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Thunell JA, Joyce GF, Ferido PM, Chen Y, Guadamuz JS, Qato DM, Zissimopoulos JM. Diagnoses and Treatment of Behavioral and Psychological Symptoms of Dementia Among Racially and Ethnically Diverse Persons Living with Dementia. J Alzheimers Dis 2024:JAD231266. [PMID: 38669535 DOI: 10.3233/jad-231266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Background Behavioral and psychological symptoms of dementia (BPSD) and prescribed central nervous system (CNS) active drugs to treat them are prevalent among persons living with Alzheimer's disease and related dementias (PLWD) and lead to negative outcomes for PLWD and their caregivers. Yet, little is known about racial/ethnic disparities in diagnosis and use of drugs to treat BPSD. Objective Quantify racial/ethnic disparities in BPSD diagnoses and CNS-active drug use among community-dwelling PLWD. Methods We used a retrospective cohort of community-dwelling Medicare Fee-for-Service beneficiaries with dementia, continuously enrolled in Parts A, B and D, 2017-2019. Multivariate logistic models estimated rates of BPSD diagnosis and, conditional on diagnosis, CNS-active drug use. Results Among PLWD, 67.1% had diagnoses of an affective, psychosis or hyperactivity symptom. White (68.3%) and Hispanic (63.9%) PLWD were most likely, Blacks (56.6%) and Asians (52.7%) least likely, to have diagnoses. Among PLWD with BPSD diagnoses, 78.6% took a CNS-active drug. Use was highest among whites (79.3%) and Hispanics (76.2%) and lowest among Blacks (70.8%) and Asians (69.3%). Racial/ethnic differences in affective disorders were pronounced, 56.8% of white PLWD diagnosed; Asians had the lowest rates (37.8%). Similar differences were found in use of antidepressants. Conclusions BPSD diagnoses and CNS-active drug use were common in our study. Lower rates of BPSD diagnoses in non-white compared to white populations may indicate underdiagnosis in clinical settings of treatable conditions. Clinicians' review of prescriptions in this population to reduce poor outcomes is important as is informing care partners on the risks/benefits of using CNS-active drugs.
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Affiliation(s)
- Johanna A Thunell
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC Sol Price School of Public Policy, Los Angeles, CA, USA
| | - Geoffrey F Joyce
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Patricia M Ferido
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
| | - Yi Chen
- Rush Alzheimer's Disease Center, Chicago, IL, USA
| | - Jenny S Guadamuz
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Dima M Qato
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC School of Pharmacy, Los Angeles, CA, USA
| | - Julie M Zissimopoulos
- USC Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA
- USC Sol Price School of Public Policy, Los Angeles, CA, USA
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Chyr LC, Wolff JL, Zissimopoulos JM, Drabo EF. Analysis of agreement between measures of subjective cognitive impairment and probable dementia in the National Health and Aging Trends Study. Alzheimers Dement 2024; 20:2817-2829. [PMID: 38426381 PMCID: PMC11032562 DOI: 10.1002/alz.13758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 01/03/2024] [Accepted: 01/29/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Subjective cognitive impairment (SCI) measures in population-based surveys offer potential for dementia surveillance, yet their validation against established dementia measures is lacking. METHODS We assessed agreement between SCI and a validated probable dementia algorithm in a random one-third sample (n = 1936) of participants in the 2012 National Health and Aging Trends Study (NHATS). RESULTS SCI was more prevalent than probable dementia (12.2% vs 8.4%). Agreement between measures was 90.0% and of substantial strength. Misclassification rates were higher among older and less-educated subgroups due to higher prevalence of false-positive misclassification but did not vary by sex or race and ethnicity. DISCUSSION SCI sensitivity (63.4%) and specificity (92.5%) against dementia were comparable with similar metrics for the NHATS probable dementia measure against the "gold-standard" Aging, Demographics, and Memory Study-based dementia criteria, implying that population-based surveys may afford cost-effective opportunities for dementia surveillance to assess risk and inform policy. HIGHLIGHTS The prevalence of subjective cognitive impairment (SCI) is generally higher than that of a validated measure of probable dementia, particularly within the youngest age group, females, Whites, and persons with a college or higher degree. Percent agreement between SCI and a validated measure of probable dementia was 90.0% and of substantial strength (prevalence- and bias-adjusted kappa, 0.80). Agreement rates were higher in older and less-educated subgroups, driven by the higher prevalence of false-positive disagreement, but did not vary significantly by sex or race and ethnicity. SCI's overall sensitivity and specificity were 63.4% and 92.5%, respectively, against a validated measure of probable dementia, suggesting utility as a low-cost option for dementia surveillance. Heterogeneity in agreement quality across subpopulations warrants caution in its use for subgroup analyses.
