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Abdel Magid HS, Jaros S, Li Y, Steinman MA, Lee S, Jing B, Fung K, Liu CK, Liu X, Graham LA, Odden MC. Effects of residential socioeconomic polarization on high blood pressure among nursing home residents. Health Place 2024; 87:103243. [PMID: 38663339 PMCID: PMC11102837 DOI: 10.1016/j.healthplace.2024.103243] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE Neighborhood concentration of racial, income, education, and housing deprivation is known to be associated with higher rates of hypertension. The objective of this study is to examine the association between tract-level spatial social polarization and hypertension in a cohort with relatively equal access to health care, a Veterans Affairs nursing home. METHODS 41,973 long-term care residents aged ≥65 years were matched with tract-level Indices of Concentration at the Extremes across four socioeconomic domains. We modeled high blood pressure against these indices controlling for individual-level cardiovascular confounders. RESULTS We found participants who had resided in the most disadvantaged quintile had a 1.10 (95% 1.01, 1.19) relative risk of high blood pressure compared to those in the other quintiles for the joint measuring race/ethnicity and income domain. CONCLUSIONS We achieved our objective by demonstrating that concentrated deprivation is associated with worse cardiovascular outcomes even in a population with equal access to care. Measures that jointly consider economic and racial/ethnic polarization elucidate larger disparities than single domain measures.
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Affiliation(s)
- Hoda S Abdel Magid
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, CA, USA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Samuel Jaros
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, CA, USA
| | - Yongmei Li
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, CA, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco and the San Francisco VA Medical Center, SF, California, USA
| | - Sei Lee
- Division of Geriatrics, University of California San Francisco and the San Francisco VA Medical Center, SF, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California San Francisco and the San Francisco VA Medical Center, SF, California, USA
| | - Kathy Fung
- Division of Geriatrics, University of California San Francisco and the San Francisco VA Medical Center, SF, California, USA; Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Christine K Liu
- Section of Geriatric Medicine, Division of Primary Care and Population Health, School of Medicine, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Xiaojuan Liu
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA; Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University, Stanford, CA, USA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, CA, USA; Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Dave CV, Li Y, Steinman MA, Lee SJ, Liu X, Jing B, Graham LA, Marcum ZA, Fung KZ, Odden MC. Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA Intern Med 2024:2818019. [PMID: 38648065 PMCID: PMC11036308 DOI: 10.1001/jamainternmed.2024.0507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/28/2023] [Indexed: 04/25/2024]
Abstract
Importance Limited evidence exists on the association between initiation of antihypertensive medication and risk of fractures in older long-term nursing home residents. Objective To assess the association between antihypertensive medication initiation and risk of fracture. Design, Setting, and Participants This was a retrospective cohort study using target trial emulation for data derived from 29 648 older long-term care nursing home residents in the Veterans Health Administration (VA) from January 1, 2006, to October 31, 2019. Data were analyzed from December 1, 2021, to November 11, 2023. Exposure Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy. Main Outcome and Measures The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, across systolic and diastolic blood pressure thresholds of 140 and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching. Results Data from 29 648 individuals were included in this study (mean [SD] age, 78.0 [8.4] years; 28 952 [97.7%] male). In the propensity score-matched cohort of 64 710 residents (mean [SD] age, 77.9 [8.5] years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. This finding corresponded to an adjusted hazard ratio (HR) of 2.42 (95% CI, 1.43-4.08) and an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95-6.78). Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalizations or emergency department visits (HR, 1.80 [95% CI, 1.53-2.13]) and syncope (HR, 1.69 [95% CI, 1.30-2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76-6.10]), systolic blood pressure of 140 mm Hg or higher (HR, 3.12 [95% CI, 1.71-5.69]), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41 [95% CI, 1.67-11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49-15.32]). Conclusions and Relevance Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressures values, and no recent antihypertensive medication use. Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.
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Affiliation(s)
- Chintan V. Dave
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey
- Department of Veterans Affairs-New Jersey Health Care System, East Orange
| | - Yongmei Li
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Sei J. Lee
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Xiaojuan Liu
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California
| | | | - Kathy Z. Fung
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, California
| | - Michelle C. Odden
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, California
- Department of Epidemiology and Population Health, School of Medicine, Stanford University, Stanford, California
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Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid-loop diuretic cascade. J Am Geriatr Soc 2024. [PMID: 38547357 DOI: 10.1111/jgs.18892] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/16/2024] [Accepted: 03/03/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years. METHODS Using Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another. RESULTS Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82). CONCLUSIONS Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
| | - W James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Amy L Byers
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth S Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Prasanna A, Jing B, Plopper G, Miller KK, Sanjak J, Feng A, Prezek S, Vidyaprakash E, Thovarai V, Maier EJ, Bhattacharya A, Naaman L, Stephens H, Watford S, Boscardin WJ, Johanson E, Lienau A. Synthetic Health Data Can Augment Community Research Efforts to Better Inform the Public During Emerging Pandemics. medRxiv 2023:2023.12.11.23298687. [PMID: 38168217 PMCID: PMC10760275 DOI: 10.1101/2023.12.11.23298687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The COVID-19 pandemic had disproportionate effects on the Veteran population due to the increased prevalence of medical and environmental risk factors. Synthetic electronic health record (EHR) data can help meet the acute need for Veteran population-specific predictive modeling efforts by avoiding the strict barriers to access, currently present within Veteran Health Administration (VHA) datasets. The U.S. Food and Drug Administration (FDA) and the VHA launched the precisionFDA COVID-19 Risk Factor Modeling Challenge to develop COVID-19 diagnostic and prognostic models; identify Veteran population-specific risk factors; and test the usefulness of synthetic data as a substitute for real data. The use of synthetic data boosted challenge participation by providing a dataset that was accessible to all competitors. Models trained on synthetic data showed similar but systematically inflated model performance metrics to those trained on real data. The important risk factors identified in the synthetic data largely overlapped with those identified from the real data, and both sets of risk factors were validated in the literature. Tradeoffs exist between synthetic data generation approaches based on whether a real EHR dataset is required as input. Synthetic data generated directly from real EHR input will more closely align with the characteristics of the relevant cohort. This work shows that synthetic EHR data will have practical value to the Veterans' health research community for the foreseeable future.
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Affiliation(s)
| | - Bocheng Jing
- Northern California Institute for Research and Education
- San Francisco VA Medical Center
| | | | | | | | | | | | | | | | | | | | | | | | - Sean Watford
- Booz Allen Hamilton
- Currently U.S. Environmental Protection Agency
| | - W John Boscardin
- University of California, San Francisco, Department of Medicine
- University of California, San Francisco, Department of Epidemiology & Biostatistics
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Jing B, Qian Y, Heitjan DF, Xie H. Tutorial: Assessing the impact of nonignorable missingness on regression analysis using Index of Local Sensitivity to Nonignorability. Psychol Methods 2023:2024-26019-001. [PMID: 37971833 DOI: 10.1037/met0000616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Data sets with missing observations are common in psychology research. One typically analyzes such data by applying statistical methods that rely on the assumption that the missing observations are missing at random (MAR). This assumption greatly simplifies analysis but is unverifiable from the data at hand, and assuming it incorrectly may lead to bias. Thus we often wish to conduct sensitivity analyses to judge whether conclusions are robust to departures from MAR-that is, whether key findings would hold up even if MAR does not in fact hold. This article describes a class of sensitivity analyses derived from a measure of robustness called the Index of Local Sensitivity to Nonignorability (ISNI). ISNI is straightforward to compute and avoids the estimation of complicated non-MAR missing-data models. The accompanying R package isni implements the method for a range of commonly used regression models; the syntax is simple and similar to that for the regular analysis that assumes MAR. We illustrate the application of the method and software to address the credibility of MAR analyses in a series of analyses of real-world data sets from psychology research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Bocheng Jing
- Faculty of Health Sciences, Simon Fraser University
| | - Yi Qian
- Division of Marketing & Behavioral Sciences, Sauder School of Business, University of British Columbia
| | - Daniel F Heitjan
- Department of Statistics & Data Science, Southern Methodist University
| | - Hui Xie
- Faculty of Health Sciences, Simon Fraser University
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Deardorff WJ, Lu K, Jing B, Jeon SY, Boscardin WJ, Fung KZ, Lee SJ. Frequency of Screening for Colorectal Cancer by Predicted Life Expectancy Among Adults 76-85 Years. JAMA 2023; 330:1280-1282. [PMID: 37676665 PMCID: PMC10485741 DOI: 10.1001/jama.2023.15820] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 09/08/2023]
Abstract
This study assesses whether colorectal cancer screening varied by predicted life expectancy in a national sample of Veterans Affairs patients aged 76 to 85 years.
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Affiliation(s)
- W. James Deardorff
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Kaiwei Lu
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Bocheng Jing
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sun Y. Jeon
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - W. John Boscardin
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Kathy Z. Fung
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sei J. Lee
- San Francisco Veterans Affairs Health Care System, San Francisco, California
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Deardorff WJ, Jing B, Growdon ME, Yaffe K, Boscardin WJ, Boockvar KS, Steinman MA. Medication misuse and overuse in community-dwelling persons with dementia. J Am Geriatr Soc 2023; 71:3086-3098. [PMID: 37272899 PMCID: PMC10592653 DOI: 10.1111/jgs.18463] [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: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. METHODS We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative. RESULTS Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively. CONCLUSION Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.
