective cohort study

BACKGROUND

For the two-thirds of patients with epilepsy who achieve seizure remission on antiseizure medications (ASMs), patients and clinicians must weigh the pros and cons of long-term ASM treatment. However, little work has evaluated how often ASM discontinuation occurs in practice. We describe the incidence of and predictors for sustained ASM fill gaps to measure discontinuation in individuals potentially eligible for ASM withdrawal.

METHODS

This was a retrospective cohort of Medicare beneficiaries. We included patients with epilepsy by requiring International Classification of Diseases codes for epilepsy/convulsions plus at least one ASM prescription each year 2014-2016, and no acute visit for epilepsy 2014-2015 (i.e., potentially eligible for ASM discontinuation). The main outcome was the first day of a gap in ASM supply (30, 90, 180, or 360 days with no pills) in 2016-2018. We displayed cumulative incidence functions and identified predictors using Cox regressions.

RESULTS

Among 21,819 beneficiaries, 5191 (24%) had a 30-day gap, 1753 (8%) had a 90-day gap, 803 (4%) had a 180-day gap, and 381 (2%) had a 360-day gap. Predictors increasing the chance of a 180-day gap included number of unique medications in 2015 (hazard ratio [HR] 1.03 per medication, 95% confidence interval [CI] 1.01-1.05) and epileptologist prescribing physician (≥25% of that physician's visits for epilepsy; HR 2.37, 95% CI 1.39-4.03). Predictors decreasing the chance of a 180-day gap included Medicaid dual eligibility (HR 0.75, 95% CI 0.60-0.95), number of unique ASMs in 2015 (e.g., 2 versus 1: HR 0.37, 95% CI 0.30-0.45), and greater baseline adherence (> 80% versus ≤80% of days in 2015 with ASM pill supply: HR 0.38, 95% CI 0.32-0.44).

CONCLUSIONS

Sustained ASM gaps were rarer than current guidelines may suggest. Future work should further explore barriers and enablers of ASM discontinuation to understand the optimal discontinuation rate.

Comparison of 6 Mortality Risk Scores for Prediction of 1-Year Mortality Risk in Older Adults With Multimorbidity

IMPORTANCE

The most appropriate therapy for older adults with multimorbidity may depend on life expectancy (ie, mortality risk), and several scores have been developed to predict 1-year mortality risk. However, often, these mortality risk scores have not been externally validated in large sample sizes, and a head-to-head comparison in a prospective contemporary cohort is lacking.

OBJECTIVE

To prospectively compare the performance of 6 scores in predicting the 1-year mortality risk in hospitalized older adults with multimorbidity.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study analyzed data of participants in the OPERAM (Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People) trial, which was conducted between December 1, 2016, and October 31, 2018, in surgical and nonsurgical departments of 4 university-based hospitals in Louvain, Belgium; Utrecht, the Netherlands; Cork, Republic of Ireland; and Bern, Switzerland. Eligible participants in the OPERAM trial had multimorbidity (≥3 coexisting chronic diseases), were aged 70 years or older, had polypharmacy (≥5 long-term medications), and were admitted to a participating ward. Data were analyzed from April 1 to September 30, 2020.

MAIN OUTCOMES AND MEASURES

The outcome of interest was any-cause death occurring in the first year of inclusion in the OPERAM trial. Overall performance, discrimination, and calibration of the following 6 scores were assessed: Burden of Illness Score for Elderly Persons, CARING (Cancer, Admissions ≥2, Residence in a nursing home, Intensive care unit admit with multiorgan failure, ≥2 Noncancer hospice guidelines) Criteria, Charlson Comorbidity Index, Gagné Index, Levine Index, and Walter Index. These scores were assessed using the following measures: Brier score (0 indicates perfect overall performance and 0.25 indicates a noninformative model); C-statistic and 95% CI; Hosmer-Lemeshow goodness-of-fit test and calibration plots; and sensitivity, specificity, and positive and negative predictive values.

RESULTS

The 1879 patients in the study had a median (IQR) age of 79 (74-84) years and 835 were women (44.4%). The median (IQR) number of chronic diseases was 11 (8-16). Within 1 year, 375 participants (20.0%) died. Brier scores ranged from 0.16 (Gagné Index) to 0.24 (Burden of Illness Score for Elderly Persons). C-statistic values ranged from 0.62 (95% CI, 0.59-0.65) for Charlson Comorbidity Index to 0.69 (95% CI, 0.66-0.72) for the Walter Index. Calibration was good for the Gagné Index and moderate for other mortality risk scores.

CONCLUSIONS AND RELEVANCE

Results of this prognostic study suggest that all 6 of the 1-year mortality risk scores examined had moderate prognostic performance, discriminatory power, and calibration in a large cohort of hospitalized older adults with multimorbidity. Overall, none of these mortality risk scores outperformed the others, and thus none could be recommended for use in daily clinical practice.

Barriers and facilitators to mobility of patients hospitalised on an acute medical ward: a systematic review

BACKGROUND

low patient mobility is common during hospitalisation and is associated with adverse outcomes. To change practice, interventions should address barriers and facilitators to mobility. Our aim was to systematically review the literature to provide a synthesised overview of patient-, health care professional (HCP)- and environment-/system-related barriers and facilitators to mobility of patients hospitalised on an acute care medical ward.

METHODS

we searched Medline, Embase, PsycInfo, Web of Science Core Collection, Cochrane CENTRAL, CINHAHL and Google Scholar (inception to 18 October 2021) to identify studies reporting barriers and/or facilitators to mobility of adults hospitalised on an acute medical ward. We applied a deductive and inductive thematic analysis to classify barriers and facilitators into themes and subthemes relevant for clinical practice.

RESULTS

among 26 studies (16 qualitative, 7 quantitative and 3 mixed methods), barriers and facilitators were categorised into 10 themes: patient situation, knowledge, beliefs, experiences, intentions, emotions, social influences, role/identity, implementation/organisation and environment/resources. Barriers included patient characteristics (e.g. impaired cognitive/physical status) and symptoms, HCPs prioritising other tasks over mobility, HCPs labelling patients as 'too sick', fear of injury, lack of time, lack of clarity about responsibility, patient medical devices and non-encouraging environment. Facilitators included knowledge of mobility importance, HCP skills, interdisciplinarity, documentation and unit expectations, encouraging staff, goal individualisation, activity programme, family/visitor/volunteer support and availability of equipment.

CONCLUSION

this synthesised overview of patient-, HCP- and environment-/system-related barriers and facilitators to mobility of adults hospitalised on an acute medical ward can help researchers and clinicians focus on what can realistically be influenced to improve mobility.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021285954.

Evaluating alternative methods of comparing antihypertensive treatment intensity

OBJECTIVES

To change blood pressure treatment, clinicians can modify medication count or dose. However, existing studies have measured count modification, which may miss clinically important dose change in the absence of count change. This research demonstrates how dose modification captures more information about management than medication count alone.

STUDY DESIGN

Retrospective cohort study.

METHODS

We included patients 65 years and older with established primary care at the Veterans Health Administration (July 2011-June 2013). We captured medication count and standardized dose change over 90 to 120 days using a validated pharmacy fill algorithm. We determined frequency of dose change without count change (and vice versa), no change in either, change in same direction ("concordant"), and change in opposite direction ("discordant"). We compared change according to systolic blood pressure (SBP) and compared concordance using a minimum threshold definition of dose change of at least 50% (instead of any change) of baseline dose modification.