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Affiliation(s)
- Linda C. Chyr
- Enterprise Analytics Core, Elevance Health, Inc.WilmingtonDelawareUSA
| | - Jennifer L. Wolff
- Department of Health Policy and ManagementJohn Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Julie M. Zissimopoulos
- Sol Price School of Public PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Leonard D. Schaeffer Center for Health PolicyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Emmanuel F. Drabo
- Department of Health Policy and ManagementJohn Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
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Zissimopoulos JM, Joyce GF, Jacobson M. Trends in Incident Dementia Diagnosis Before and After Medicare Risk Adjustment. JAMA Netw Open 2023; 6:e2347708. [PMID: 38100111 PMCID: PMC10724756 DOI: 10.1001/jamanetworkopen.2023.47708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/31/2023] [Indexed: 12/18/2023] Open
Abstract
This cohort study examines rates of new diagnosis of Alzheimer disease and related dementias among beneficiaries of Medicare Advantage plans vs traditional Medicare from 2016 through 2020.
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Affiliation(s)
- Julie M Zissimopoulos
- USC Price School of Public Policy, University of Southern California, Los Angeles
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Geoffrey F Joyce
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- USC School of Pharmacy, University of Southern California, Los Angeles
| | - Mireille Jacobson
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- Leonard Davis School of Gerontology, University of Southern California, Los Angeles
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Mattke S, Batie D, Chodosh J, Felten K, Flaherty E, Fowler NR, Kobylarz FA, O'Brien K, Paulsen R, Pohnert A, Possin KL, Sadak T, Ty D, Walsh A, Zissimopoulos JM. Expanding the use of brief cognitive assessments to detect suspected early-stage cognitive impairment in primary care. Alzheimers Dement 2023; 19:4252-4259. [PMID: 37073874 DOI: 10.1002/alz.13051] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/24/2023] [Accepted: 01/25/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Mild cognitive impairment remains substantially underdiagnosed, especially in disadvantaged populations. Failure to diagnose deprives patients and families of the opportunity to treat reversible causes, make necessary life and lifestyle changes and receive disease-modifying treatments if caused by Alzheimer's disease. Primary care, as the entry point for most, plays a critical role in improving detection rates. METHODS We convened a Work Group of national experts to develop consensus recommendations for policymakers and third-party payers on ways to increase the use of brief cognitive assessments (BCAs) in primary care. RESULTS The group recommended three strategies to promote routine use of BCAs: providing primary care clinicians with suitable assessment tools; integrating BCAs into routine workflows; and crafting payment policies to encourage adoption of BCAs. DISSCUSSION Sweeping changes and actions of multiple stakeholders are necessary to improve detection rates of mild cognitive impairment so that patients and families may benefit from timely interventions.