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Affiliation(s)
- W. James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Matthew E. Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California
- Department of Neurology, University of California, San Francisco, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - W. John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Kenneth S. Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, Alabama
| | - Michael A. Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
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Anderson TS, Herzig SJ, Jing B, Boscardin WJ, Fung K, Marcantonio ER, Steinman MA. Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults. JAMA Intern Med 2023; 183:715-723. [PMID: 37252732 PMCID: PMC10230372 DOI: 10.1001/jamainternmed.2023.1667] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/24/2023] [Indexed: 05/31/2023]
Abstract
Importance Asymptomatic blood pressure (BP) elevations are common in hospitalized older adults, and widespread heterogeneity in the clinical management of elevated inpatient BPs exists. Objective To examine the association of intensive treatment of elevated inpatient BPs with in-hospital clinical outcomes of older adults hospitalized for noncardiac conditions. Design, Setting, and Participants This retrospective cohort study examined Veterans Health Administration data between October 1, 2015, and December 31, 2017, for patients aged 65 years or older hospitalized for noncardiovascular diagnoses and who experienced elevated BPs in the first 48 hours of hospitalization. Interventions Intensive BP treatment following the first 48 hours of hospitalization, defined as receipt of intravenous antihypertensives or oral classes not used prior to admission. Main Outcome and Measures The primary outcome was a composite of inpatient mortality, intensive care unit transfer, stroke, acute kidney injury, B-type natriuretic peptide elevation, and troponin elevation. Data were analyzed between October 1, 2021, and January 10, 2023, with propensity score overlap weighting used to adjust for confounding between those who did and did not receive early intensive treatment. Results Among 66 140 included patients (mean [SD] age, 74.4 [8.1] years; 97.5% male and 2.6% female; 17.4% Black, 1.7% Hispanic, and 75.9% White), 14 084 (21.3%) received intensive BP treatment in the first 48 hours of hospitalization. Patients who received early intensive treatment vs those who did not continued to receive a greater number of additional antihypertensives during the remainder of their hospitalization (mean additional doses, 6.1 [95% CI, 5.8-6.4] vs 1.6 [95% CI, 1.5-1.8], respectively). Intensive treatment was associated with a greater risk of the primary composite outcome (1220 [8.7%] vs 3570 [6.9%]; weighted odds ratio [OR], 1.28; 95% CI, 1.18-1.39), with the highest risk among patients receiving intravenous antihypertensives (weighted OR, 1.90; 95% CI, 1.65-2.19). Intensively treated patients were more likely to experience each component of the composite outcome except for stroke and mortality. Findings were consistent across subgroups stratified by age, frailty, preadmission BP, early hospitalization BP, and cardiovascular disease history. Conclusions and Relevance The study's findings indicate that among hospitalized older adults with elevated BPs, intensive pharmacologic antihypertensive treatment was associated with a greater risk of adverse events. These findings do not support the treatment of elevated inpatient BPs without evidence of end organ damage, and they highlight the need for randomized clinical trials of inpatient BP treatment targets.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - W. John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Edward R. Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael A. Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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Liu X, Steinman MA, Lee SJ, Peralta CA, Graham LA, Li Y, Jing B, Fung KZ, Odden MC. Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents. J Am Geriatr Soc 2023; 71:2131-2140. [PMID: 36826917 PMCID: PMC10363184 DOI: 10.1111/jgs.18301] [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: 07/13/2022] [Revised: 01/18/2023] [Accepted: 01/28/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications. METHODS Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications). RESULTS More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group). CONCLUSIONS The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.
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Affiliation(s)
- Xiaojuan Liu
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Sei J. Lee
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Carmen A. Peralta
- Kidney Health Research Collaborative, University of California San Francisco and San Francisco VA Medical Center, San Francisco, CA
- Cricket Health, Inc, San Francisco, CA
| | - Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Yongmei Li
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Kathy Z. Fung
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Michelle C. Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
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10
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Rizzo A, Jing B, Boscardin WJ, Shah SJ, Steinman MA. Can markers of disease severity improve the predictive power of claims-based multimorbidity indices? J Am Geriatr Soc 2023; 71:845-857. [PMID: 36495264 PMCID: PMC10023343 DOI: 10.1111/jgs.18150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/02/2022] [Revised: 10/20/2022] [Accepted: 11/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden. METHODS We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases. RESULTS Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (<0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers. CONCLUSIONS Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.
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Affiliation(s)
- Anael Rizzo
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Sachin J Shah
- Section of Hospital Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco and San Francisco VA Medical Center, San Francisco, California, USA
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11
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Steinman MA, Jing B, Shah SJ, Rizzo A, Lee SJ, Covinsky KE, Ritchie CS, Boscardin WJ. Development and validation of novel multimorbidity indices for older adults. J Am Geriatr Soc 2023; 71:121-135. [PMID: 36282202 PMCID: PMC9870862 DOI: 10.1111/jgs.18052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/19/2022] [Revised: 07/24/2022] [Accepted: 08/21/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Measuring multimorbidity in claims data is used for risk adjustment and identifying populations at high risk for adverse events. Multimorbidity indices such as Charlson and Elixhauser scores have important limitations. We sought to create a better method of measuring multimorbidity using claims data by incorporating geriatric conditions, markers of disease severity, and disease-disease interactions, and by tailoring measures to different outcomes. METHODS Health conditions were assessed using Medicare inpatient and outpatient claims from subjects age 67 and older in the Health and Retirement Study. Separate indices were developed for ADL decline, IADL decline, hospitalization, and death, each over 2 years of follow-up. We validated these indices using data from Medicare claims linked to the National Health and Aging Trends Study. RESULTS The development cohort included 5012 subjects with median age 76 years; 58% were female. Claims-based markers of disease severity and disease-disease interactions yielded minimal gains in predictive power and were not included in the final indices. In the validation cohort, after adjusting for age and sex, c-statistics for the new multimorbidity indices were 0.72 for ADL decline, 0.69 for IADL decline, 0.72 for hospitalization, and 0.77 for death. These c-statistics were 0.02-0.03 higher than c-statistics from Charlson and Elixhauser indices for predicting ADL decline, IADL decline, and hospitalization, and <0.01 higher for death (p < 0.05 for each outcome except death), and were similar to those from the CMS-HCC model. On decision curve analysis, the new indices provided minimal benefit compared with legacy approaches. C-statistics for both new and legacy indices varied substantially across derivation and validation cohorts. CONCLUSIONS A new series of claims-based multimorbidity measures were modestly better at predicting hospitalization and functional decline than several legacy indices, and no better at predicting death. There may be limited opportunity in claims data to measure multimorbidity better than older methods.
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Affiliation(s)
- Michael A. Steinman
- Division of Geriatrics, UCSF, San Francisco, California, USA
- The San Francisco VA Health Care System, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, UCSF, San Francisco, California, USA
- The San Francisco VA Health Care System, San Francisco, California, USA
| | - Sachin J. Shah
- Division of Hospital Medicine, UCSF, San Francisco, California, USA
| | - Anael Rizzo
- Division of Geriatrics, UCSF, San Francisco, California, USA
- The San Francisco VA Health Care System, San Francisco, California, USA
- David Geffen School of Medicine at UCLA, San Francisco, California, USA
| | - Sei J. Lee
- Division of Geriatrics, UCSF, San Francisco, California, USA
- The San Francisco VA Health Care System, San Francisco, California, USA
| | - Kenneth E. Covinsky
- Division of Geriatrics, UCSF, San Francisco, California, USA
- The San Francisco VA Health Care System, San Francisco, California, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital and the Mongan Institute Center for Aging and Serious Illness, Boston, MA, USA
| | - W. John Boscardin
- Division of Geriatrics, UCSF, San Francisco, California, USA
- The San Francisco VA Health Care System, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California, USA
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12
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Deardorff WJ, Jing B, Growdon M, Yaffe K, Boockvar K, Steinman M. UNNECESSARY AND HARMFUL MEDICATION USE IN COMMUNITY DWELLING PERSONS WITH DEMENTIA. Innov Aging 2022. [PMCID: PMC9766249 DOI: 10.1093/geroni/igac059.1626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Persons with dementia (PWD) often have multiple comorbidities which results in extensive medication use despite potentially limited benefit and increased risk of adverse events. Compared to the nursing home, little is known about medication overuse and misuse among the ~70% of PWD in the community. Therefore, we examined medication use from Medicare Part D prescriptions among 1,289 community-dwelling PWD aged ≥66 from the Health and Retirement Study. We classified medication overuse as over-aggressive treatment of chronic conditions (e.g., insulin/sulfonylurea use with hemoglobin A1c<7.5%) and medications inappropriate near the end of life. We classified medication misuse as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics) and problematic medications (using Beers and STOPP criteria). We describe the prevalence and patterns of different types of medication overuse/misuse. Frequently problematic medications included antipsychotics (9%), benzodiazepines (12%), and gabapentinoids (13%). Our findings highlight the burden of unnecessary/harmful medications among PWD and inform future deprescribing interventions.
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Affiliation(s)
- W James Deardorff
- University of California, San Francisco, San Francisco, California, United States
| | - Bocheng Jing
- University of California, San Francisco, San Francisco, California, United States
| | - Matthew Growdon
- University of California, San Francisco, San Francisco, California, United States
| | - Kristine Yaffe
- University of California, San Francisco, San Francisco, California, United States
| | - Kenneth Boockvar
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Michael Steinman
- University of California, San Francisco, San Francisco, California, United States
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13
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Nguyen B, James Deardorff W, Shi Y, Jing B, Lee AK, Lee SJ. Fingerstick glucose monitoring by cognitive impairment status in Veterans Affairs nursing home residents with diabetes. J Am Geriatr Soc 2022; 70:3176-3184. [PMID: 35924668 PMCID: PMC9705158 DOI: 10.1111/jgs.17962] [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: 03/15/2022] [Revised: 06/07/2022] [Accepted: 06/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels. METHODS We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/- metformin but no insulin), (4) long-acting insulin (+/- oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission. RESULTS Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation = 1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status. Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact). CONCLUSION NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration in monitoring decisions. Future studies should determine whether decreasing fingersticks in NH residents with moderate/severe cognitive impairment can reduce burdens without compromising safety.