RESULTS

Among 440,801 patients, 64.2% had dose change; 22.0%, count change; 35.6%, no change in either; 42.4%, dose change without count modification; and 0.2%, count change without dose modification. Discordance occurred in 2.1% of observations. Using the minimum threshold definition of change, 68.7% had no change in either dose or count. Treatment was more frequently changed at SBP greater than 140 mm Hg.

CONCLUSIONS

Measuring change in antihypertensive treatment using medication count frequently missed an isolated dose change in treatment modification and less often misclassified regimen modifications where there was no modification in total dose. In future research, measuring dose modification using our new algorithm would capture change in hypertension treatment intensity more precisely than current methods.

[Should dyslipidemia be treated in the elderly and very old people?]

The beneficial effect of statins on the risk of recurrence of cardiovascular disease (secondary prevention) is well demonstrated. In primary prevention (no symptomatic cardiovascular disease), the benefit of statins after the age of 70 years is less clear and elderly patients with comorbidities have often been excluded from large, randomized trials. Some ongoing clinical trials will provide more information on the potential benefits and risks of starting or stopping statins in older adults. In clinical practice, the decision to treat with statins needs to take into account age, comorbidities, life expectancy, functional and cognitive status and patient preferences (shared decision), but statin discontinuation is only recommended in the context of a clinical trial, as reviewed in this article.

HOSPITAL Score and LACE Index to Predict Mortality in Multimorbid Older Patients

Background

Estimating life expectancy of older adults informs whether to pursue future investigation and therapy. Several models to predict mortality have been developed but often require data not immediately available during routine clinical care. The HOSPITAL score and the LACE index were previously validated to predict 30-day readmissions but may also help to assess mortality risk. We assessed their performance to predict 1-year and 30-day mortality in hospitalized older multimorbid patients with polypharmacy.

Methods

We calculated the HOSPITAL score and LACE index in patients from the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly) trial (patients aged ≥ 70 years with multimorbidity and polypharmacy, admitted to hospital across four European countries in 2016–2018). Our primary and secondary outcomes were 1-year and 30-day mortality. We assessed the overall accuracy (scaled Brier score, the lower the better), calibration (predicted/observed proportions), and discrimination (C-statistic) of the models.

Results

Within 1 year, 375/1879 (20.0%) patients had died, including 94 deaths within 30 days. The overall accuracy was good and similar for both models (scaled Brier score 0.01–0.08). The C-statistics were identical for both models (0.69 for 1-year mortality, p = 0.81; 0.66 for 30-day mortality, p = 0.94). Calibration showed well-matching predicted/observed proportions.

Conclusion

The HOSPITAL score and LACE index showed similar performance to predict 1-year and 30-day mortality in older multimorbid patients with polypharmacy. Their overall accuracy was good, their discrimination low to moderate, and the calibration good. These simple tools may help predict older multimorbid patients’ mortality after hospitalization, which may inform post-hospitalization intensity of care.

Type 2 Diabetes Management, Control and Outcomes During the COVID-19 Pandemic in Older US Veterans: an Observational Study

BACKGROUND

The COVID-19 pandemic required a change in outpatient care delivery models, including shifting from in-person to virtual visits, which may have impacted care of vulnerable patients.

OBJECTIVE

To describe the changes in management, control, and outcomes in older people with type 2 diabetes (T2D) associated with the shift from in-person to virtual visits.

DESIGN AND PARTICIPANTS

In veterans aged ≥ 65 years with T2D, we assessed the rates of visits (in person, virtual), A1c measurements, antidiabetic deintensification/intensification, ER visits and hospitalizations (for hypoglycemia, hyperglycemia, other causes), and A1c level, in March 2020 and April-November 2020 (pandemic period). We used negative binomial regression to assess change over time (reference: pre-pandemic period, July 2018 to February 2020), by baseline Charlson Comorbidity Index (CCI; > 2 vs. <= 2) and A1c level.

KEY RESULTS

Among 740,602 veterans (mean age 74.2 [SD 6.6] years), there were 55% (95% CI 52-58%) fewer in-person visits, 821% (95% CI 793-856%) more virtual visits, 6% (95% CI 1-11%) fewer A1c measurements, and 14% (95% CI 10-17%) more treatment intensification during the pandemic, relative to baseline. Patients with CCI > 2 had a 14% (95% CI 12-16%) smaller relative increase in virtual visits than those with CCI <= 2. We observed a seasonality of A1c level and treatment modification, but no association of either with the pandemic. After a decrease at the beginning of the pandemic, there was a rebound in other-cause (but not hypo- and hyperglycemia-related) ER visits and hospitalizations from June to November 2020.

CONCLUSION

Despite a shift to virtual visits and a decrease in A1c measurement during the pandemic, we observed no association with A1c level or short-term T2D-related outcomes, providing some reassurance about the adequacy of virtual visits. Further studies should assess the longer-term effects of shifting to virtual visits in different populations to help individualize care, improve efficiency, and maintain appropriate care while reducing overuse.

Adherence to Antiseizure vs Other Medications Among US Medicare Beneficiaries With and Without Epilepsy

BACKGROUND AND OBJECTIVE

The objectives of this study were to compare adherence to antiseizure medications (ASMs) vs non-ASMs among individuals with epilepsy, to assess the degree to which variation in adherence is due to differences between individuals vs between medication classes among individuals with epilepsy, and to compare adherence in individuals with vs without epilepsy.

METHODS

This was a retrospective cohort study using Medicare. We included beneficiaries with epilepsy (≥1 ASM, plus ICD-9-CM diagnostic codes) and a 20% random sample without epilepsy. Adherence for each medication class was measured by the proportion of days covered (PDC) in 2013 to 2015. We used Spearman correlation coefficients, Cohen κ statistics, and multilevel logistic regressions.

RESULTS

There were 83,819 beneficiaries with epilepsy. Spearman correlation coefficients between ASM PDCs and each of the 5 non-ASM PDCs ranged from 0.44 to 0.50; Cohen κ ranged from 0.33 to 0.38; and within-person differences between the PDC of each ASM minus the PDC of each non-ASM were all statistically significant (p < 0.01), although median differences were all very close to 0. Fifty-four percent of variation in adherence across medications was due to differences between individuals. Adjusted predicted probabilities of adherence were as follows: ASMs 74% (95% confidence interval [CI] 73%-74%), proton pump inhibitors 74% (95% CI 74%-74%), antihypertensives 77% (95% CI 77%-78%), selective serotonin reuptake inhibitors 77% (95% CI 77%-78%), statins 78% (95% CI 78%-79%), and levothyroxine 82% (95% CI 81%-82%). Adjusted predicted probabilities of adherence to non-ASMs were 80% (95% CI 80%-81%) for beneficiaries with epilepsy vs 77% (95% CI 77%-77%) for beneficiaries without epilepsy.

DISCUSSION

Among individuals with epilepsy, ASM adherence and non-ASM adherence were moderately correlated, half of the variation in adherence was due to between-person rather than between-medication differences, adjusted adherence was slightly lower for ASMs than several non-ASMs, and epilepsy was associated with a quite small increase in adherence to non-ASMs. Nonadherence to ASMs may provide an important cue to the clinician to inquire about adherence to other potentially life-prolonging medications as well. Although efforts should focus on improving ASM adherence, patient-level rather than purely medication-specific behaviors are also critical to consider when developing interventions to optimize adherence.

Predictors of 1‐year drug‐related admissions in older multimorbid hospitalized adults

Background

Methods

Results

Conclusion

Definition of patient complexity in adults: A narrative review

Background

Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years.

Methods

We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model.

Results

Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles.

Conclusion

A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.