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Affiliation(s)
- Soeren Mattke
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Center for Improving Chronic Illness Care, University of Southern California, Los Angeles, California, USA
| | - Donnie Batie
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Baton Rouge General Medical Center, Baton Rouge, Louisiana, USA
| | - Joshua Chodosh
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Division of Geriatric Medicine and Palliative Care, Department of Medicine, New York University School of Medicine, New York, New York, USA
- NYU School of Medicine, New York Harbor VA Healthcare System, New York, New York, USA
| | - Kristen Felten
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Wisconsin Department of Health Services, Office on Aging, Madison, Wisconsin, USA
| | - Ellen Flaherty
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire, USA
- Dartmouth Centers for Health and Aging, Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Nicole R Fowler
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Indiana University Center for Aging Research, Indiana University School of Medicine and the Regenstrief Institute, Indianapolis, Indiana, USA
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Center for Health Innovation and Implementation Science, Indiana University, Indianapolis, Indiana, USA
| | - Fred A Kobylarz
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Department of Family Medicine and Community Health, Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey, USA
| | - Kelly O'Brien
- UsAgainstAlzheimer's, Washington, District of Columbia, USA
| | - Russ Paulsen
- UsAgainstAlzheimer's, Washington, District of Columbia, USA
| | - Anne Pohnert
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- CVS Health MinuteClinic, Woonsocket, Rhode Island, USA
| | - Katherine L Possin
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Department of Neurology, University of California, San Francisco Memory and Aging Center, San Francisco, California, USA
| | - Tatiana Sadak
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- University of Washington School of Nursing, Seattle, Washington, USA
| | - Diane Ty
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Alliance to Improve Dementia Care, Milken Institute Center for the Future of Aging, Washington, District of Columbia, USA
| | - Amy Walsh
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Age-Friendly Health Systems, Institute for Healthcare Improvement, Boston, Massachusetts, USA
| | - Julie M Zissimopoulos
- Brief Cognitive Assessment Work Group, District of Columbia, USA
- Sol Price School of Public Policy, University of Southern California, Los Angeles, California, USA
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Thunell JA, Ferido P, Zissimopoulos JM. COVID-19 hospitalization and mortality in community-dwelling racially and ethnically diverse persons living with dementia. J Am Geriatr Soc 2023; 71:1429-1439. [PMID: 36637869 PMCID: PMC10175159 DOI: 10.1111/jgs.18230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 12/08/2022] [Accepted: 12/23/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Community-dwelling persons living with dementia (PLWD) are vulnerable to COVID-19 infection, severity, and mortality due to the high prevalence of comorbidities, reliance on caregivers, and potential inability to employ risk reduction measures, among other factors. METHODS We used a retrospective cohort of Medicare Fee-For-Service beneficiaries enrolled from January 2018 to September 2020 (n = 13,068,583), a comparison cohort from January 2019 to April 2021 (n = 13,250,297), and logistic regression to estimate the effect of dementia on COVID-19 hospitalization and mortality in community-dwelling older persons. RESULTS COVID-19 diagnoses were higher among persons living with dementia (PLWD) than those without dementia. Conditional on COVID-19 in the 2020 cohort, White PLWD were at higher risk of hospitalization compared to White persons without dementia (aOR 1.31, 95% CI: 1.26-1.36) and marginal for Black PLWD (aOR 1.10, 95% CI: 1.01-1.20), no significant differences were found within other racial/ethnic groups. PLWD were 1.8 times (aOR 1.78, 95% CI: 1.72-1.84) more likely to die within 30 days of COVID-19 on average. Within racial/ethnic groups, the estimate for White PLWD, compared with White persons without dementia, was highest (aOR 2.01, 95% CI: 1.92-2.10), followed by Black PLWD (aOR 1.55, 95% CI: 1.41-1.70), and smallest among Hispanic PLWD (aOR 1.37, 95% CI: 1.24-1.50). PLWD hospitalized with COVID-19 were 1.6 times (aOR 1.59, 95% CI: 1.52-1.67) more likely to die within 30 days than similar persons without dementia. Estimates from the 2021 cohort, when vaccines were available to older persons, were similar to those in 2020. CONCLUSIONS Community-dwelling PLWD experienced worse outcomes after a COVID-19 diagnosis than their counterparts without dementia. Results demonstrating higher mortality, but not hospitalization rates, for all races/ethnicities except White PLWD suggest there may have been differential care/treatment that point to potential health care system inequities that persisted into 2021. Understanding the mechanisms underlying these differences may improve ongoing care for community-dwelling PLWD.