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Affiliation(s)
- Brian Nguyen
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - William James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Sei J Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, California
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14
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Liang X, Guan F, Hu ZQ, Li B, Li YK, Jing B, Huang H, Zhu GT, Mao BB. [The related factors of postoperative recurrence in trigeminalneuralgia patients undergoing fully neuroendoscopic microvascular decompression]. Zhonghua Yi Xue Za Zhi 2022; 102:2465-2469. [PMID: 36000377 DOI: 10.3760/cma.j.cn112137-20211218-02820] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: To evaluate the related factors of postoperative recurrence intrigeminal neuralgia (TN) patients treated with fully neuroendoscopic microvascular decompression (MVD). Methods: The clinical baseline data and preoperative MRI imaging data of 112 patients with TN treated by neuroendoscopic MVD from December 2008 to December 2020 in the Department of Neurosurgery, Beijing Shijitan Hospital Affiliated to Capital Medical University were retrospectively analyzed, including: area ratio of cerebellopontine area (CPA)(healthy side/affected side), trigeminal nerve(TGN)length ratio(healthy side/affected side), TGN angle ratio(healthy side/affected side), and criminal vessel type. Multivariate Cox proportional hazards model was used to analyze the factors affecting postoperative recurrence. Results: Among the 112 patients in this group, there were 49 males and 63 females. The age ranged from 20 to 82 (59±9) years, and the course of disease was 0.05 to 30.00 (5.60±5.15) years. Pain was located on the left side in 43 cases (38.39%) and on the right side in 69 cases (61.61%), respectively. All patients were followed up for more than 1 year, with an average follow-up time of 21.5 months, and 11 cases recurred. Multivariate Cox regression analysis revealed that disease duration≥3 years(HR=9.34, 95%CI:1.12-39.07), CPA area ratio(healthy side/affected side)>1 (HR=27.47, 95%CI:1.69-44.20), criminal vessel type with vein(HR=35.39, 95%CI:1.26-18.60) and criminal vessel type with arteriovenous (HR=46.07, 95%CI: 2.74-27.75) were the main factors influencing recurrence of MVD surgery (all P<0.05). Conclusion: The disease duration≥3 years, CPA area ratio(healthy side/affected side)>1, and criminal vessel type with vein/arteriovenous are the relevant factors that affect the recurrence rate after the fully neuroendoscopic MVD treatment for trigeminal neuralgia.
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Affiliation(s)
- X Liang
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - F Guan
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Z Q Hu
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - B Li
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Y K Li
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - B Jing
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - H Huang
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - G T Zhu
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - B B Mao
- Department of Neurosurgery, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
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15
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Odden MC, Li Y, Graham LA, Steinman MA, Marcum ZA, Liu CK, Jing B, Fung KZ, Peralta CA, Lee SJ. Trends in blood pressure diagnosis, treatment, and control among VA nursing home residents, 2007-2018. J Am Geriatr Soc 2022; 70:2280-2290. [PMID: 35524763 PMCID: PMC9378662 DOI: 10.1111/jgs.17821] [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] [Received: 12/20/2021] [Revised: 03/09/2022] [Accepted: 03/20/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms. METHODS Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65 years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs. RESULTS The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend <0.001). Rates of BP treatment and control among residents with hypertension at admission declined slightly over time (p-values for trend <0.001) but remained high (80.3% treated in FY2017-2018, 80.1% with average BP <140/90 mmHg). The age-adjusted prevalence of chronic low BP (average <90/60 mmHg) also declined from 11.1% in FY2007-2008 to 4.7% in FY2017-2018 (p-value for trend <0.001). Persons identified as Black race or Hispanic ethnicity and those with a history of diabetes, stroke, and renal disease were less likely to have an average BP <140/90 mmHg. CONCLUSIONS Hypertension is well controlled in VA nursing homes, and recent trends of less intensive BP control were accompanied by a lower prevalence of chronic low BP. Nonetheless, some high-risk populations have average BP levels >140/90 mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.
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Affiliation(s)
- Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA,Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Yongmei Li
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA
| | - Laura A. Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Michael A. Steinman
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA,Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | | | - Christine K. Liu
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA,Department of Medicine, Division of Primary Care and Population Health, Stanford University, Stanford CA
| | - Bocheng Jing
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Kathy Z. Fung
- Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
| | - Carmen A Peralta
- Kidney Health Research Collaborative, University of California San Francisco and San Francisco VA Medical Center, San Francisco, CA,Cricket Health, Inc
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA,Geriatrics, Palliative, and Extended Care Service Line, San Francisco VA Medical Center, San Francisco, CA
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16
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Lederle LI, Steinman MA, Jing B, Nguyen B, Lee SJ. Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes. J Am Geriatr Soc 2022; 70:2019-2028. [PMID: 35318647 PMCID: PMC9283249 DOI: 10.1111/jgs.17735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/02/2022] [Accepted: 02/12/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting. METHODS We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose-lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c. RESULTS Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long-acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14-1.65 and OR 1.35, 95% CI 1.10-1.66, respectively). Severe functional impairment (MDS-ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56-0.95). Hypoglycemia was not associated with decreased odds of overtreatment. CONCLUSIONS Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification.
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Affiliation(s)
- Lauren I. Lederle
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Michael A. Steinman
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Bocheng Jing
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Brian Nguyen
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Sei J. Lee
- Geriatrics and Extended Care ServiceSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Veterans Affairs Quality Scholars FellowshipSan Francisco Virginia Medical CenterSan FranciscoCaliforniaUSA
- Division of GeriatricsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
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17
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Lam K, Gan S, Nguyen B, Jing B, Lee SJ. Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes. J Am Geriatr Soc 2022; 70:2008-2018. [PMID: 35357692 PMCID: PMC9283241 DOI: 10.1111/jgs.17771] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/17/2022] [Accepted: 01/23/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Guidelines discourage sliding scale insulin (SSI) use after the first week of a nursing home (NH) admission. We sought to determine the prevalence of SSI and identify factors associated with stopping SSI or transitioning to another short-acting insulin regimen. METHODS In an observational study from October 1, 2013, to June 30, 2017 of non-hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week, we compared the weekly prevalence of SSI versus two other short-acting insulin regimens - fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) - from week 2 to week 12 of admission. Among those on SSI in week 2, we examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty-related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes-related factors (e.g., HbA1c, long-acting insulin use, hyperglycemia, and hypoglycemia). RESULTS In week 2, 21% of our cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate-severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes-related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non-SSI short-acting insulin regimen than frailty-related factors. CONCLUSIONS SSI is the most common method of administering short-acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.
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Affiliation(s)
- Kenneth Lam
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
| | - Siqi Gan
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Brian Nguyen
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Sei J. Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
- Geriatrics, Palliative and Extended Care Service Line, San Francisco VA (Veterans Affairs) Health Care System, San Francisco, California
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18
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Jing B, Boscardin WJ, Deardorff WJ, Jeon SY, Lee AK, Donovan AL, Lee SJ. Comparing Machine Learning to Regression Methods for Mortality Prediction Using Veterans Affairs Electronic Health Record Clinical Data. Med Care 2022; 60:470-479. [PMID: 35352701 PMCID: PMC9106858 DOI: 10.1097/mlr.0000000000001720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND It is unclear whether machine learning methods yield more accurate electronic health record (EHR) prediction models compared with traditional regression methods. OBJECTIVE The objective of this study was to compare machine learning and traditional regression models for 10-year mortality prediction using EHR data. DESIGN This was a cohort study. SETTING Veterans Affairs (VA) EHR data. PARTICIPANTS Veterans age above 50 with a primary care visit in 2005, divided into separate training and testing cohorts (n= 124,360 each). MEASUREMENTS AND ANALYTIC METHODS The primary outcome was 10-year all-cause mortality. We considered 924 potential predictors across a wide range of EHR data elements including demographics (3), vital signs (9), medication classes (399), disease diagnoses (293), laboratory results (71), and health care utilization (149). We compared discrimination (c-statistics), calibration metrics, and diagnostic test characteristics (sensitivity, specificity, and positive and negative predictive values) of machine learning and regression models. RESULTS Our cohort mean age (SD) was 68.2 (10.5), 93.9% were male; 39.4% died within 10 years. Models yielded testing cohort c-statistics between 0.827 and 0.837. Utilizing all 924 predictors, the Gradient Boosting model yielded the highest c-statistic [0.837, 95% confidence interval (CI): 0.835-0.839]. The full (unselected) logistic regression model had the highest c-statistic of regression models (0.833, 95% CI: 0.830-0.835) but showed evidence of overfitting. The discrimination of the stepwise selection logistic model (101 predictors) was similar (0.832, 95% CI: 0.830-0.834) with minimal overfitting. All models were well-calibrated and had similar diagnostic test characteristics. LIMITATION Our results should be confirmed in non-VA EHRs. CONCLUSION The differences in c-statistic between the best machine learning model (924-predictor Gradient Boosting) and 101-predictor stepwise logistic models for 10-year mortality prediction were modest, suggesting stepwise regression methods continue to be a reasonable method for VA EHR mortality prediction model development.
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Affiliation(s)
- Bocheng Jing
- San Francisco VA Health Care System, San Francisco, California
- Northern California Institute for Research and Education, San Francisco, California
- University of California, San Francisco, Division of Geriatrics, San Francisco, California
| | - W. John Boscardin
- San Francisco VA Health Care System, San Francisco, California
- University of California, San Francisco, Division of Geriatrics, San Francisco, California
- University of California, San Francisco, Department of Epidemiology and Biostatistics, San Francisco, California
| | - W. James Deardorff
- University of California, San Francisco, Division of Geriatrics, San Francisco, California
| | - Sun Young Jeon
- San Francisco VA Health Care System, San Francisco, California
- University of California, San Francisco, Division of Geriatrics, San Francisco, California
| | - Alexandra K. Lee
- San Francisco VA Health Care System, San Francisco, California
- University of California, San Francisco, Division of Geriatrics, San Francisco, California
| | - Anne L. Donovan
- University of California, San Francisco, Department of Anesthesia and Perioperative Medicine, San Francisco, California
| | - Sei J. Lee
- San Francisco VA Health Care System, San Francisco, California
- University of California, San Francisco, Division of Geriatrics, San Francisco, California
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Deardorff WJ, Jing B, Jeon SY, Boscardin WJ, Lee AK, Fung KZ, Lee SJ. Do functional status and Medicare claims data improve the predictive accuracy of an electronic health record mortality index? Findings from a national Veterans Affairs cohort. BMC Geriatr 2022; 22:434. [PMID: 35585537 PMCID: PMC9118715 DOI: 10.1186/s12877-022-03126-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 05/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background Electronic health record (EHR) prediction models may be easier to use in busy clinical settings since EHR data can be auto-populated into models. This study assessed whether adding functional status and/or Medicare claims data (which are often not available in EHRs) improves the accuracy of a previously developed Veterans Affairs (VA) EHR-based mortality index. Methods This was a retrospective cohort study of veterans aged 75 years and older enrolled in VA primary care clinics followed from January 2014 to April 2020 (n = 62,014). We randomly split participants into development (n = 49,612) and validation (n = 12,402) cohorts. The primary outcome was all-cause mortality. We performed logistic regression with backward stepwise selection to develop a 100-predictor base model using 854 EHR candidate variables, including demographics, laboratory values, medications, healthcare utilization, diagnosis codes, and vitals. We incorporated functional measures in a base + function model by adding activities of daily living (range 0-5) and instrumental activities of daily living (range 0-7) scores. Medicare data, including healthcare utilization (e.g., emergency department visits, hospitalizations) and diagnosis codes, were incorporated in a base + Medicare model. A base + function + Medicare model included all data elements. We assessed model performance with the c-statistic, reclassification metrics, fraction of new information provided, and calibration plots. Results In the overall cohort, mean age was 82.6 years and 98.6% were male. At the end of follow-up, 30,263 participants (48.8%) had died. The base model c-statistic was 0.809 (95% CI 0.805-0.812) in the development cohort and 0.804 (95% CI 0.796-0.812) in the validation cohort. Validation cohort c-statistics for the base + function, base + Medicare, and base + function + Medicare models were 0.809 (95% CI 0.801-0.816), 0.811 (95% CI 0.803-0.818), and 0.814 (95% CI 0.807-0.822), respectively. Adding functional status and Medicare data resulted in similarly small improvements among other model performance measures. All models showed excellent calibration. Conclusions Incorporation of functional status and Medicare data into a VA EHR-based mortality index led to small but likely clinically insignificant improvements in model performance. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03126-z.