Polypharmacy composition and patient- and provider-related variation in patients with epilepsy

OBJECTIVE

To describe polypharmacy composition, and the degree to which patients versus providers contribute to variation in medication fills, in people with epilepsy.

METHODS

We performed a retrospective study of Medicare beneficiaries with epilepsy (antiseizure medication plus diagnostic codes) in 2014 (N = 78,048). We described total number of medications and prescribers, and specific medications. Multilevel models evaluated the percentage of variation in two outcomes (1. number of medications per patient-provider dyad, and 2. whether a medication was filled within thirty days of a visit) due to patient-to-patient differences versus provider-to-provider differences.

RESULTS

Patients filled a median of 12 (interquartile range [IQR] 8-17) medications, from median of 5 (IQR 3-7) prescribers. Twenty-two percent filled an opioid, and 61% filled at least three central nervous system medications. Levetiracetam was the most common medication (40%), followed by hydrocodone/acetaminophen (27%). The strongest predictor of medications per patient was Charlson comorbidity index (7.5 [95% confidence interval (CI) 7.2-7.8] additional medications for index 8+ versus 0). Provider-to-provider variation explained 36% of variation in number of medications per patient, whereas patient-to-patient variation explained only 2% of variation. Provider-to-provider variation explained 57% of variation in whether a patient filled a medication within 30 days of a visit, whereas patient-to-patient variation explained only 30% of variation.

CONCLUSION

Patients with epilepsy fill a large number of medications from a large number of providers, including high-risk medications. Variation in medication fills was substantially more related to provider-to-provider rather than patient-to-patient variation. The better understanding of drivers of high-prescribing practices may reduce avoidable medication-related harms.

Adding a New Medication Versus Maximizing Dose to Intensify Hypertension Treatment in Older Adults : A Retrospective Observational Study

BACKGROUND

There are 2 approaches to intensifying antihypertensive treatment when target blood pressure is not reached, adding a new medication and maximizing dose. Which strategy is better is unknown.

OBJECTIVE

To assess the frequency of intensification by adding a new medication versus maximizing dose, as well as the association of each method with intensification sustainability and follow-up systolic blood pressure (SBP).

DESIGN

Large-scale, population-based, retrospective cohort study. Observational data were used to emulate a target trial with 2 groups, new medication and maximizing dose, who underwent intensification of their drug regimen.

SETTING

Veterans Health Administration (2011 to 2013).

PATIENTS

Veterans aged 65 years or older with hypertension, an SBP of 130 mm Hg or higher, and at least 1 antihypertensive medication at less than the maximum dose.

MEASUREMENTS

The following 2 intensification approaches were emulated: adding a new medication, defined as a total dose increase with new medication, and maximizing dose, defined as a total dose increase without new medication. Inverse probability weighting was used to assess the observational effectiveness of the intensification approach on sustainability of intensified treatment and follow-up SBP at 3 and 12 months.

RESULTS

Among 178 562 patients, 45 575 (25.5%) had intensification by adding a new medication and 132 987 (74.5%) by maximizing dose. Compared with maximizing dose, adding a new medication was associated with less intensification sustainability (average treatment effect, -15.2% [95% CI, -15.7% to -14.6%] at 3 months and -15.1% [CI, -15.6% to -14.5%] at 12 months) but a slightly larger reduction in mean SBP (-0.8 mm Hg [CI, -1.2 to -0.4 mm Hg] at 3 months and -1.1 mm Hg [CI, -1.6 to -0.6 mm Hg] at 12 months).

LIMITATION

Observational data; largely male population.

CONCLUSION

Adding a new antihypertensive medication was less frequent and was associated with less intensification sustainability but slightly larger reductions in SBP. Trials would provide the most definitive support for our findings.

PRIMARY FUNDING SOURCE

National Institute on Aging and Veterans Health Administration.

Association of Thyroid Dysfunction With Cognitive Function: An Individual Participant Data Analysis

IMPORTANCE

In clinical guidelines, overt and subclinical thyroid dysfunction are mentioned as causal and treatable factors for cognitive decline. However, the scientific literature on these associations shows inconsistent findings.

OBJECTIVE

To assess cross-sectional and longitudinal associations of baseline thyroid dysfunction with cognitive function and dementia.

DESIGN, SETTING, AND PARTICIPANTS

This multicohort individual participant data analysis assessed 114 267 person-years (median, 1.7-11.3 years) of follow-up for cognitive function and 525 222 person-years (median, 3.8-15.3 years) for dementia between 1989 and 2017. Analyses on cognitive function included 21 cohorts comprising 38 144 participants. Analyses on dementia included eight cohorts with a total of 2033 cases with dementia and 44 573 controls. Data analysis was performed from December 2016 to January 2021.

EXPOSURES

Thyroid function was classified as overt hyperthyroidism, subclinical hyperthyroidism, euthyroidism, subclinical hypothyroidism, and overt hypothyroidism based on uniform thyrotropin cutoff values and study-specific free thyroxine values.

MAIN OUTCOMES AND MEASURES

The primary outcome was global cognitive function, mostly measured using the Mini-Mental State Examination. Executive function, memory, and dementia were secondary outcomes. Analyses were first performed at study level using multivariable linear regression and multivariable Cox regression, respectively. The studies were combined with restricted maximum likelihood meta-analysis. To overcome the use of different scales, results were transformed to standardized mean differences. For incident dementia, hazard ratios were calculated.

RESULTS

Among 74 565 total participants, 66 567 (89.3%) participants had normal thyroid function, 577 (0.8%) had overt hyperthyroidism, 2557 (3.4%) had subclinical hyperthyroidism, 4167 (5.6%) had subclinical hypothyroidism, and 697 (0.9%) had overt hypothyroidism. The study-specific median age at baseline varied from 57 to 93 years; 42 847 (57.5%) participants were women. Thyroid dysfunction was not associated with global cognitive function; the largest differences were observed between overt hypothyroidism and euthyroidism-cross-sectionally (-0.06 standardized mean difference in score; 95% CI, -0.20 to 0.08; P = .40) and longitudinally (0.11 standardized mean difference higher decline per year; 95% CI, -0.01 to 0.23; P = .09). No consistent associations were observed between thyroid dysfunction and executive function, memory, or risk of dementia.

CONCLUSIONS AND RELEVANCE

In this individual participant data analysis of more than 74 000 adults, subclinical hypothyroidism and hyperthyroidism were not associated with cognitive function, cognitive decline, or incident dementia. No rigorous conclusions can be drawn regarding the role of overt thyroid dysfunction in risk of dementia. These findings do not support the practice of screening for subclinical thyroid dysfunction in the context of cognitive decline in older adults as recommended in current guidelines.

Clinical outcomes of modifying hypertension treatment intensity in older adults treated to low blood pressure

BACKGROUND/OBJECTIVES

Hypertension treatment reduces cardiovascular events. However, uncertainty remains about benefits and harms of deintensification or further intensification of antihypertensive medication when systolic blood pressure (SBP) is tightly controlled in older multimorbid patients, because of their frequent exclusion in trials. We assessed the association of hypertension treatment deintensification or intensification with clinical outcomes in older adults with tightly controlled SBP.

DESIGN

Longitudinal cohort study (2011-2013) with 9-month follow-up.

SETTING

U.S.-nationwide primary care Veterans Health Administration healthcare system.

PARTICIPANTS

Veterans aged 65 and older with baseline SBP <130 mmHg and ≥1 antihypertensive medication during ≥2 consecutive visits (N = 228,753).

EXPOSURE

Deintensification or intensification, compared with stable treatment.