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Affiliation(s)
- Johanna A Thunell
- Price School of Public Policy, University of Southern California, Los Angeles, California, USA
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
| | - Patricia Ferido
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
| | - Julie M Zissimopoulos
- Price School of Public Policy, University of Southern California, Los Angeles, California, USA
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California, USA
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Thunell JA, Jacobson M, Joe EB, Zissimopoulos JM. Medicare's Annual Wellness Visit and diagnoses of dementias and cognitive impairment. Alzheimers Dement (Amst) 2022; 14:e12357. [PMID: 36177153 PMCID: PMC9473487 DOI: 10.1002/dad2.12357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/08/2022] [Accepted: 08/09/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Early detection of Alzheimer's disease and related dementias allows clinicians and patients to prepare for future needs and identify treatment options. Medicare's Annual Wellness Visit (AWV) requires detection of cognitive impairment and may increase dementia diagnosis. We estimated the relationship between AWV receipt and incident dementia. METHODS Using a retrospective cohort of Medicare Fee-For-Service (FFS) beneficiaries enrolled for at least 3 years from 2009 to 2016 and two-stage least squares, we quantified the relationship between AWV and incident diagnosis of cognitive impairment/dementia, and by race/ethnicity. The county-level change in percent of beneficiaries receiving AWVs was used as an instrumental variable to account for unobserved factors associated with individuals' AWV receipt and diagnosis. Sample included 3,333,617 beneficiaries ages 67 years and older, without dementia at the beginning of the study. RESULTS Beneficiaries included 2,713,573 White, 251,958 Black, 196,845 Hispanic, 95,719 Asian, 11,727 American Indian/Alaska Native, and 63,795 of other race/ethnicity. Using ordinary least squares, dementia incidence was -0.79 percentage points (95% CI -0.81 to -0.76) lower for persons receiving an AWV compared to no AWV. Using instrumental variables reversed the direction of the effect: AWV receipt increased dementia diagnoses by 0.47 percentage points (95% CI 0.14 to 0.80), 15% over baseline. AWVs increased diagnoses 2.0 percentage points (95% CI 0.05 to 3.94) among Blacks, 0.40 percentage points (95% CI 0.05 to 0.75) among Whites, but est were imprecise for Hispanics and Asians. DISCUSSION Increasing AWV take-up and supporting physicians' performance of cognitive assessment may further improve dementia detection in the population and among groups at higher risk of undiagnosed dementia.
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Affiliation(s)
- Johanna A. Thunell
- University of Southern California Price School of Public PolicyLos AngelesCaliforniaUSA
- Schaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Mireille Jacobson
- Schaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- University of Southern California Leonard Davis School of GerontologyLos AngelesCaliforniaUSA
| | - Elizabeth B. Joe
- University of Southern California Keck School of MedicineLos AngelesCaliforniaUSA
- University of Southern California Department of NeurologyLos AngelesCaliforniaUSA
| | - Julie M. Zissimopoulos
- University of Southern California Price School of Public PolicyLos AngelesCaliforniaUSA
- Schaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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Chen Y, Crimmins E, Ferido P, Zissimopoulos JM. Racial/Ethnic Disparities in Length of Life after Dementia Diagnosis: an 18-Year Follow-up Study of Medicare Beneficiaries. The Lancet Regional Health - Americas 2022; 8. [PMID: 35814361 PMCID: PMC9264371 DOI: 10.1016/j.lana.2021.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background Methods Findings Interpretation
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Zhu Y, Zissimopoulos JM, Crimmins EM. Cognitive decline at middle age. Alzheimers Dement 2021. [DOI: 10.1002/alz.056007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Zhu Y, Chen Y, Crimmins EM, Zissimopoulos JM. Sex, Race, and Age Differences in Prevalence of Dementia in Medicare Claims and Survey Data. J Gerontol B Psychol Sci Soc Sci 2021; 76:596-606. [PMID: 32588052 DOI: 10.1093/geronb/gbaa083] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES This study provides the first comparison of trends in dementia prevalence in the U.S. population using 3 different dementia ascertainments/data sources: neuropsychological assessment, cognitive tests, and diagnosis codes from Medicare claims. METHODS We used data from the nationally representative Health and Retirement Study and Aging, Demographics, and Memory Study, and a 20% random sample of Medicare beneficiaries. We compared dementia prevalence across the 3 sources by race, gender, and age. We estimated trends in dementia prevalence from 2006 to 2013 based on cognitive tests and diagnosis codes utilizing logistic regression. RESULTS Dementia prevalence among older adults aged 70 and older in 2004 was 16.6% (neuropsychological assessment), 15.8% (cognitive tests), and 12.2% (diagnosis codes). The difference between dementia prevalence based on cognitive tests and diagnosis codes diminished in 2012 (12.4% and 12.9%, respectively), driven by decreasing rates of cognitive test-based and increasing diagnosis codes-based dementia prevalence. This difference in dementia prevalence between the 2 sources by sex and for age groups 75-79 and 90 and older vanished over time. However, there remained substantial differences across measures in dementia prevalence among blacks and Hispanics (10.9 and 9.8 percentage points, respectively) in 2012. DISCUSSION Our results imply that ascertainment of dementia through diagnosis may be improving over time, but gaps across measures among racial/ethnic minorities highlight the need for improved measurement of dementia prevalence in these populations.