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Affiliation(s)
- William James Deardorff
- Division of Geriatrics, University of California, San Francisco, 490 Illinois Street, Floor 08, San Francisco, CA, 94158, USA.
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, 490 Illinois Street, Floor 08, San Francisco, CA, 94158, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, 490 Illinois Street, Floor 08, San Francisco, CA, 94158, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, 490 Illinois Street, Floor 08, San Francisco, CA, 94158, USA
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, 490 Illinois Street, Floor 08, San Francisco, CA, 94158, USA
| | - Kathy Z Fung
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Sei J Lee
- Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
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20
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Growdon ME, Espejo E, Jing B, Boscardin WJ, Zullo AR, Yaffe K, Boockvar KS, Steinman MA. Attitudes toward deprescribing among older adults with dementia in the United States. J Am Geriatr Soc 2022; 70:1764-1773. [PMID: 35266141 DOI: 10.1111/jgs.17730] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/09/2022] [Accepted: 02/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD. METHODS This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking. RESULTS The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%-38%] vs. 13% [95% CI, 8%-20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%-95%] vs. 83% [95% CI, 76%-89%]; p = 0.04). CONCLUSIONS A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Edie Espejo
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
| | - W John Boscardin
- San Francisco VA Medical Center, San Francisco, California, USA.,Department of Medicine, University of California-San Francisco, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.,Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA.,Department of Pharmacy, Lifespan-Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kristine Yaffe
- San Francisco VA Medical Center, San Francisco, California, USA.,Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA.,Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA.,Department of Neurology, University of California-San Francisco, San Francisco, California, USA
| | - Kenneth S Boockvar
- The New Jewish Home, New York, New York, USA.,Icahn School of Medicine at Mount Sinai, New York, New York, USA.,James J. Peters VA Medical Center, Bronx, New York, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California-San Francisco, San Francisco, California, USA.,San Francisco VA Medical Center, San Francisco, California, USA
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21
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Lee AK, Jing B, Jeon SY, Boscardin WJ, Lee SJ. Predicting Life Expectancy to Target Cancer Screening Using Electronic Health Record Clinical Data. J Gen Intern Med 2022; 37:499-506. [PMID: 34327653 PMCID: PMC8858374 DOI: 10.1007/s11606-021-07018-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 06/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Guidelines recommend breast and colorectal cancer screening for older adults with a life expectancy >10 years. Most mortality indexes require clinician data entry, presenting a barrier for routine use in care. Electronic health records (EHR) are a rich clinical data source that could be used to create individualized life expectancy predictions to identify patients for cancer screening without data entry. OBJECTIVE To develop and internally validate a life expectancy calculator from structured EHR data. DESIGN Retrospective cohort study using national Veteran's Affairs (VA) EHR databases. PATIENTS Veterans aged 50+ with a primary care visit during 2005. MAIN MEASURES We assessed demographics, diseases, medications, laboratory results, healthcare utilization, and vital signs 1 year prior to the index visit. Mortality follow-up was complete through 2017. Using the development cohort (80% sample), we used LASSO Cox regression to select ~100 predictors from 913 EHR data elements. In the validation cohort (remaining 20% sample), we calculated the integrated area under the curve (iAUC) and evaluated calibration. KEY RESULTS In 3,705,122 patients, the mean age was 68 years and the majority were male (97%) and white (85%); nearly half (49%) died. The life expectancy calculator included 93 predictors; age and gender most strongly contributed to discrimination; diseases also contributed significantly while vital signs were negligible. The iAUC was 0.816 (95% confidence interval, 0.815, 0.817) with good calibration. CONCLUSIONS We developed a life expectancy calculator using VA EHR data with excellent discrimination and calibration. Automated life expectancy prediction using EHR data may improve guideline-concordant breast and colorectal cancer screening by identifying patients with a life expectancy >10 years.
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Affiliation(s)
- Alexandra K Lee
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA.
- San Francisco Veterans Affairs Medical Center, San Francisco, USA.
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
- Northern California Institute for Research and Education, San Francisco, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
- Division of Biostatistics, University of California, San Francisco, San Francisco, USA
| | - Sei J Lee
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA, 94121, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, USA
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22
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Graham LA, Lee SJ, Steinman MA, Peralta CA, Rubinsky AD, Jing B, Fung KZ, Odden MC. Exploring the Dynamics of Week-to-Week Blood Pressure in Nursing Home Residents Before Death. Am J Hypertens 2022; 35:65-72. [PMID: 34505872 DOI: 10.1093/ajh/hpab142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 06/06/2021] [Revised: 08/25/2021] [Accepted: 09/09/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Aging is accompanied by an overall dysregulation of many dynamic physiologic processes including those related to blood pressure (BP). While year-to-year BP variability is associated with cardiovascular events and mortality, no studies have examined this trend with more frequent BP assessments. Our study objective is to take the next step to examine week-to-week BP dynamics-pattern, variability, and complexity-before death. METHODS Using a retrospective study design, we assessed BP dynamics in the 6 months before death in long-term nursing home residents between 1 October 2006 and 30 September 2017. Variability was characterized using SD and mean squared error after adjusting for diurnal variations. Complexity (i.e., amount of novel information in a trend) was examined using Shannon's entropy (bits). Generalized linear models were used to examine factors associated with overall BP variability. RESULTS We identified 17,953 nursing home residents (98.0% male, 82.5% White, mean age 80.2 years, and mean BP 125.7/68.6 mm Hg). Despite a slight trend of decreasing systolic week-to-week BP over time (delta = 7.2 mm Hg), week-to-week complexity did not change in the 6 months before death (delta = 0.02 bits). Average weekly BP variability was stable until the last 3-4 weeks of life, at which point variability increased by 30% for both systolic and diastolic BP. Factors associated with BP variability include average weekly systolic/diastolic BP, days in the nursing home, days in the hospital, and changes to antihypertensive medications. CONCLUSIONS Week-to-week BP variability increases substantially in the last month of life, but complexity does not change. Changes in care patterns may drive the increase in BP variability as one approaches death.
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Affiliation(s)
- Laura A Graham
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Sei J Lee
- San Francisco Health Care System, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, California, USA
| | - Michael A Steinman
- San Francisco Health Care System, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, California, USA
| | - Carmen A Peralta
- San Francisco Health Care System, San Francisco, California, USA
- Kidney Research Collaborative, University of California, San Francisco, California, USA
- Cricket Health, Inc., San Francisco, California, USA
| | - Anna D Rubinsky
- San Francisco Health Care System, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Bocheng Jing
- San Francisco Health Care System, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, California, USA
| | - Kathy Z Fung
- San Francisco Health Care System, San Francisco, California, USA
- Division of Geriatrics, University of California, San Francisco, California, USA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
- Geriatric Research Education and Clinical Center VA Palo Alto Health Care System, Palo Alto, California, USA
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Marcum ZA, Li Y, Lee SJ, Steinman MA, Graham L, Jing B, Fung K, Peralta CA, Odden MC. Association of Antihypertensives and Cognitive Impairment in Long-Term Care Residents. J Alzheimers Dis 2022; 86:1149-1158. [PMID: 35147539 PMCID: PMC9128024 DOI: 10.3233/jad-215393] [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: 11/15/2022]
Abstract
BACKGROUND Certain classes of antihypertensive medication may have different associations with cognitive impairment. OBJECTIVE To examine the association between prevalent use of antihypertensive medications that stimulate (thiazides, dihydropyridine calcium channel blockers, angiotensin type I receptor blockers) versus inhibit (angiotensin-converting enzyme inhibitors, beta-blockers, non-dihydropyridine calcium channel blockers) type 2 and 4 angiotensin II receptors on cognitive impairment among older adults residing in Veterans Affairs (VA) nursing homes for long-term care. METHODS Retrospective cohort study. Long-term care residents aged 65 + years admitted to a VA nursing home from 2012 to 2019 using blood pressure medication and without cognitive impairment at admission. Main exposure was prevalent use of angiotensin II receptor type 2 and 4-'stimulating' (N = 589), 'inhibiting' (N = 3,219), or 'mixed' (N = 1,715) antihypertensive medication regimens at admission. Primary outcome was any cognitive impairment (Cognitive Function Scale). RESULTS Over an average of 5.4 months of follow-up, prevalent use of regimens containing exclusively 'stimulating' antihypertensives was associated with a lower risk of any incident cognitive impairment as compared to prevalent use of regimens containing exclusively 'inhibiting' antihypertensives (HR 0.83, 95% CI 0.74-0.93). Results for the comparison between 'mixed' versus 'inhibiting' regimens were in the same direction but not statistically significant (HR 0.96, 95% CI 0.88-1.06). CONCLUSION For residents without cognitive impairment at baseline, prevalent users of regimens containing exclusively antihypertensives that stimulate type 2 and 4 angiotensin II receptors had lower rates of cognitive impairment as compared to prevalent users of regimens containing exclusively antihypertensives that inhibit these receptors. Residual confounding cannot be ruled out.