MAIN OUTCOMES AND MEASURES

Cardiovascular events, syncope, or fall injury, as composite and distinct outcomes, within 9 months after exposure. Adjusted logistic regression and inverse probability of treatment weighting (IPTW, sensitivity analysis).

RESULTS

Among 228,753 patients (mean age 75 [SD 7.5] years), the composite outcome occurred in 11,982/93,793 (12.8%) patients with stable treatment, 14,768/72,672 (20.3%) with deintensification, and 11,821/62,288 (19.0%) with intensification. Adjusted absolute outcome risk (95% confidence interval) was higher for deintensification (18.3% [18.1%-18.6%]) and intensification (18.7% [18.4%-19.0%]), compared with stable treatment (14.8% [14.6%-15.0%]), p < 0.001 for both effects in the multivariable model). Deintensification was associated with fewer cardiovascular events than intensification. At baseline SBP <95 mmHg, cardiovascular event risk was similar for deintensification and stable treatment, and fall risk lower for deintensification than intensification. IPTW yielded similar results. Mean follow-up SBP was 124.1 mmHg for stable treatment, 125.1 mmHg after deintensification (p < 0.001), and 124.0 mmHg after intensification (p < 0.001).

CONCLUSION

Antihypertensive treatment deintensification in older patients with tightly controlled SBP was associated with worse outcomes than continuing same treatment intensity. Given higher mortality among patients with treatment modification, confounding by indication may not have been fully corrected by advanced statistical methods for observational data analysis.

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial

OBJECTIVE

To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital.

DESIGN

Cluster randomised controlled trial.

SETTING

110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors.

PARTICIPANTS

2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term).

INTERVENTION

Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing.

MAIN OUTCOME MEASURE

Primary outcome was first drug related hospital admission within 12 months.

RESULTS

2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths).

CONCLUSIONS

Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02986425.

Factors associated with antihypertensive treatment intensification and deintensification in older outpatients

Background

New hypertension performance measures encourage more intensive treatment in older adults. Treatment intensification includes starting new medications and increasing the dose of old ones. Medication dose is particularly important to older adults, given their vulnerability to dose-related side effects. We previously validated a standardized measure of beneficial doses tested in hypertension trials, Hypertension Daily Dose (HDD).

Aim of the study

To test whether changes in treatment intensity using HDD was associated with systolic blood pressure (SBP) and patient characteristics.

Methods

Longitudinal study of all Veterans aged ≥65 years with a diagnosis of hypertension. We defined 3 groups of risk: 1) cardiovascular risk; 2) geriatric/frail; 3) low-risk (comparator). Using multinomial regression, we assessed the probability of deintensification, intensification, vs. stable treatment, according to SBP and group.

Results

Among 1,331,111 Veterans, 19.9% had deintensification, and 29.6% intensification. Deintensification decreased, while intensification increased, with SBP. Compared to low-risk patients, cardiovascular risk patients had 1.11 (95% CI 1.10-1.13) times the odds of intensifying, and geriatric/frail patients 1.45 (95%CI 1.43-1.47) times the odds of deintensifying.

Discussion

Patient-level HDD change was consistent with an expected association with cardiovascular risk and geriatric/frail conditions, suggesting that HDD can be used longitudinally to assess hypertension treatment modification in large health systems.

A Method to Quantify Mean Hypertension Treatment Daily Dose Intensity Using Health Care System Data

Importance

Simple measures of hypertension treatment, such as achievement of blood pressure (BP) targets, ignore the intensity of treatment once the BP target is met. High-intensity treatment involves increased treatment burden and can be associated with potential adverse effects in older adults. A method was previously developed to identify older patients receiving intense hypertension treatment by low BP and number of BP medications using national Veterans Health Administration and Medicare Part D administrative pharmacy data to evaluate which BP medications a patient is likely taking on any given day.

Objective

To further develop and validate a method to more precisely quantify dose intensity of hypertension treatment using only health system administrative pharmacy fill data.

Design, Setting, and Participants

Observational, cross-sectional study of 319 randomly selected older veterans in the national Veterans Health Administration health care system who were taking multiple BP-lowering medications and had a total of 3625 ambulatory care visits from July 1, 2011, to June 30, 2013. Measure development and medical record review occurred January 1, 2017, through November 30, 2018, and data analysis was conducted from December 1, 2019, to August 31, 2020.

Main Outcomes and Measures

For each BP-lowering medication, a moderate hypertension daily dose (HDD) was defined as half the maximum dose above which no further clinical benefit has been demonstrated by that medication in hypertension trials. Patients' total HDD was calculated using pharmacy data (pharmacy HDDs), accounting for substantial delays in refills (>30 days) when a patient's pill supply was stretched (eg, cutting existing pills in half). As an external comparison, the pharmacy HDDs were correlated with doses manually extracted from clinicians' visit notes (clinically noted HDDs). How well the pharmacy HDDs correlated with clinically noted HDDs was calculated (using C statistics). To facilitate interpretation, HDDs were described in association with the number of medications.

Results

A total of 316 patients (99.1%) were male; the mean (SD) age was 75.6 (7.2) years. Pharmacy HDDs were highly correlated (r = 0.92) with clinically noted HDDs, with a mean (SD) of 2.7 (1.8) for pharmacy HDDs and 2.8 (1.8) for clinically noted HDDs. Pharmacy HDDs correlated with high-intensity, clinically noted HDDs ranging from a C statistic of 92.8% (95% CI, 92.0%-93.7%) for 2 or more clinically noted HDDs to 88.1% (95% CI, 85.5%-90.6%) for 6 or more clinically noted HDDs.

Conclusions and Relevance

This study suggests that health system pharmacy data may be used to accurately quantify hypertension regimen dose intensity. Together with clinic-measured BP, this tool can be used in future health system-based research or quality improvement efforts to fine-tune, manage, and optimize hypertension treatment in older adults.

Focus and features of prescribing indications spanning multiple chronic conditions in older adults: A narrative review

Background:

Inappropriate prescribing is frequent in older adults and associated with adverse outcomes. Prescribing indications aim to optimize prescribing, but little is known about the focus and features of prescribing indications for the most common chronic conditions in older adults. Understanding the conditions, medications, and issues addressed (e.g., patient perspective, drug-disease interaction, adverse drug event) in current prescribing indications may help to identify missing indications and develop standardized measures to improve prescribing quality.

Methods:

We searched Ovid/MEDLINE and EMBASE for articles published between 2015 and 2020 reporting prescribing indications for older adults. Prescribing indication included 1) prescribing “criteria,” or statements that guide prescribing action, and 2) prescribing “measures,” or prescribing actions observed in a population. We categorized their focus by conditions, medications and issues addressed, as well as level of evidence provided.

Results:

Among 16 sets of prescribing indications, we identified 748 criteria and 47 measures. The most common addressed medications were antihypertensives, analgesics/antirheumatics, and antiplatelets/anticoagulants. The most frequently addressed issues were drug-disease interaction, adverse drug event, administration, better therapeutic alternative, and (co-)prescription omission (20.8–36.1%). Age/functioning, drug-drug interaction, monitoring, and efficacy/safety ratio were found in only 9.9–16.5% of indications. Indications rarely focused on the patient perspective or issues with multiple providers.

Conclusion:

Most prescribing indications for chronic conditions in older patients are criteria rather than measures. Indications accounting for patient perspective and multiple providers are limited. The gaps identified in this review may help improve the development of prescribing measures for older adults and ultimately improve quality of care.

Polypharmacy in patients with epilepsy: A nationally representative cross-sectional study

OBJECTIVE

The objective of the study was to characterize the prevalence of polypharmacy and central nervous system (CNS)-acting medications in patients with epilepsy, and particular types of medications.