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Affiliation(s)
- Yingying Zhu
- Price School of Public Policy & Schaeffer Center, University of Southern California, Los Angeles
| | - Yi Chen
- Price School of Public Policy & Schaeffer Center, University of Southern California, Los Angeles
| | - Eileen M Crimmins
- Davis School of Gerontology, University of Southern California, Los Angeles
| | - Julie M Zissimopoulos
- Price School of Public Policy & Schaeffer Center, University of Southern California, Los Angeles
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Torrandell‐Haro G, Branigan GL, Vitali F, Geifman N, Zissimopoulos JM, Brinton RD. Statin therapy and risk of Alzheimer's and age-related neurodegenerative diseases. Alzheimers Dement (N Y) 2020; 6:e12108. [PMID: 33283039 PMCID: PMC7687291 DOI: 10.1002/trc2.12108] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Establishing efficacy of and molecular pathways for statins has the potential to impact incidence of Alzheimer's and age-related neurodegenerative diseases (NDD). METHODS This retrospective cohort study surveyed US-based Humana claims, which includes prescription and patient records from private-payer and Medicare insurance. Claims from 288,515 patients, aged 45 years and older, without prior history of NDD or neurological surgery, were surveyed for a diagnosis of NDD starting 1 year following statin exposure. Patients were required to be enrolled with claims data for at least 6 months prior to first statin prescription and at least 3 years thereafter. Computational system biology analysis was conducted to determine unique target engagement for each statin. RESULTS Of the 288,515 participants included in the study, 144,214 patients (mean [standard deviation (SD)] age, 67.22 [3.8] years) exposed to statin therapies, and 144,301 patients (65.97 [3.2] years) were not treated with statins. The mean (SD) follow-up time was 5.1 (2.3) years. Exposure to statins was associated with a lower incidence of Alzheimer's disease (1.10% vs 2.37%; relative risk [RR], 0.4643; 95% confidence interval [CI], 0.44-0.49; P < .001), dementia 3.03% vs 5.39%; RR, 0.56; 95% CI, 0.54-0.58; P < .001), multiple sclerosis (0.08% vs 0.15%; RR, 0.52; 95% CI, 0.41-0.66; P < .001), Parkinson's disease (0.48% vs 0.92%; RR, 0.53; 95% CI, 0.48-0.58; P < .001), and amyotrophic lateral sclerosis (0.02% vs 0.05%; RR, 0.46; 95% CI, 0.30-0.69; P < .001). All NDD incidence for all statins, except for fluvastatin (RR, 0.91; 95% CI, 0.65-1.30; P = 0.71), was reduced with variances in individual risk profiles. Pathway analysis indicated unique and common profiles associated with risk reduction efficacy. DISCUSSION Benefits and risks of statins relative to neurological outcomes should be considered when prescribed for at-risk NDD populations. Common statin activated pathways indicate overarching systems required for risk reduction whereas unique targets could advance a precision medicine approach to prevent neurodegenerative diseases.
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Affiliation(s)
- Georgina Torrandell‐Haro
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- Department of PharmacologyUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Gregory L. Branigan
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- Department of PharmacologyUniversity of Arizona College of MedicineTucsonArizonaUSA
- MD‐PhD Training ProgramUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Francesca Vitali
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- Department of NeurologyUniversity of Arizona College of MedicineTucsonArizonaUSA
- Center for Biomedical Informatics and BiostatisticsUniversity of ArizonaTucsonArizonaUSA
| | - Nophar Geifman
- Division of Informatics, Imaging & Data SciencesUniversity of ManchesterTucsonArizonaUSA
| | - Julie M. Zissimopoulos
- Sol Price School of Public PolicySchaeffer Center for Health Policy and EconomicsUniversity of Southern CaliforniaTucsonArizonaUSA
| | - Roberta Diaz Brinton
- Center for Innovation in Brain ScienceUniversity of ArizonaTucsonArizonaUSA
- Department of PharmacologyUniversity of Arizona College of MedicineTucsonArizonaUSA
- Department of NeurologyUniversity of Arizona College of MedicineTucsonArizonaUSA
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Zissimopoulos JM, Tysinger BC, St Clair PA, Crimmins EM. The Impact of Changes in Population Health and Mortality on Future Prevalence of Alzheimer's Disease and Other Dementias in the United States. J Gerontol B Psychol Sci Soc Sci 2019; 73:S38-S47. [PMID: 29669100 DOI: 10.1093/geronb/gbx147] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Indexed: 12/14/2022] Open
Abstract
Objectives We assessed potential benefits for older Americans of reducing risk factors associated with dementia. Methods A dynamic simulation model tracked a national cohort of persons 51 and 52 years of age to project dementia onset and mortality in risk reduction scenarios for diabetes, hypertension, and dementia. Results We found reducing incidence of diabetes by 50% did not reduce number of years a person ages 51 or 52 lived with dementia and increased the population ages 65 and older in 2040 with dementia by about 115,000. Eliminating hypertension at middle and older ages increased life expectancy conditional on survival to age 65 by almost 1 year, however, it increased years living with dementia. Innovation in treatments that delay onset of dementia by 2 years increased longevity, reduced years with dementia, and decreased the population ages 65 and older in 2040 with dementia by 2.2 million. Conclusions Prevention of chronic disease may generate health and longevity benefits but does not reduce burden of dementia. A focus on treatments that provide even short delays in onset of dementia can have immediate impacts on longevity and quality of life and reduce the number of Americans with dementia over the next decades.