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Affiliation(s)
| | - Yongmei Li
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Sei J. Lee
- San Francisco VA Medical Center, San Francisco, CA, USA,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A. Steinman
- San Francisco VA Medical Center, San Francisco, CA, USA,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Laura Graham
- Department of Surgery, Stanford University, Stanford, CA, USA,Health Economics Research Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Bocheng Jing
- NCIRE – The Veterans Health Research Institute, San Francisco. USA
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, CA, USA,Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Carmen A. Peralta
- Cricket Health, Inc and the Kidney Health Research Collaborative, University of California San Francisco and San Francisco VA Medical Center, San Francisco, CA, USA
| | - Michelle C. Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA,Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Zeng Y, Pu Y, Niu L, Deng J, Zeng D, Amato K, Li Y, Zhou Y, Lin Y, Wang J, Wu L, Chen B, Pan K, Jing B, Ni X. Comparison of gastrointestinal microbiota in golden snub-nosed monkey (Rhinopithecus roxellanae), green monkey (Chlorocebus aethiops sabaeus), and ring-tailed lemur (Lemur catta) by high throughput sequencing. Glob Ecol Conserv 2022. [DOI: 10.1016/j.gecco.2021.e01946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Graham L, Lee S, Steinman M, Peralta C, Rubinsky A, Jing B, Fung K, Odden M. Blood Pressure Variability and Complexity in Nursing Home Residents Before Death. Innov Aging 2021. [PMCID: PMC8682427 DOI: 10.1093/geroni/igab046.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Blood pressure (BP) is a complex dynamic system in the human body and an important determinant of healthy aging. Exploring BP as a dynamic data system may provide important insights into how BP patterns can provide complementary information to the static, one-time BP measurements that are more commonly used for clinical decision making. Thus, we sought to describe BP as a dynamic data system in older adults nearing death. Using a prospective cohort study design, we assessed BP measures 6 months before death in Veterans Health Administrative nursing home residents between 10/1/2006 and 9/30/2017. Variability was characterized using standard deviation and mean square error after adjusting for diurnal variations. Complexity (i.e., amount of novel information vs. redundancy) was examined using Shannon’s entropy (bits). Generalized linear models were used to examine factors associated with overall BP variability. We identified 17,953 patients (98.0% male, 82.5% White, mean age 80.2 years, and mean BP 125.7/68.6 mmHg). In the last 6 months of life, systolic BP decreased slightly (□-7.2mmHg). Variability was stable until the last month of life, at which point variability increased by as much as 30%. In contrast, complexity did not change in the 6 months before death (□0.02 bits). Factors associated with BP variability before death include hospitalizations, hospice care, and medication changes. Systolic BP decreases in the last 6 months before death, and BP variability increases in the last month of life. Further, the increase in BP variability may be driven by increasingly complex care patterns as one approaches death.
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Affiliation(s)
- Laura Graham
- VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Sei Lee
- University of California San Francisco, San Francisco, California, United States
| | - Michael Steinman
- University of California San Francisco, San Francisco, California, United States
| | - Carmen Peralta
- University of California, San Francisco, San Francisco, California, United States
| | - Anna Rubinsky
- University of California, San Francisco, San Francisco, California, United States
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Michelle Odden
- Stanford University, Stanford, California, United States
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Odden M, Lee S, Steinman M, Rubinsky A, Jing B, Fung K, Graham L, Peralta C. Deprescribing Blood Pressure Treatment in VA Long-Term Care Residents. Innov Aging 2021. [PMCID: PMC8680287 DOI: 10.1093/geroni/igab046.1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
There is growing interest in deprescribing of antihypertensive medications in response to adverse effects, or when a patient’s situation evolves such that the benefits are outweighed by the harms. We conducted a retrospective cohort study to evaluate the incidence and predictors of deprescribing of antihypertensive medication among VA long-term care residents ≥ 65 years admitted between 2006 and 2017. Data were extracted from the VA electronic health record, CMS Minimum Data Set, and Bar Code Medication Administration. Deprescribing was defined as a reduction in the number of antihypertensive medications, sustained for 2 weeks. Potentially triggering events for deprescribing included low blood pressure (<90/60 mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and fall in the past 30 days. Among 22,826 VA nursing home residents on antihypertensive medication, 57% had describing event during their stay (median length of stay = 6 months). Deprescribing events were most common in the first 4 weeks after admission and the last 4 weeks of life. Among potentially triggering events, acute renal impairment was associated with greatest increase in the likelihood of deprescribing over the subsequent 4 weeks: among residents with this event, 32.7% were described compared to 7.3% in those without (risk difference = 25.5%, p<0.001). Falls were associated with the smallest increased risk of deprescribing (risk difference = 2.1%, p<0.001) of the events considered. Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.
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Affiliation(s)
- Michelle Odden
- Stanford University, Stanford, California, United States
| | - Sei Lee
- University of California San Francisco, San Francisco, California, United States
| | - Michael Steinman
- University of California San Francisco, San Francisco, California, United States
| | - Anna Rubinsky
- University of California, San Francisco, San Francisco, California, United States
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Laura Graham
- VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Carmen Peralta
- University of California, San Francisco, San Francisco, California, United States
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Liu X, Lee S, Steinman M, Graham L, Li Y, Jing B, Odden M. Blood Pressure Control and Cardiovascular and Mortality Risk in VA Nursing Home Residents. Innov Aging 2021. [PMCID: PMC8680779 DOI: 10.1093/geroni/igab046.2320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Optimal blood pressure (BP) control in nursing home residents is controversial and this population has been excluded from trials. We evaluated the associations of BP level with cardiovascular (CV) events and all-cause mortality across antihypertensive medication categories in Veterans Affairs (VA) nursing home residents. Data for 18,589 residents aged 65 years and older was obtained from the VA Corporate Data Warehouse from October 2006 through September 2017. Baseline systolic BP (SBP) and diastolic BP (DBP) were divided into categories and analyses were stratified by antihypertensive therapy (0, 1, and ≥2 medications). Over a median follow-up of 1.8 years, CV events occurred in 3,519 (19%) residents and 15,897 (86%) residents died. In participants on no BP medications, high SBP (>150 mmHg) was associated with a greater risk of CV events (adjusted [cause-specific] hazard ratio, 1.39; 95% confidence interval, 0.94-2.06) compared with normal SBP (110-130mmHg). By contrast, in participants on ≥2 BP medications, the subgroup with low SBP (<110 mmHg) had a higher CV risk (1.38; 1.20-1.57). For DBP, in participants without BP medications, there were no differences in CV risk across DBP subgroups. Whereas among those on 1 or ≥2 medications, DBP <60 mmHg was associated with a higher CV risk (1.26; 1.03-1.55 and 1.35; 1.18-1.54, respectively) compared with normal DBP (70-80 mmHg). Participants with low SBP (<110 mmHg) and DBP (<70 mmHg) had an increased mortality risk regardless of the number of medications. These findings suggest a potential risk of low BP among nursing home residents on multiple antihypertensive medications.
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Affiliation(s)
- Xiaojuan Liu
- Stanford University, Stanford, California, United States
| | - Sei Lee
- University of California San Francisco, San Francisco, California, United States
| | - Michael Steinman
- University of California San Francisco, San Francisco, California, United States
| | - Laura Graham
- VA Palo Alto Health Care System, Menlo Park, California, United States
| | - Yongmei Li
- Stanford University, Stanford, California, United States
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Michelle Odden
- Stanford University, Stanford, California, United States
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Anderson TS, Lee AK, Jing B, Lee S, Herzig SJ, Boscardin WJ, Fung K, Rizzo A, Steinman MA. Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System. JAMA Netw Open 2021; 4:e2128998. [PMID: 34673963 PMCID: PMC8531994 DOI: 10.1001/jamanetworkopen.2021.28998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE To investigate outcomes associated with intensification of outpatient diabetes medications at discharge. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021. EXPOSURE Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications. MAIN OUTCOMES AND MEASURES Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge. RESULTS The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled. CONCLUSIONS AND RELEVANCE In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Alexandra K. Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sei Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - W. John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Anael Rizzo
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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Odden MC, Lee SJ, Steinman MA, Rubinsky AD, Graham L, Jing B, Fung K, Marcum ZA, Peralta CA. Deprescribing Blood Pressure Treatment in Long-Term Care Residents. J Am Med Dir Assoc 2021; 22:2540-2546.e2. [PMID: 34364847 DOI: 10.1016/j.jamda.2021.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 01/20/2021] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate the incidence of deprescribing of antihypertensive medication among older adults residing in Veterans Affairs (VA) nursing homes for long-term care and rates of deprescribing after potentially triggering events. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Long-term care residents aged 65 years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure medication at admission. METHODS Data were extracted from the VA electronic health record, and Centers for Medicare & Medicaid Services Minimum Data Set and Bar Code Medication Administration. Deprescribing was defined on a rolling basis as a reduction in the number or dose of antihypertensive medications, sustained for ≥2 weeks. We examined potentially triggering events for deprescribing, including low blood pressure (<90/60 mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and falls. RESULTS Among 31,499 VA nursing home residents on antihypertensive medication, 70.4% had ≥1 deprescribing event (median length of stay = 6 months), and 48.7% had a net reduction in antihypertensive medications over their stay. Deprescribing events were most common in the first 4 weeks after admission and the last 4 weeks of life. Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent 4 weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference = 30.3%, P < .001). A fall in the past 30 days was associated with the smallest magnitude increased risk of deprescribing (risk difference = 3.8%, P < .001) of the events considered. CONCLUSIONS AND IMPLICATIONS Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.
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Affiliation(s)
- Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA; Geriatric Research, Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Sei J Lee
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Division of Geriatrics, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Michael A Steinman
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Division of Geriatrics, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Anna D Rubinsky
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Laura Graham
- Health Economics Research Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Bocheng Jing
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Kathy Fung
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Zachary A Marcum
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Carmen A Peralta
- Kidney Health Research Collaborative, University of California San Francisco and San Francisco VA Medical Center, San Francisco, CA, USA; Cricket Health, Inc, San Francisco, CA, USA
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Lee A, Jing B, Jeon SY, Boscardin J, Lee S. Predicting Life Expectancy Using Veterans Affairs Electronic Health Record Data. Innov Aging 2020. [PMCID: PMC7740909 DOI: 10.1093/geroni/igaa057.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Electronic health records (EHRs) are a rich source of health data that could be used to create individualized life expectancy predictions to aid in clinical decision-making for long-term preventative treatments, such as cancer screening. Few previous studies have incorporated all possible predictors from the EHR. We aimed to screen and incorporate a large number of possible predictors from EHR data into a life expectancy (LE) prediction equation. Using the national Veteran’s Affairs (VA) EHR databases, we identified all patients aged 50+ with a primary care visit during 2005 and assessed demographics, diseases, medications, laboratory results, healthcare utilization, and vital signs during the one year prior to the visit. Mortality follow-up was complete through 2017. We used an 80% random sample for model development and a 20% random sample for model validation. We used a Gompertz survival model with backwards selection to identify approximately 100 variables for the final LE prediction equation. In 1,263,595 VA patients, the mean age was 68 years and the majority were male (94%) and white (87%). During 12 years of follow-up, 602,576 (47.7%) died. Of 930 predictors from the EHR, 99 were included in the LE prediction equation. Harrell’s C-statistic was 0.7705 (95%CI: 0.7693, 0.7718). The model estimated 10-year life expectancy with sensitivity of 81.6% (81.4%, 81.8%) and specificity of 68.8% (68.5%, 69.1%). In conclusion, we developed an LE prediction equation from hundreds of predictors in the VA EHR with good discrimination and calibration that may help clinicians weigh the potential benefit of long-term preventative treatments.