METHODS

This was a retrospective cross-sectional study using data from the nationally representative National Health and Nutrition Examination Survey (NHANES). We included patients who reported taking at least one prescription medication in order to treat seizures or epilepsy during NHANES survey years 2013-2016. We assessed the number and types of drugs and predictors of total number of medications using a negative binomial regression. We then assessed prevalence of polypharmacy (≥5 medications), CNS polypharmacy (≥3 CNS-acting medications) and additional CNS-acting medications, and drugs that lower the seizure threshold (i.e., bupropion and tramadol), and extrapolated prevalence to estimated affected US population.

RESULTS

The NHANES contained 20,146 participants, of whom 135 reported taking ≥1 antiseizure medication (ASM) for seizures or epilepsy representing 2,399,520 US citizens using NHANES's sampling frame. Patients reported taking a mean 5.3 (95% confidence interval (CI): 4.3-6.3) prescription medications. Adjusting for race, sex, and uninsurance, both age and number of chronic conditions predicted increased number of medications (incident rate ratio (IRR) per decade: 1.16, 95% CI: 1.04-1.28; IRR per chronic condition: 1.19, 95% CI: 1.11-1.27). Polypharmacy was reported by 47% (95% CI: 38%-57%) of patients, CNS polypharmacy by 34% (23%-47%), benzodiazepine use by 21% (14%-30%), opioid use by 16% (11%-24%), benzodiazepine plus opioid use by 6% (3%-14%), and 6% (2%-15%) reported a drug that lowers the seizure threshold. Twelve percent (7%-20%) took an opioid with either a benzodiazepine or gabapentinoid.

CONCLUSIONS

Polypharmacy is common in patients with epilepsy. Patients taking ASMs frequently reported also taking other CNS-acting medications (i.e., opioids, benzodiazepines, seizure threshold-lowering medications), and medication combinations with black box warnings. Central nervous system polypharmacy poses health risks. Future research is needed to explore drivers of polypharmacy and strategies to help mitigate potentially harmful prescription use in this high-risk population.

Association of patterns of multimorbidity with length of stay: A multinational observational study

The aim of this study was to identify the combinations of chronic comorbidities associated with length of stay (LOS) among multimorbid medical inpatients.Multinational retrospective cohort of 126,828 medical inpatients with multimorbidity, defined as ≥2 chronic diseases (data collection: 2010-2011). We categorized the chronic diseases into comorbidities using the Clinical Classification Software. We described the 20 combinations of comorbidities with the strongest association with prolonged LOS, defined as longer than or equal to country-specific LOS, and reported the difference in median LOS for those combinations. We also assessed the association between the number of diseases or body systems involved and prolonged LOS.The strongest association with prolonged LOS (odds ratio [OR] 7.25, 95% confidence interval [CI] 6.64-7.91, P < 0.001) and the highest difference in median LOS (13 days, 95% CI 12.8-13.2, P < 0.001) were found for the combination of diseases of white blood cells and hematological malignancy. Other comorbidities found in the 20 top combinations had ORs between 2.37 and 3.65 (all with P < 0.001) and a difference in median LOS of 2 to 5 days (all with P < 0.001), and included mostly neurological disorders and chronic ulcer of skin. Prolonged LOS was associated with the number of chronic diseases and particularly with the number of body systems involved (≥7 body systems: OR 21.50, 95% CI 19.94-23.18, P < 0.001).LOS was strongly associated with specific combinations of comorbidities and particularly with the number of body systems involved. Describing patterns of multimorbidity associated with LOS may help hospitals anticipate resource utilization and judiciously allocate services to shorten LOS.

Best Definitions of Multimorbidity to Identify Patients With High Health Care Resource Utilization

Objective

To compare different definitions of multimorbidity to identify patients with higher health care resource utilization.

Patients and Methods

We used a multinational retrospective cohort including 147,806 medical inpatients discharged from 11 hospitals in 3 countries (United States, Switzerland, and Israel) between January 1, 2010, and December 31, 2011. We compared the area under the receiver operating characteristic curve (AUC) of 8 definitions of multimorbidity, based on International Classification of Diseases codes defining health conditions, the Deyo-Charlson Comorbidity Index, the Elixhauser-van Walraven Comorbidity Index, body systems, or Clinical Classification Software categories to predict 30-day hospital readmission and/or prolonged length of stay (longer than or equal to the country-specific upper quartile). We used a lower (yielding sensitivity ≥90%) and an upper (yielding specificity ≥60%) cutoff to create risk categories.

Results

Definitions had poor to fair discriminatory power in the derivation (AUC, 0.61-0.65) and validation cohorts (AUC, 0.64-0.71). The definitions with the highest AUC were number of (1) health conditions with involvement of 2 or more body systems, (2) body systems, (3) Clinical Classification Software categories, and (4) health conditions. At the upper cutoff, sensitivity and specificity were 65% to 79% and 50% to 53%, respectively, in the validation cohort; of the 147,806 patients, 5% to 12% (7474 to 18,008) were classified at low risk, 38% to 55% (54,484 to 81,540) at intermediate risk, and 32% to 50% (47,331 to 72,435) at high risk.

Conclusion

Of the 8 definitions of multimorbidity, 4 had comparable discriminatory power to identify patients with higher health care resource utilization. Of these 4, the number of health conditions may represent the easiest definition to apply in clinical routine. The cutoff chosen, favoring sensitivity or specificity, should be determined depending on the aim of the definition.

Multimorbidity and healthcare resource utilization in Switzerland: a multicentre cohort study

BACKGROUND

Multimorbidity is associated with higher healthcare resource utilization, but we lack data on the association of specific combinations of comorbidities with healthcare resource utilization. We aimed to identify the combinations of comorbidities associated with high healthcare resource utilization among multimorbid medical inpatients.

METHODS

We performed a multicentre retrospective cohort study including 33,871 multimorbid (≥2 chronic diseases) medical inpatients discharged from three Swiss hospitals in 2010-2011. Healthcare resource utilization was measured as 30-day potentially avoidable readmission (PAR), prolonged length of stay (LOS) and difference in median LOS. We identified the combinations of chronic comorbidities associated with the highest healthcare resource utilization and quantified this association using regression techniques.

RESULTS

Three-fourths of the combinations with the strongest association with PAR included chronic kidney disease. Acute and unspecified renal failure combined with solid malignancy was most strongly associated with PAR (OR 2.64, 95%CI 1.79;3.90). Miscellaneous mental health disorders combined with mood disorders was the most strongly associated with LOS (difference in median LOS: 17 days) and prolonged LOS (OR 10.77, 95%CI 8.38;13.84). The number of chronic diseases was strongly associated with prolonged LOS (OR 9.07, 95%CI 8.04;10.24 for ≥10 chronic diseases), and to a lesser extent with PAR (OR 2.16, 95%CI 1.75;2.65 for ≥10 chronic diseases).

CONCLUSIONS

Multimorbidity appears to have a higher impact on LOS than on PAR. Combinations of comorbidities most strongly associated with healthcare utilization included kidney disorders for PAR, and mental health disorders for LOS.

Patterns of multimorbidity in internal medicine patients in Swiss university hospitals: a multicentre cohort study

AIMS OF THE STUDY

Despite the high prevalence of multimorbidity, we lack detailed descriptive data on the most prevalent combinations of chronic comorbidities in Switzerland. We aimed to describe and quantify the most prevalent combinations of comorbidities in internal medicine multimorbid inpatients.