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Affiliation(s)
- Julie M Zissimopoulos
- Price School of Public Policy & Schaeffer Center, University of Southern California, Los Angeles
| | - Bryan C Tysinger
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Patricia A St Clair
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Eileen M Crimmins
- Davis School of Gerontology, University of Southern California, Los Angeles
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Zhu Y, Chen Y, Crimmins EM, Zissimopoulos JM. P1-517: SEX, RACE AND AGE DIFFERENCES IN PREVALENCE OF ALZHEIMER'S DISEASE AND RELATED DEMENTIA IN MEDICARE CLAIMS AND SURVEY DATA. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.1122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Yingying Zhu
- University of Southern California; Los Angeles CA USA
| | - Yi Chen
- University of Southern California; Los Angeles CA USA
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Zissimopoulos JM, Barthold D, Drabo E, Joyce G. P4-446: ALZHEIMER'S DISEASE AND DEMENTIA DIAGNOSIS AND CARE. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.4118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen Y, Tysinger B, Crimmins EM, Zissimopoulos JM. O5‐09‐05: RACIAL AND ETHNIC DIFFERENCES IN DEMENTIA DIAGNOSIS FOLLOWING COGNITIVE DECLINE: INSIGHTS FROM LINKED SURVEY AND HEALTH CARE CLAIMS DATA. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.4886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Yi Chen
- University of Southern California Los Angeles CA USA
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Zissimopoulos JM, Thunell J, Ferido P. P1-570: MEASURING ALZHEIMER'S DISEASE AND DEMENTIA IN MEDICARE CLAIMS DATA. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chen Y, Tysinger B, Crimmins E, Zissimopoulos JM. Analysis of dementia in the US population using Medicare claims: Insights from linked survey and administrative claims data. Alzheimers Dement (N Y) 2019; 5:197-207. [PMID: 31198838 PMCID: PMC6556828 DOI: 10.1016/j.trci.2019.04.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Introduction Medicare claims data may be a rich data source for tracking population dementia rates. Insufficient understanding of completeness of diagnosis, and for whom, limits their use. Methods We analyzed agreement in prevalent and incident dementia based on cognitive assessment from the Health and Retirement Study for persons with linked Medicare claims from 2000 to 2008 (N = 10,450 persons). Multinomial logistic regression identified sociodemographic factors associated with disagreement. Results Survey-based cognitive tests and claims-based dementia diagnosis yielded equal prevalence estimates, yet only half were identified by both measures. Race and education were associated with disagreement. Eighty-five percent of respondents with incident dementia measured by cognitive decline received a diagnosis or died within the study period, with lower odds among blacks and Hispanics than among whites. Discussions Claims data are valuable for tracking dementia in the US population and improve over time. Delayed diagnosis may underestimate rates within black and Hispanic populations.
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Affiliation(s)
- Yi Chen
- Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Bryan Tysinger
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
| | - Eileen Crimmins
- Davis School of Gerontology, University of Southern California, Los Angeles, CA, USA
| | - Julie M. Zissimopoulos
- Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
- Corresponding author. Tel.: +213 821 7947; Fax: +213 740 3460.