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Affiliation(s)
- Alexandra Lee
- University of California, San Francisco, San Francisco, California, United States
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Sun Young Jeon
- University of California, San Francisco, San Francisco, California, United States
| | - John Boscardin
- University of California, San Francisco, San Francisco, California, United States
| | - Sei Lee
- University of California, San Francisco, San Francisco, California, United States
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Lam K, Gan S, Jing B, Nguyen B, Lee S. A Wasteful and Harmful Practice: Sliding Scale Insulin Use Among Nursing Home Veterans. Innov Aging 2020. [PMCID: PMC7740958 DOI: 10.1093/geroni/igaa057.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The American Medical Directors Association and the American Diabetes Association discourage the use of sliding scale insulin (SSI) in nursing home residents with diabetes due to its association with hypoglycemia, hyperglycemia, nursing burden, and patient discomfort. However, prevalence of SSI use is unclear. We used Veterans Affairs (VA) data from October 2013 to September 2016 to determine the weekly prevalence of SSI among 22,847 veterans with diabetes admitted to VA nursing homes (NHs). Average age was 75.3 (SD 8.3) years, mean A1c was 7.3% (SD 1.6%) and 57% were admitted from hospital. We first identified residents receiving any short-acting insulin. We then classified short-acting insulin use into three mutually exclusive regimens: (1) fixed scheduled doses, (2) SSI, defined as a variable dose of short-acting insulin without a concurrent fixed dose or (3) bolus with correction (BWC), defined as a variable dose given concurrently with a fixed dose that day. During the first week of NH admission, 64.7% of residents with diabetes received no short-acting insulin, 7.4% received fixed scheduled doses, 6.3% received BWC and 21.4% were on SSI. At week 12, the prevalence of fixed dose and BWC regimens was unchanged from baseline (fixed dose = 8.4%; BWC = 7.0%). In contrast, the prevalence of SSI decreased weekly to 15.8% (p for linear trend < 0.0001). Although SSI prevalence decreased from week 1 to week 12, 51% of residents on short-acting insulin were still using SSI in their 12th week of their NH stay.
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Affiliation(s)
- Kenneth Lam
- VA Medical Center--San Francisco, San Francisco, California, United States
| | - Siqi Gan
- University of California, San Francisco, San Francisco, California, United States
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Brian Nguyen
- San Francisco VA Medical Center, San Francisco, California, United States
| | - Sei Lee
- University of California, San Francisco, San Francisco, California, United States
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Ya X, Qian W, Huiqing L, Haixiao W, Weiwei Z, Jing B, Lei C, Jianping Y, Shuping Y, Jiaya M, Dong W, Ruixia G. Role of carbon nanoparticle suspension in sentinel lymph node biopsy for early-stage cervical cancer: a prospective study. BJOG 2020; 128:890-898. [PMID: 32930483 DOI: 10.1111/1471-0528.16504] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the clinical diagnostic validity of carbon nanoparticle suspension (CNS) in sentinel lymph node biopsy (SLNB) for assessing lymphatic spread of early-stage cervical cancer. DESIGN A prospective study. SETTING AND POPULATION 356 cases. METHODS We enrolled 356 stage Ia2-IIa2 cervical cancer patients to undergo SLNB using CNS, followed by systematic pelvic lymphadenectomy. All lymph node specimens were assessed using conventional histopathologic ± pathologic ultrastaging analyses. MAIN OUTCOME MEASURES Sentinel lymph node detection rate (DR), clinical diagnostic validity and various related factors were analysed. RESULTS CNS identified 1456 SLNs in 325 patients. The overall SLN DR was 91.29%. A significantly higher DR was found for patients with tumours <20 mm (97.75% versus 71.91%; P < 0.001). Two patients had false-negative results. SLNB with CNS had sensitivity of 96.65%, false-negative rate (FNR) of 4.35% and negative predictive value (NPV) of 99.29%. Importantly, sensitivity (100%), NPV (100%) and FNR (0%) were improved when testing the subgroup of patients with tumours <20 mm (267 cases). There were no observed differences in DR based on pathological type or grade, stage, depth of stromal invasion, surgical approach, menopausal status or prior treatment with chemotherapy (P > 0.05). CONCLUSIONS Sentinel lymph node biopsy with CNS results in favourable DR, sensitivity and NPV for women with early-stage cervical cancer with small tumour sizes. SLNB with CNS is safe, feasible and relatively effective for guiding precise surgical treatment of early-stage cervical cancer. TWEETABLE ABSTRACT Sentinel lymph node biopsy with carbon nanoparticle suspension is safe and feasible for early-stage cervical cancer.
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Affiliation(s)
- X Ya
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - W Qian
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - L Huiqing
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - W Haixiao
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zh Weiwei
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - B Jing
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - C Lei
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Y Jianping
- Department of Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Y Shuping
- Department of Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - M Jiaya
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - W Dong
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - G Ruixia
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Tang VL, Jing B, Boscardin J, Ngo S, Silvestrini M, Finlayson E, Covinsky KE. Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery. JAMA Surg 2020; 155:412-418. [PMID: 32159753 PMCID: PMC7066523 DOI: 10.1001/jamasurg.2020.0091] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/16/2020] [Indexed: 01/12/2023]
Abstract
Importance More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults. Objective To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery. Design, Setting, and Participants Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery. Exposures Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy. Main Outcomes and Measures Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors. Results Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55%) were women, 99 (7%) underwent abdominal aortic aneurysm repair, 686 (51%) coronary artery bypass graft, and 556 (42%) colectomy; 223 (17%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29% vs 13%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21% vs 14%; aHR, 1.32; P = .05), the inability to walk several blocks (17% vs 11%; aHR, 1.64; P = .01), dementia (21% vs 12%; aHR, 1.91; P = .03), and depression (19% vs 12%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0%; 1 factor: 16.2%; 2 factors: 27.8%). Conclusions and Relevance In this older adult cohort, 223 participants (17%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.
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Affiliation(s)
- Victoria L. Tang
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | - Bocheng Jing
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
- Northern California Institute for Research and Education, San Francisco
| | - John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
| | - Sarah Ngo
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
| | - Molly Silvestrini
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
- Northern California Institute for Research and Education, San Francisco
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
- Phillip R. Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Kenneth E. Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco
- Division of Geriatrics, Veterans Affairs Medical Center, San Francisco, California
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Anderson TS, Lee S, Jing B, Fung K, Ngo S, Silvestrini M, Steinman MA. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open 2020; 3:e201511. [PMID: 32207832 PMCID: PMC7093767 DOI: 10.1001/jamanetworkopen.2020.1511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/24/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. Objective To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. Design, Setting, and Participants This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. Main Outcomes and Measures Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. Results Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. Conclusions and Relevance In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sei Lee
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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Tang VL, Covinsky K, Finlayson E, Jing B, Boscardin J, Ngo S. GERIATRIC MEASURES AS PREDICTORS OF 1-YEAR MORTALITY IN MAJOR SURGERY PATIENTS. Innov Aging 2019. [PMCID: PMC6840257 DOI: 10.1093/geroni/igz038.1670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A growing proportion of older adults are undergoing major surgery despite the higher risk of post-operative mortality. Geriatric measures (i.e. physical, cognitive, and psychosocial function) are often not included in studies evaluating post-operative outcomes in older adults. Our goal was to determine the association of geriatric measures and 1-year mortality in older adults after major surgery. We analyzed longitudinal data from the Health and Retirement Study linked to Medicare claims (N=1364 participants), age ≥ 65 and who underwent abdominal aortic aneurysm [AAA] repair, coronary artery bypass graft [CABG], or colectomy. Our outcome was mortality within 1 year of the major operation. Predictors included the following geriatric measures: dependence in activities of daily living (ADL), dependence in independent activities of daily living (IADL), mobility ability, and dementia, and depression. We analyzed using multivariate cox proportional hazard models. Mean participant age was 76±6 years, 56% were women, 11% underwent a AAA repair, 50% CABG, 40% colectomy; 18% died within 1 year of their major operation. After adjusting for age, comorbidity burden, surgical type, gender, race, wealth, income, and education, the following measures were significantly associated with 1-year mortality: depression (adjusted HR (aHR): 1.53, p=0.03), dementia (aHR: 1.90, p=0.03), >1 ADL dependence (aHR: 2.35, p<0.01), >1 IADL dependence (aHR: 1.95, p<0.01), and inability to walk several blocks (aHR: 1.69, p<0.01). In this cohort, 18% of participants who underwent major surgery died within 1 year and function, cognition, and psychological well-being were significantly associated with mortality. These measures should be incorporated into pre-operative assessment.