METHODS

We conducted a multicentre retrospective cohort study including all consecutive adults (n = 42,739) discharged from the general internal medicine department of three Swiss tertiary teaching hospitals in 2010&ndash;2011. We used the Chronic Condition Indicator and the Clinical Classification Software to classify International Classification of Diseases diagnosis codes into chronic or acute diseases, into body system categories and into categories of chronic comorbidities. We defined multimorbidity as &ge;2 chronic diseases. We described the most prevalent combinations of comorbidities and their prevalence.

RESULTS

Seventy-nine percent (n = 33,871) of the patients were multimorbid, with a median of four chronic diseases. Chronic heart disease, chronic kidney disease, solid malignancy and substance-related disorders were the most prevalent comorbidities, with a prevalence of more than 10% for each. All these comorbidities were frequently found in combination with chronic obstructive pulmonary disease and bronchiectasis, pulmonary heart disease, and peripheral and visceral atherosclerosis. Chronic heart disease was identified in 80% of the most prevalent combinations. Half of the combinations occurred more often than it would have been expected if they were independent.

CONCLUSIONS

The vast majority of patients fulfilled the criteria for multimorbidity. Chronic heart disease, chronic kidney disease, solid malignancy and substance-related disorders were each present in at least one tenth of the patients. This in-depth description of the most frequent comorbidities and of their frequent associations in a multicentre population may advise healthcare providers to improve preventive care and develop appropriate guidelines for multimorbid patients. &nbsp.

Patterns of multimorbidity associated with 30-day readmission: a multinational study

BACKGROUND

Multimorbidity is associated with higher healthcare utilization; however, data exploring its association with readmission are scarce. We aimed to investigate which most important patterns of multimorbidity are associated with 30-day readmission.

METHODS

We used a multinational retrospective cohort of 126,828 medical inpatients with multimorbidity defined as ≥2 chronic diseases. The primary and secondary outcomes were 30-day potentially avoidable readmission (PAR) and 30-day all-cause readmission (ACR), respectively. Only chronic diseases were included in the analyses. We presented the OR for readmission according to the number of diseases or body systems involved, and the combinations of diseases categories with the highest OR for readmission.

RESULTS

Multimorbidity severity, assessed as number of chronic diseases or body systems involved, was strongly associated with PAR, and to a lesser extend with ACR. The strength of association steadily and linearly increased with each additional disease or body system involved. Patients with four body systems involved or nine diseases already had a more than doubled odds for PAR (OR 2.35, 95%CI 2.15-2.57, and OR 2.25, 95%CI 2.05-2.48, respectively). The combinations of diseases categories that were most strongly associated with PAR and ACR were chronic kidney disease with liver disease or chronic ulcer of skin, and hematological malignancy with esophageal disorders or mood disorders, respectively.

CONCLUSIONS

Readmission was associated with the number of chronic diseases or body systems involved and with specific combinations of diseases categories. The number of body systems involved may be a particularly interesting measure of the risk for readmission in multimorbid patients.

Serum concentration and vascular expression of adiponectin are differentially associated with the diabetic calcifying peripheral arteriopathy

BACKGROUND

Medial calcification in diabetes contributes to the arterial occlusive process occurring below the knee level. Adiponectin is an adipokine with atheroprotective properties and possible protective role against arterial calcification. The aim of the study was to investigate, in type 2 diabetes, the link between vascular expression and serum concentration of adiponectin and (1) peripheral arterial calcification and (2) lower limb occlusive arterial disease.

METHODS

Scoring of peripheral vascular calcification and peripheral arterial occlusive disease, using CT-scan and color-duplex ultrasonography respectively, were conducted and explored in relation to serum adiponectin level in a cross sectional study of 197 patients with type 2 diabetes. Vascular adiponectin expression in the arterial wall of diabetic patients with and without medial calcification was evaluated by immunohistochemistry.

RESULTS

Peripheral arterial calcification score was higher in patients with the highest adiponectin concentration. In a multivariate logistic regression analysis, an increase of 1 µg/mL of adiponectin was associated with a 22% increase of arterial calcification (adjusted OR = 1.22; 95% CI 1.03-1.44; p = 0.02). Arterial occlusive score was also higher in patients with adiponectin concentration > median (2.8 ± 4.8 vs 4.2 ± 5.7, p = 0.034). Immunohistochemical analyses showed a strong and specific staining of adiponectin in smooth muscle cells in calcified arteries, with a more pronounced expression of adiponectin in early stages of medial calcification.

CONCLUSIONS

Peripheral arterial calcification is positively associated with circulating adiponectin levels in patients with type 2 diabetes, but vascular adiponectin expression is already observed at early stages of calcification. Adiponectin secretion could be a compensatory mechanism against the calcification process.Trial registration DIACART NCT number: NCT02431234. Registered 30 April 2015.

Thyroid Dysfunction and Anemia: A Prospective Cohort Study and a Systematic Review

BACKGROUND

Even though the association between thyroid dysfunction and anemia is commonly described, it is not known whether it is clinically relevant. This study set out to quantify the association of thyroid dysfunction on hemoglobin (Hb) concentration and risk of anemia. A systematic review (MEDLINE and EMBASE, from inception until May 15, 2017) was conducted to interpret the findings in context.

METHODS

Participants from the EPIC-Norfolk cohort with available baseline thyrotropin (TSH), free thyroxine (fT4), and Hb were included. Euthyroidism was defined as TSH 0.45-4.49 mIU/L (reference category), hypothyroidism as TSH ≥4.50 mIU/L (subclinical [SHypo] with normal fT4 or overt [OHypo] with low fT4), and hyperthyroidism as TSH ≤0.44 mIU/L (subclinical [SHyper] with normal fT4 or overt [OHyper] with elevated fT4). Anemia was defined as Hb <12 g/dL in women and Hb <13 g/dL in men. In the cross-sectional analyses, multiple linear regression was used to compare Hb across TSH categories. In the prospective analysis, participants with OHypo/OHyper at baseline were excluded, as it was assumed that they were treated for overt thyroid disease. A covariance model was used to determine change in Hb concentration from baseline to last follow-up, and multivariable Cox regression was used to analyze anemia risk.

RESULTS

In the cross-sectional population (n = 12,337), the adjusted Hb was 0.22 g/dL lower [confidence interval (CI) 0.07-0.38] in OHypo compared to euthyroids, and 0.08 g/dL lower [CI -0.23 to 0.38] in OHyper. In the prospective analysis, 460/7031 participants developed anemia over a median follow-up of 4.7 years. The adjusted mean Hb change over time was -0.04 g/dL in SHypo [CI -0.14 to 0.06] and 0.05 g/dL in SHyper [CI -0.10 to 0.20]. The adjusted hazard ratio for anemia was 0.99 [CI 0.67-1.48] in SHypo, and 0.52 [CI 0.23-1.16] in SHyper. The systematic review returned no other prospective studies on this association, but cross-sectional and case-control studies showed comparable results.

CONCLUSION

In this first prospective population-based cohort, subclinical thyroid dysfunction was not associated with a change in Hb concentration during follow-up and was not an independent risk factor for developing anemia; variations in Hb concentration in patients with overt thyroid dysfunction were not clinically relevant.

[Subclinical hypothyroidism : should we still treat elderly patients? Clinical implications of a new trial in primary care]

Subclinical hypothyroidism, defined as an elevated level of thyrotropin hormone (TSH) and normal thyroxin, is more frequent in women and above 65 years old. This condition is associated with an increased cardiovascular risk, in particular with TSH > 10,0 mIU/L. Although overt hypothyroidism is rare (prevalence of 0,3 %), levothyroxine has become the most prescribed medication in the US, while its indications are still debated. The European-funded TRUST trial showed no improvement in Hypothyroid Symptoms and Tiredness scores among patients ≥ 65 years with subclinical hypothyroidism treated with levothyroxine, and no improvement in blood pressure, weight, muscle strength and cognition. The results of this study call for a revision of the current international recommendations on the treatment of subclinical hypothyroidism.