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Abstract
Over the past decade, the number of studies examining the effects of health insurance has grown rapidly, along with the breadth of outcomes considered. In light of growing research in this area and the intense policy focus on coverage expansions in the United States, there is need for an up-to-date and comprehensive literature review and synthesis of lessons learned. We reviewed 112 experimental or quasi-experimental studies on the effects of health insurance prior to people becoming eligible for Medicare on a broad set of outcomes. Over the past decade, evidence related to the effect of increased access to health insurance has strengthened, illuminating that children and vulnerable adults are most likely to see health and economic benefits. We identified promising areas for future study in this active and burgeoning research area, noting benefit design of health insurance and outcomes such as government program participation and self-reported health status as targets.
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Affiliation(s)
| | - Gwyn C. Pauley
- University of Southern California, Los Angeles, CA, USA
- University of Wisconson, Madison, WI, USA
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Abstract
INTRODUCTION Disparities in dementia prevalence across racial/ethnic groups in the United States may not be narrowing over time. METHODS Data from Health and Retirement Study (2000 to 2012) were analyzed. Dementia was ascertained based on cognitive, functional measures. Logistic regression was used to quantify association between dementia and risk factors, including chronic conditions, use of drug treatment for them, separately for whites, blacks, and Hispanics. RESULTS Disparities in dementia prevalence declined between blacks and whites and increased between Hispanics and whites. Adjusting for risk factors reduced but did not eliminate disparities. Compared to no hypertension, untreated hypertension was associated with increased risk of dementia for all racial/ethnic groups while treated hypertension was associated with reduced risk for whites. Diabetes treated with oral drugs was not associated with increased dementia risk. DISCUSSION Racial disparities in dementia may be reduced by prevention and management of disease and promoting educational attainment among blacks and Hispanics.
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Affiliation(s)
- Cynthia Chen
- Leonard D. Schaeffer Center for Health Policy and Economics, Price School of Public Policy, University of Southern California, Los Angeles, United States of America
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Julie M. Zissimopoulos
- Leonard D. Schaeffer Center for Health Policy and Economics, Price School of Public Policy, University of Southern California, Los Angeles, United States of America
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Abstract
Importance To our knowledge, no effective treatments exist for Alzheimer disease, and new molecules are years away. However, several drugs prescribed for other conditions have been associated with reducing its risk. Objective To analyze the association between statin exposure and Alzheimer disease incidence among Medicare beneficiaries. Design, Setting, and Participants We examined the medical and pharmacy claims of a 20% sample of Medicare beneficiaries from 2006 to 2013 and compared rates of Alzheimer disease diagnosis for 399 979 statin users 65 years of age or older with high or low exposure to statins and with drug molecules for black, Hispanic, and non-Hispanic white people, and men and women of Asian, Native American, or unkown race/ethnicity who are referred to as "other." Main Outcomes and Measures The main outcome was incident diagnosis of Alzheimer disease based on the International Classification of Diseases, Ninth Revision, Clinical Modification. We used Cox proportional hazard models to analyze the association between statin exposure and Alzheimer disease diagnosis for different sexes, races and ethnicities, and statin molecules. Results The 399 979 study participants included 7794 (1.95%) black men, 24 484 (6.12%) black women, 11 200 (2.80%) Hispanic men, 21 458 (5.36%) Hispanic women, 115 059 (28.77%) white men, and 195 181 (48.80%) white women. High exposure to statins was associated with a lower risk of Alzheimer disease diagnosis for women (hazard ratio [HR], 0.85; 95% CI, 0.82-0.89; P<.001) and men (HR, 0.88; 95% CI, 0.83-0.93; P<.001). Simvastatin was associated with lower Alzheimer disease risk for white women (HR, 0.86; 95% CI, 0.81-0.92; P<.001), white men (HR, 0.90; 95% CI, 0.82-0.99; P=.02), Hispanic women (HR, 0.82; 95% CI, 0.68-0.99; P=.04), Hispanic men (HR, 0.67; 95% CI, 0.50-0.91; P=.01), and black women (HR, 0.78; 95% CI, 0.66-0.93; P=.005). Atorvastatin was associated with a reduced risk of incident Alzheimer disease diagnosis for white women (HR, 0.84, 95% CI, 0.78-0.89), black women (HR, 0.81, 95% CI, 0.67-0.98), and Hispanic men (HR, 0.61, 95% CI, 0.42-0.89) and women (HR, 0.76, 95% CI, 0.60-0.97). Pravastatin and rosuvastatin were associated with reduced Alzheimer disease risk for white women only (HR, 0.82, 95% CI, 0.70-0.95 and HR, 0.81, 95% CI, 0.67-0.98, respectively). High statin exposure was not associated with a statistically significant lower Alzheimer disease risk among black men. Conclusions and Relevance The reduction in Alzheimer disease risk varied across statin molecules, sex, and race/ethnicity. Clinical trials that include racial and ethnic groups need to confirm these findings. Because statins may affect Alzheimer disease risk, physicians should consider which statin is prescribed to each patient.