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Affiliation(s)
- Victoria L Tang
- University of California San Francisco, San Francisco, California, United States
| | - Kenneth Covinsky
- University of California San Francisco, San Francisco, California, United States
| | - Emily Finlayson
- University of California San Francisco, San Francisco, California, United States
| | - Bocheng Jing
- University of California San Francisco, San Francisco, California, United States
| | - John Boscardin
- University of California San Francisco, San Francisco, California, United States
| | - Sarah Ngo
- University of California San Francisco, San Francisco, California, United States
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Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ, Fung K, Ngo S, Silvestrini M, Steinman MA. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med 2019; 179:1528-1536. [PMID: 31424475 PMCID: PMC6705136 DOI: 10.1001/jamainternmed.2019.3007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization. OBJECTIVE To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019. EXPOSURES Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge. MAIN OUTCOMES AND MEASURES The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge. RESULTS The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg). CONCLUSIONS AND RELEVANCE Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California.,now with Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline, Massachusetts
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California School of Medicine, San Francisco
| | - Charlie M Wray
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Hospital Medicine, University of California School of Medicine, San Francisco
| | - Sei Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - W John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Michael A Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
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Abstract
BACKGROUND Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance. OBJECTIVES The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use. RESEARCH DESIGN Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications. RESULTS The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care. CONCLUSION Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Charlie M. Wray
- Department of Medicine, University of California San Francisco, San Francisco, CA California, USA
| | - Sarah Ngo
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Edison Xu
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Kathy Fung
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
| | - Michael A. Steinman
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- Division of Geriatrics, San Francisco VA Medical Center, San Francisco, California, USA
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Anderson TS, Wray CM, Jing B, Fung K, Ngo S, Xu E, Shi Y, Steinman MA. Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study. BMJ 2018; 362:k3503. [PMID: 30209052 PMCID: PMC6283373 DOI: 10.1136/bmj.k3503] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess how often older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment, and to identify markers of appropriateness for these intensifications. DESIGN Retrospective cohort study. SETTING US Veterans Administration Health System. PARTICIPANTS Patients aged 65 years or over with hypertension admitted to hospital with non-cardiac conditions between 2011 and 2013. MAIN OUTCOME MEASURES Intensification of antihypertensive treatment, defined as receiving a new or higher dose antihypertensive agent at discharge compared with drugs used before admission. Hierarchical logistic regression analyses were used to control for characteristics of patients and hospitals. RESULTS Among 14 915 older adults (median age 76, interquartile range 69-84), 9636 (65%) had well controlled outpatient blood pressure before hospital admission. Overall, 2074 (14%) patients were discharged with intensified antihypertensive treatment, more than half of whom (1082) had well controlled blood pressure before admission. After adjustment for potential confounders, elevated inpatient blood pressure was strongly associated with being discharged on intensified antihypertensive regimens. Among patients with previously well controlled outpatient blood pressure, 8% (95% confidence interval 7% to 9%) of patients without elevated inpatient blood pressure, 24% (21% to 26%) of patients with moderately elevated inpatient blood pressure, and 40% (34% to 46%) of patients with severely elevated inpatient blood pressure were discharged with intensified antihypertensive regimens. No differences were seen in rates of intensification among patients least likely to benefit from tight blood pressure control (limited life expectancy, dementia, or metastatic malignancy), nor in those most likely to benefit (history of myocardial infarction, cerebrovascular disease, or renal disease). CONCLUSIONS One in seven older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment. More than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. More attention is needed to reduce potentially harmful overtreatment of blood pressure as older adults transition from hospital to home.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA 94123, USA
| | - Charlie M Wray
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Sarah Ngo
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Edison Xu
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Ying Shi
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
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Abstract
This retrospective cohort study examines whether patients with type 2 diabetes on hospice are assessed for dysglycemia, receive insulin or oral hypoglycemic medications, or experience hypoglycemia and hyperglycemia in the nursing home setting.
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Affiliation(s)
- Laura A Petrillo
- Department of Medicine, Massachusetts General Hospital, Boston.,Department of Medicine, University of California, San Francisco, San Francisco
| | - Siqi Gan
- Healthcare Department, Philips Research China. Shanghai, China
| | - Bocheng Jing
- Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Sean Lang-Brown
- Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - W John Boscardin
- Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Sei J Lee
- Department of Medicine, University of California, San Francisco, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California
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Zhou Y, Ni X, Wen B, Duan L, Sun H, Yang M, Zou F, Lin Y, Liu Q, Zeng Y, Fu X, Pan K, Jing B, Wang P, Zeng D. Appropriate dose of Lactobacillus buchneri supplement improves intestinal microbiota and prevents diarrhoea in weaning Rex rabbits. Benef Microbes 2018; 9:401-416. [DOI: 10.3920/bm2017.0055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This study examined the effects on intestinal microbiota and diarrhoea of Lactobacillus buchneri supplementation to the diet of weaning Rex rabbits. To this end, rabbits were treated with L. buchneri at two different doses (LC: 104 cfu/g diet and HC: 105 cfu/g diet) for 4 weeks. PCR-DGGE was used to determine the diversity of the intestinal microbiota, while real-time PCR permitted the detection of individual bacterial species. ELISA and real-time PCR allowed the identification of numerous cytokines in the intestinal tissues. Zonula occludens-1, polymeric immunoglobulin receptor and immunoglobulin A genes were examined to evaluate intestinal barriers. Results showed that the biodiversity of the intestinal microbiota of weaning Rex rabbits improved in the whole tract of the treated groups. The abundance of most detected bacterial species was highly increased in the duodenum, jejunum and ileum after L. buchneri administration. The species abundance in the HC group was more increased than in the LC group when compared to the control. Although the abundance of Enterobacteriaceae exhibited a different pattern, Escherichia coli was inhibited in all treatment groups. Toll-like receptor (TLR)2 and TLR4 genes were down-regulated in all intestinal tissues as the microbiota changed. In the LC group, the secretion of the inflammatory cytokine tumour necrosis factor-α was reduced, the gene expression of the anti-inflammatory cytokine interleukin (IL)-4 was up-regulated and the expression of intestinal-barrier-related genes was enhanced. Conversely, IL-4 expression was increased and the expression of other tested genes did not change in the HC group. The beneficial effects of LC were greater than those of HC or the control in terms of improving the daily weight gain and survival rate of weaning Rex rabbits and reducing their diarrhoea rate. Therefore, 104 cfu/g L. buchneri treatment improved the microbiota of weaning Rex rabbits and prevented diarrhoea in these animals.
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Affiliation(s)
- Y. Zhou
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
| | - X. Ni
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, Sichuan 611130, China P.R
| | - B. Wen
- Sichuan Academy of Grassland Science, Chengdu, Sichuan 611731, China P.R
| | - L. Duan
- Qu Country Extension Station for Husbandry Technology, Dazhou, Sichuan 635299, China P.R
| | - H. Sun
- Ya’an City Bureau of Agriculture, Ya’an, Sichuan 625099, China P.R
| | - M. Yang
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
| | - F. Zou
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
| | - Y. Lin
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
| | - Q. Liu
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
| | - Y. Zeng
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
| | - X. Fu
- Sichuan Academy of Grassland Science, Chengdu, Sichuan 611731, China P.R
| | - K. Pan
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, Sichuan 611130, China P.R
| | - B. Jing
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, Sichuan 611130, China P.R
| | - P. Wang
- Sichuan Academy of Grassland Science, Chengdu, Sichuan 611731, China P.R
| | - D. Zeng
- Animal Microecology Research Center, College of Veterinary Medicine, Sichuan Agricultural University, Huiming Road 211, Chengdu, Sichuan 611130, China P.R
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, Sichuan 611130, China P.R
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41
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Zeng Y, Zeng D, Zhang Y, Ni XQ, Wang J, Jian P, Zhou Y, Li Y, Yin ZQ, Pan KC, Jing B. Lactobacillus plantarumBS22 promotes gut microbial homeostasis in broiler chickens exposed to aflatoxin B1. J Anim Physiol Anim Nutr (Berl) 2017; 102:e449-e459. [DOI: 10.1111/jpn.12766] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/15/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Y. Zeng
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - D. Zeng
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - Y. Zhang
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - X. Q. Ni
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - J. Wang
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - P. Jian
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - Y. Zhou
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - Y. Li
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - Z. Q. Yin
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - K. C. Pan
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
| | - B. Jing
- Animal Microecology Institute; College of Veterinary Medicine; Sichuan Agricultural University; Sichuan China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province; Sichuan Agricultural University; Sichuan China
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42
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Weng Y, Liu Y, Du H, Li L, Jing B, Zhang Q, Wang X, Wang Z, Sun Y. Glycosylation of DMP1 Is Essential for Chondrogenesis of Condylar Cartilage. J Dent Res 2017; 96:1535-1545. [PMID: 28759313 DOI: 10.1177/0022034517717485] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Y. Weng
- Department of Implantology, School and Hospital of Stomatology, Tongji University, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Shanghai, China
| | - Y. Liu
- Department of Endodontics, School and Hospital of Stomatology, Tongji University, Shanghai, China
| | - H. Du
- Department of Endodontics, School and Hospital of Stomatology, Tongji University, Shanghai, China
| | - L. Li
- Department of Oral Maxillofacial Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - B. Jing
- School of Medicine, Stem Cell Center, Tongji University, Shanghai, China
| | - Q. Zhang
- Department of Endodontics, School and Hospital of Stomatology, Tongji University, Shanghai, China
| | - X. Wang
- Department of Cell Biology and Institute of Biomedicine, College of Life Science and Technology, Jinan University, Guangzhou, China
| | - Z. Wang
- Department of Implantology, School and Hospital of Stomatology, Tongji University, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Shanghai, China
| | - Y. Sun
- Department of Implantology, School and Hospital of Stomatology, Tongji University, Shanghai Engineering Research Center of Tooth Restoration and Regeneration, Shanghai, China
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Imam TH, Fischer H, Jing B, Burchette R, Henry S, DeRose SF, Coleman KJ. Estimated GFR Before and After Bariatric Surgery in CKD. Am J Kidney Dis 2016; 69:380-388. [PMID: 27927587 DOI: 10.1053/j.ajkd.2016.09.020] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [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: 03/30/2016] [Accepted: 09/12/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several reviews have recently detailed the beneficial effects of weight loss surgery for kidney function. However, these studies have a number of limitations, including small sample size, few done in chronic kidney disease (CKD) stages 3 and 4, and many not including the main bariatric surgery procedures used in the United States today. STUDY DESIGN This was an observational retrospective cohort study comparing propensity score-matched bariatric surgery patients and nonsurgery control patients who were referred for, but did not have, surgery. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy were also compared using propensity matching. SETTING & PARTICIPANTS Patients (714 surgery patients; 714 controls) were from a large integrated health care system, a mean of 58±8 (SD) years old, and mostly women (77%) and non-Hispanic whites (56%) and had diabetes mellitus (66%) and/or hypertension (91%). PREDICTOR Predictors at the time of surgery or referral to surgery were age, sex, race/ethnicity, weight, and presence of diabetes and/or hypertension. OUTCOMES The primary outcome for this study was change in estimated glomerular filtration rate (eGFR) from serum creatinine level over a median 3-year follow-up period. MEASUREMENTS Serum creatinine was used to calculate eGFR using the CKD-EPI (CKD Epidemiology Collaboration) creatinine equation. RESULTS Surgery patients had 9.84 (95% CI, 8.05-11.62) mL/min/1.73m2 greater eGFRs than controls at a median 3 years' follow-up and RYGB patients had 6.60 (95% CI, 3.42-9.78) mL/min/1.73m2 greater eGFRs than sleeve gastrectomy patients during the same period. LIMITATIONS This study is limited by its nonrandomized observational study design, estimation of GFR, and large changes in muscle mass, which may affect serum creatinine level independent of changes in kidney function. CONCLUSIONS Bariatric surgery, especially the RYGB procedure, results in significant improvements for up to 3 years in eGFRs for patients with CKD stages 3 and 4.