[2018 new recommendations for dyslipidemia : a critical review of evidence]

Dyslipidemia is an important cardiovascular risk factor. Its management should be individualized according to cardiovascular risk, which can be estimated using PROCAM score, taking into account patients' comorbidities. Cardiovascular risk is classified as low, moderated or high. The Swiss Atherosclerosis Association (AGLA) recently published new recommendations that we are describing taking into account evidence of recent studies, in order to avoid overmedicalisation. Lifestyle interventions should always be implemented and are the main therapy for most patients in primary prevention. A secondary etiology should be excluded, as its treatment can often normalize the lipid disturbance. Familial dyslipidemia should be looked for, as it is associated with a particularly high cardiovascular risk, and because of its specific management.

Association between subclinical thyroid dysfunction and change in bone mineral density in prospective cohorts

BACKGROUND

Subclinical hyperthyroidism (SHyper) has been associated with increased risk of hip and other fractures, but the linking mechanisms remain unclear.

OBJECTIVE

To investigate the association between subclinical thyroid dysfunction and bone loss.

METHODS

Individual participant data analysis was performed after a systematic literature search in MEDLINE/EMBASE (1946-2016). Two reviewers independently screened and selected prospective cohorts providing baseline thyroid status and serial bone mineral density (BMD) measurements. We classified thyroid status as euthyroidism (thyroid-stimulating hormone [TSH] 0.45-4.49 mIU/L), SHyper (TSH < 0.45 mIU/L) and subclinical hypothyroidism (SHypo, TSH ≥ 4.50-19.99 mIU/L) both with normal free thyroxine levels. Our primary outcome was annualized percentage BMD change (%ΔBMD) from serial dual X-ray absorptiometry scans of the femoral neck, total hip and lumbar spine, obtained from multivariable regression in a random-effects two-step approach.

RESULTS

Amongst 5458 individuals (median age 72 years, 49.1% women) from six prospective cohorts, 451 (8.3%) had SHypo and 284 (5.2%) had SHyper. During 36 569 person-years of follow-up, those with SHyper had a greater annual bone loss at the femoral neck versus euthyroidism: %ΔBMD = -0.18 (95% CI: -0.34, -0.02; I2 = 0%), with a nonstatistically significant pattern at the total hip: %ΔBMD = -0.14 (95% CI: -0.38, 0.10; I2 = 53%), but not at the lumbar spine: %ΔBMD = 0.03 (95% CI: -0.30, 0.36; I2 = 25%); especially participants with TSH < 0.10 mIU/L showed an increased bone loss in the femoral neck (%Δ BMD = -0.59; [95% CI: -0.99, -0.19]) and total hip region (%ΔBMD = -0.46 [95% CI: -1.05, -0.13]). In contrast, SHypo was not associated with bone loss at any site.

CONCLUSION

Amongst adults, SHyper was associated with increased femoral neck bone loss, potentially contributing to the increased fracture risk.

The association between subclinical thyroid dysfunction and dementia: The Health, Aging and Body Composition (Health ABC) Study

OBJECTIVE

Data on the association between subclinical thyroid dysfunction and dementia are limited and conflicting. We aimed to determine whether subclinical thyroid dysfunction was associated with dementia and cognitive decline.

DESIGN

Population-based prospective cohort study.

PATIENTS

Adults aged 70-79 years with measured thyroid function, but no dementia at baseline, and Modified Mini-Mental State (3MS) at baseline and follow-up.

MEASUREMENTS

Primary outcome was incident-adjudicated dementia, based on 3MS, hospital records and dementia drugs. Secondary outcome was change in 3MS. Models were adjusted for age, sex, race, education and baseline 3MS, and then further for cardiovascular risk factors.

RESULTS

Among 2558 adults, 85% were euthyroid (TSH 0.45-4.49mIU/L), 2% had subclinical hyperthyroidism with mildly decreased TSH (TSH 0.10-0.44 mIU/L), 1% subclinical hyperthyroidism with suppressed TSH (TSH < 0.10 mIU/L with normal free thyroxine [FT4]) and 12% subclinical hypothyroidism (TSH 4.50-19.99 mIU/L with normal FT4). Over 9 years, 22% developed dementia. Compared to euthyroidism, risk of dementia was higher in participants with subclinical hyperthyroidism with suppressed TSH (HR 2.38, 95% CI = 1.13;5.04), while we found no significant association in those with mildly decreased TSH (HR 0.79, 95% CI = 0.45;1.38) or with subclinical hypothyroidism (HR 0.91, 95% CI = 0.70;1.19). Participants with subclinical hyperthyroidism with suppressed TSH had a larger decline in 3MS (-3.89, 95% CI = -7.62; -0.15).

CONCLUSIONS

Among older adults, subclinical hyperthyroidism with a TSH < 0.10 mIU/L was associated with a higher risk of dementia and a larger cognitive decline, while subclinical hyperthyroidism with mildly decreased TSH or subclinical hypothyroidism were not.

Thyroid Function Tests in the Reference Range and Fracture: Individual Participant Analysis of Prospective Cohorts

CONTEXT

Hyperthyroidism is associated with increased fracture risk, but it is not clear if lower thyroid-stimulating hormone (TSH) and higher free thyroxine (FT4) in euthyroid individuals are associated with fracture risk.

OBJECTIVE

To evaluate the association of TSH and FT4 with incident fractures in euthyroid individuals.

DESIGN

Individual participant data analysis.

SETTING

Thirteen prospective cohort studies with baseline examinations between 1981 and 2002.

PARTICIPANTS

Adults with baseline TSH 0.45 to 4.49 mIU/L.

MAIN OUTCOME MEASURES

Primary outcome was incident hip fracture. Secondary outcomes were any, nonvertebral, and vertebral fractures. Results were presented as hazard ratios (HRs) with 95% confidence interval (CI) adjusted for age and sex. For clinical relevance, we studied TSH according to five categories: 0.45 to 0.99 mIU/L; 1.00 to 1.49 mIU/L; 1.50 to 2.49 mIU/L; 2.50 to 3.49 mIU/L; and 3.50 to 4.49 mIU/L (reference). FT4 was assessed as study-specific standard deviation increase, because assays varied between cohorts.

RESULTS

During 659,059 person-years, 2,565 out of 56,835 participants had hip fracture (4.5%; 12 studies with data on hip fracture). The pooled adjusted HR (95% CI) for hip fracture was 1.25 (1.05 to 1.49) for TSH 0.45 to 0.99 mIU/L, 1.19 (1.01 to 1.41) for TSH 1.00 to 1.49 mIU/L, 1.09 (0.93 to 1.28) for TSH 1.50 to 2.49 mIU/L, and 1.12 (0.94 to 1.33) for TSH 2.50 to 3.49 mIU/L (P for trend = 0.004). Hip fracture was also associated with FT4 [HR (95% CI) 1.22 (1.11 to 1.35) per one standard deviation increase in FT4]. FT4 only was associated with any and nonvertebral fractures. Results remained similar in sensitivity analyses.

CONCLUSIONS

Among euthyroid adults, lower TSH and higher FT4 are associated with an increased risk of hip fracture. These findings may help refine the definition of optimal ranges of thyroid function tests.