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Affiliation(s)
- Julie M Zissimopoulos
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Douglas Barthold
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Roberta Diaz Brinton
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles2Center for Innovation in Brain Science, University of Arizona Health Sciences, Tucson
| | - Geoffrey Joyce
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
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Asch BJ, Haider SJ, Zissimopoulos JM. The effects of workforce-shaping tools on retirement: the case of the Department of Defense civil service. J Public Health Manag Pract 2009; 15:S64-72. [PMID: 19829235 DOI: 10.1097/phh.0b013e3181b6107c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Apriority area for the public health workforce research agenda is the study of the public health labor market and how wages and benefits affect workforce outcomes, including recruiting, retention, and retirement. This study provides an example of such a study for the Department of Defense civil service workforce. We analyze the financial incentives to retire that are specifically embedded in the retirement system and how different workforce-shaping policies would affect these incentives. The study then uses a recently estimated model of the effects of financial incentives on retirement behavior among defense civilians to predict how these workforce-shaping tools would affect retirement behavior. We find that buyouts, retention incentives, and other workforce-shaping tools have a sizable effect on predicted retirement behavior and therefore, could be useful policies to help manage retirement outflows.
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Affiliation(s)
- Beth J Asch
- RAND Corporation, Santa Monica, CA 90401, USA.
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Abstract
We use data from the earlier and later cohorts of the NLSY to estimate the effect of marriage and childbearing on wages. Our estimates imply that marriage lowers female wages 2-4 percent in the year of marriage. Marriage also lowers the wage growth of men and women by about two and four percentage points, respectively. A first birth lowers female wages 2-3 percent, but has no effect on wage growth. Male wages are unaffected by childbearing. These findings suggest that early marriage and childbearing can lead to substantial decreases in lifetime earnings.
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Affiliation(s)
- David S Loughran
- David S. Loughran is a senior economist and Julie M. Zissimopoulos is an economist at the RAND Corporation in Santa Monica, Calif. Both are also faculty members of the Frederick S. Pardee RAND Graduate School. The authors gratefully acknowledge the financial support of the National Institute of Child Health and Development under grant 5 R03 HD 40853. The data used in this article can be obtained beginning October 2009 through September 2012 from David Loughran, RAND Corporation; Santa Monica, CA 90407;
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Abstract
Labor-market transitions toward the latter parts of workers' careers can be complex, with movement between jobs and classes of work and in and out of retirement. The authors analyzed factors associated with the labor-market transitions of older workers to self-employment from unemployment or disability, retirement, or wage and salary work using rich panel data from seven waves of the Health and Retirement Study (HRS). They found evidence that (prior) job characteristics and liquidity constraints are important predictors of movements to self-employment for workers and nonworkers, while risk aversion is a significant predictor only for workers.
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Affiliation(s)
- Cynthia Chen
- University of Southern CaliforniaCaliforniaCAUSA
- National University of SingaporeSingaporeSingapore
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Abstract
We use data from the Health and Retirement Study to examine the elderly's out-of-pocket health care spending. We find that Medicare HMOs, employer supplements, and Medicaid effectively insulate against the risk of high expenditures. At the ninetieth percentile, Medicare beneficiaries with employer supplements or enrolled in Medicare HMOs spend 1,600 dollars less out of pocket than beneficiaries with traditional Medicare spend. For the poor elderly, Medicaid offers similar protection. Among the near-poor elderly, there is little employer coverage, so Medicare HMOs provide most of the protection against financial risk. There is evidence that Medicare HMO benefits have eroded since 1998, raising the question of whether the near-poor have lost financial protection since then.
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