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Affiliation(s)
- Talha H Imam
- Department of Nephrology, Fontana Medical Center, Kaiser Permanente Southern California, Fontana.
| | - Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Bocheng Jing
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Raoul Burchette
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Shayna Henry
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Stephen F DeRose
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Karen J Coleman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
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Abstract
Ocular graft-vs-host disease (GvHD) is a major complication following allogenic blood stem cell transplantation (aBSCT) leading to a disturbance of the ocular surface integrity with a broad range of severity. Leading symptom is a pronounced autoinflammatory reaction in particular at the ocular surface with typical features of dry eye disease. Potential complications include visual loss, pain and damage to the ocular structures with, e. g. corneal ulcerations. Diagnosis and treatment of ocular GvHD are a challenge for attending ophthalmologists and require intensive interdisciplinary patient care in particular with haemato-oncologists. First and follow-up examinations consist of several diagnostic steps that include quantitative and qualitative analysis of tearfilm, visual acuity, ocular surface and retinal integrity, cataract development and subjective symptoms. Available tests are mostly evaluated for usage in dry eye diagnosis but are, however, mostly unspecific for diagnosing ocular GvHD reliably. Only combinations of several clinical tests together with the experience of specialised ophthalmologists may lead to the certain diagnosis and treatment decisions at state. This review illustrates the available established and innovative non-invasive diagnostic tests and evaluates their potential use for diagnosing ocular GvHD.
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Affiliation(s)
- S Siebelmann
- Kompetenzzentrum Okuläre GvHD, Zentrum für Augenheilkunde, Uniklinik Köln
| | - B Jing
- Kompetenzzentrum Okuläre GvHD, Zentrum für Augenheilkunde, Uniklinik Köln
| | - C Cursiefen
- Kompetenzzentrum Okuläre GvHD, Zentrum für Augenheilkunde, Uniklinik Köln
| | - P Steven
- Kompetenzzentrum Okuläre GvHD, Zentrum für Augenheilkunde, Uniklinik Köln
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Yiru W, Yu W, Jing B, Jie C, Lifeng L, Yu W. Endothelial differentiation promoted by hypoxia in human amniotic fluid-derived stem cells. Heart 2011. [DOI: 10.1136/heartjnl-2011-300867.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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46
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Lu F, Hu X, Jing B, Ma Y. [Analysis of nuclear DNA gene types of Leishmania isolates from hilly and plain foci of China]. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing Za Zhi 2002; 16:432-5. [PMID: 12078288] [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] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
AIM To analyse the nuclear DNA (nDNA) polymorphism of Leishmania isolates from hilly and plain foci of China. METHODS nDNA were analysed by endonuclease digestion, Southern blotting and chromosomal localization. Probes were labeled with digoxigenin. RESULTS Using gp63 gene probe, similar hybridization bands were found to be existed between nDNAs of Leishmania donovani Jiangsu human isolate and L. d. Jeddah, also between nDNAs of L. d. Sichuan human isolate and L. infantum. Using beta-tubulin gene probe, there were two similar hybridization bands existed between nDNAs of L. d. Jiangsu human isolate and L. d. Jeddah, and three similar hybridization bands existed between nDNAs of L. d. Sichuan canine isolate and L. d. Gansu canine isolate, and two similar hybridization bands existed between nDNA of L. d. Sichuan canine isolate and L. d. Wenchuan human isolate. CONCLUSION Homology exists between L. d. Jiangsu human isolate and L. d. Jeddah from plain foci, between L. d. Sichuan human isolate from hilly foci and L. infantum, between L. d. Sichuan canine isolate and L. d. Gansu canine isolate from hilly foci. Homology as well as differences exist between L. d. Sichuan canine isolate and L. d. Wenchuan human isolate. Heterogeneity exists between isolates from hilly foci and plain foci.
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Affiliation(s)
- F Lu
- Department of Parasitology, West China University of Medical Sciences, Chengdu 610041
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Abstract
RATIONALE AND OBJECTIVES The authors performed this study to evaluate a new method (medial axis reformation [MAR]) for visualizing three-dimensional vascular data at electron-beam computed tomographic (CT) angiography. MATERIALS AND METHODS MAR was performed automatically with a personal computer-based workstation. After the region of interest was edited, voxels were divided into groups according to their path lengths. Centroids of groups were connected to form the medial axis. Then, the medial axis was refined with multiscale medial response. Bifurcations were also detected and refined. Finally, curved sections were generated through the branches and laid out onto a single image by using a splitting method. The authors performed MAR during electron-beam CT angiography of coronary arteries, common carotid arteries, and iliac arteries. RESULTS MAR displayed curved sections of branched vessels on one image, cut through the axis of vessels to show the vessel diameter objectively, and allowed the viewing direction to be altered arbitrarily. CONCLUSION Results of preliminary applications demonstrate that MAR is a valuable new visualization method for CT angiography.
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Affiliation(s)
- S He
- Department of Radiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Science, Peking Union Medical College, Beijing
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Lu B, Dai R, Jing B, Bai H, He S, Zhuang N, Wu Q, Zhu X. Evaluation of coronary artery bypass graft patency using three-dimensional reconstruction and flow study of electron beam tomography. Chin Med J (Engl) 2001; 114:466-72. [PMID: 11780405] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
OBJECTIVE To establish and evaluate two protocols for the noninvasive visualization and assessment of coronary artery bypass graft (CABG) patency on electron beam tomography (EBT). METHODS Two hundred and fourteen consecutive patients who underwent coronary artery bypass graft surgery were scanned using both EBT angiography with 3-dimensional reconstruction and EBT flow study with time-density-curve analysis. RESULTS There were 589 CABGs evaluated in this study (10 grafts were excluded because of artifacts). Among them, 133 (98.5%) of 135 arterial grafts were patent, and 345 (77.7%) of 444 saphenous-vein grafts were patent. Within 5 years or between 5 and 10 years after operation, arterial graft patency exceeded venous graft patency (P < 0.001). Three-dimensional EBT angiography achieved higher sensitivity, specificity and accuracy (97.7%, 94.1% and 96.7%, respectively) than did EBT flow study (88.4%, 82.4% and 85.2%, respectively) for evaluating occlusion or patency of CABG. The intra-graft flow of patent arterial and venous grafts were 4.9 +/- 2.2 ml.min-1.g-1 and 6.9 +/- 2.8 ml.min-1.g-1, respectively (P < 0.001). CONCLUSION The combination of EBT three-dimensional reconstruction and flow study can be more effective in the assessment of CABG anatomy and quantification of patent CABG blood flow.
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Affiliation(s)
- B Lu
- Department of Radiology, Cardiovascular Institute, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100037, China.
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Chen D, Qiao L, Jing B. [Effect of rhubarb on oxygen radicals leakage from mitochondria of intestinal mucosa in burned rats]. Zhongguo Zhong Xi Yi Jie He Za Zhi 2000; 20:849-52. [PMID: 11938834] [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] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To investigate the effects of rhubarb on oxygen radicals leakage from the mitochondria of intestinal mucosa in burned rats. METHODS The activity of cytochrome oxidase and superoxide dismutase (SOD) in mitochondria isolated from intestinal mucosa of burn model of rats was used to evaluate the oxygen radicals leakage from the mitochondria. And the SOD and malondialdehyde (MDA) levels in plasma, liver, intestinal mucosa and its mitochondria were also determined. RESULTS After burn injury, the activity of cytochrome oxidase in intestinal mucosa decreased as the time elapses, rhubarb could improve it obviously. Furthermore, rhubarb could reduce the massive consumption of SOD and production of MDA obviously increased in plasma, liver, intestinal mucosa and its mitochondria after burning. CONCLUSION Rhubarb could enhance the activity of cytochrome oxidase and SOD in small intestine mucosal epithelia in burned rats, thus the oxygen radicals leakage from the mitochondria to be reduced.
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Affiliation(s)
- D Chen
- Changzheng Hospital, Second Military Medical University, Shanghai (200003)
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Lu B, Dai R, Bai H, He S, Jing B, Zhuang N, Gao R, Yang Y, Chen J, Budoff MJ. Evaluation of electron beam tomographic coronary arteriography with three-dimensional reconstruction in healthy subjects. Angiology 2000; 51:895-904. [PMID: 11103858 DOI: 10.1177/000331970005101102] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this study, the authors evaluated the performance characteristics of contrast-enhanced electron-beam tomography (EBT) with three-dimensional reconstruction in defining the coronary artery lumen in healthy subjects. Thirty patients with normal coronary angiograms by selective coronary arteriography (SCA) underwent contrast-enhanced EBT examination. Measured parameters included degree of luminal enhancement, intravascular contrast-to-noise ratio (CNR), and diameter and length of visualized lumen. Ventricular cavity, aortic blood pool, and coronary artery attenuation were found to be significantly different before and after intravenous injection of contrast material (p < 0.001). CNR decreased from proximal to distal segments within each vessel (p < 0.001), with a peak of 11.2 +/- 2.3 occurring in the proximal left anterior descending coronary artery (LAD) to a low of 4.8 +/- 2.0 in the distal left circumflex (LCX). Luminal diameters visualized by EBT had no significant difference with that of SCA (p > 0.05). Therefore, EBT angiography with three-dimensional reconstruction allows for noninvasive coronary arteriography revealing long segments of the major coronary arteries in normal subjects.
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Affiliation(s)
- B Lu
- Department of Radiology, FuWai Cardiovascular Institute and Hospital, Peking Union Medical College, and Chinese Academy of Medical Sciences, Beijing
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