Thyroid Hormone Therapy for Older Adults with Subclinical Hypothyroidism

BACKGROUND

The use of levothyroxine to treat subclinical hypothyroidism is controversial. We aimed to determine whether levothyroxine provided clinical benefits in older persons with this condition.

METHODS

We conducted a double-blind, randomized, placebo-controlled, parallel-group trial involving 737 adults who were at least 65 years of age and who had persisting subclinical hypothyroidism (thyrotropin level, 4.60 to 19.99 mIU per liter; free thyroxine level within the reference range). A total of 368 patients were assigned to receive levothyroxine (at a starting dose of 50 μg daily, or 25 μg if the body weight was <50 kg or the patient had coronary heart disease), with dose adjustment according to the thyrotropin level; 369 patients were assigned to receive placebo with mock dose adjustment. The two primary outcomes were the change in the Hypothyroid Symptoms score and Tiredness score on a thyroid-related quality-of-life questionnaire at 1 year (range of each scale is 0 to 100, with higher scores indicating more symptoms or tiredness, respectively; minimum clinically important difference, 9 points).

RESULTS

The mean age of the patients was 74.4 years, and 396 patients (53.7%) were women. The mean (±SD) thyrotropin level was 6.40±2.01 mIU per liter at baseline; at 1 year, this level had decreased to 5.48 mIU per liter in the placebo group, as compared with 3.63 mIU per liter in the levothyroxine group (P<0.001), at a median dose of 50 μg. We found no differences in the mean change at 1 year in the Hypothyroid Symptoms score (0.2±15.3 in the placebo group and 0.2±14.4 in the levothyroxine group; between-group difference, 0.0; 95% confidence interval [CI], -2.0 to 2.1) or the Tiredness score (3.2±17.7 and 3.8±18.4, respectively; between-group difference, 0.4; 95% CI, -2.1 to 2.9). No beneficial effects of levothyroxine were seen on secondary-outcome measures. There was no significant excess of serious adverse events prespecified as being of special interest.

CONCLUSIONS

Levothyroxine provided no apparent benefits in older persons with subclinical hypothyroidism. (Funded by European Union FP7 and others; TRUST ClinicalTrials.gov number, NCT01660126 .).

Performance-based functional impairment and readmission and death: a prospective study

OBJECTIVES

Readmission and death are frequent after a hospitalisation and difficult to predict. While many predictors have been identified, few studies have focused on functional status. We assessed whether performance-based functional impairment at discharge is associated with readmission and death after an acute medical hospitalisation.

DESIGN, SETTING AND PARTICIPANTS

We prospectively included patients aged ≥50 years admitted to the Department of General Internal Medicine of a large community hospital. Functional status was assessed shortly before discharge using the Timed Up and Go test performed twice in a standard way by trained physiotherapists and was defined as a test duration ≥15 s. Sensitivity analyses using a cut-off at >10 and >20 s were performed.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary and secondary outcome measures were unplanned readmission and death, respectively, within 6 months after discharge.

RESULTS

Within 6 months after discharge, 107/338 (31.7%) patients had an unplanned readmission and 31/338 (9.2%) died. Functional impairment was associated with higher risk of death (OR 2.44, 95% CI 1.15 to 5.18), but not with unplanned readmission (OR 1.34, 95% CI 0.84 to 2.15). No significant association was found between functional impairment and the total number of unplanned readmissions (adjusted OR 1.59, 95% CI 0.95 to 2.67).

CONCLUSIONS

Functional impairment at discharge of an acute medical hospitalisation was associated with higher risk of death, but not of unplanned readmission within 6 months after discharge. Simple performance-based assessment may represent a better prognostic measure for mortality than for readmission.

Simplification of the HOSPITAL score for predicting 30-day readmissions

OBJECTIVE

The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted.

DESIGN AND SETTING

Retrospective study in 9 large hospitals across 4 countries, from January through December 2011.

PARTICIPANTS

We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility.

MEASUREMENTS

The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) 'discharge from an oncology division' was replaced by 'cancer diagnosis or discharge from an oncology division'; (2) 'any procedure' was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration.

RESULTS

Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2-5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories.

CONCLUSIONS

The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Blood cultures in the evaluation of uncomplicated cellulitis

PURPOSE

The frequency of bacteremia and the array of microorganisms involved in cellulitis vary greatly among studies. Although current guidelines do not recommend routine blood culture in uncomplicated cellulitis, their implementation in clinical practice remains challenging. We therefore aimed to assess the frequency, determinants and microbiology of bacteremia in hospitalized patients with uncomplicated cellulitis.

METHODS

We retrospectively reviewed the medical records of all adult patients admitted at a primary-care hospital with a diagnosis of community-acquired uncomplicated cellulitis during a 4-year period. We looked at the factors associated with blood cultures sampling and at the incidence, determinants and microbiology of bacteremia in this population.

RESULTS

Among the 476 patients hospitalized with a diagnosis of cellulitis, 250 (52.5%) had blood cultures. Fever, high C-reactive protein and lymphatic insufficiency were significantly associated with the sampling of blood cultures. Twelve (4.8%) patients had bacteremia. Alcoholism and duration of hospitalization were associated with bacteremia in multivariate analysis. Among the 12 patients with bacteremia, 9 had Streptococcus sp. and 3 had Staphylococcus aureus infection.

CONCLUSION

In our study population with uncomplicated cellulitis, representative of unselected population admitted at primary-care hospitals, bacteremia was uncommon and not associated with discriminant patient characteristics, except for alcohol abuse. Episodes of bacteremia were exclusively due to gram-positive cocci susceptible to co-amoxicilin, a common first-line empirical therapy. In accordance with existing guidelines, we do not recommend to collect blood for cultures in uncomplicated cellulitis. Clinicians' awareness of guidelines and of the poor yield of blood cultures could reduce useless investigation.

Subclinical Thyroid Dysfunction and the Risk of Cognitive Decline: a Meta-Analysis of Prospective Cohort Studies

CONTEXT

Although both overt hyper- and hypothyroidism are known to lead to cognitive impairment, data on the association between subclinical thyroid dysfunction and cognitive function are conflicting.

OBJECTIVE

This study sought to determine the risk of dementia and cognitive decline associated with subclinical thyroid dysfunction among prospective cohorts.

DATA SOURCES

We searched in MEDLINE and EMBASE from inception until November 2014.

STUDY SELECTION

Two physicians identified prospective cohorts that assessed thyroid function and cognitive outcomes (dementia; Mini-Mental State Examination [MMSE]).

DATA EXTRACTION

Data were extracted by one reviewer following standardized protocols and verified by a second reviewer. The primary outcome was dementia and decline in cognitive function was the secondary outcome.

DATA SYNTHESIS

Eleven prospective cohorts followed 16,805 participants during a median followup of 44.4 months. Five studies analyzed the risk of dementia in subclinical hyperthyroidism (SHyper) (n = 6410), six in subclinical hypothyroidism (SHypo) (n = 7401). Five studies analyzed MMSE decline in SHyper (n = 7895), seven in SHypo (n = 8960). In random-effects models, the pooled adjusted risk ratio for dementia in SHyper was 1.67 (95% confidence interval, 1.04; 2.69) and 1.14 (95% confidence interval, 0.84; 1.55) in SHypo vs euthyroidism, both without evidence of significant heterogeneity (I² = 0.0%). The pooled mean MMSE decline from baseline to followup (mean 32 mo) did not significantly differ between SHyper or SHypo vs euthyroidism.

CONCLUSIONS

SHyper might be associated with an elevated risk for dementia, whereas SHypo is not, and both conditions are not associated with faster decline in MMSE over time. Available data are limited, and additional large, high-quality studies are needed.