352 THE IMPACT OF ETHNICITY ON ACUTE STROKE ADMISSIONS IN AN IRISH HOSPITAL

Background

Recent studies have demonstrated the variability of aetiology, clinical presentation and overall mortality between different ethnic groups presenting with acute stroke. The non-native Irish population accounts for almost 13% of the total population and is predicted to grow over the next decade. Recording and analysis of acute stroke patients based on their ethnicity and population demographics is an important step in planning for the future of stroke care in Ireland. In this study, we aimed to evaluate key differences between the Irish and non-Irish population presenting with acute stroke to an Irish hospital.

Methods

We reviewed our hospital stroke registry over a 12-month period (January-December 2021). Key parameters including country of birth, ethnicity, other patient demographics, clinical presentation, aetiology and subtype of stroke, stroke management and clinical outcomes.

Results

Of the 245 acute strokes admitted to our hospital in 2021, non-ethically Irish patients made up 12.2% (n = 30). The average age of non-ethnically Irish stroke presentations was younger than Irish stroke presentations (59 versus 71 years). Haemorrhagic strokes were more common in the non-Irish population (13.3% in non-Irish cohort vs 9.8% in Irish cohort). Median time of symptom onset to presentation to hospital was 3 hours and 58 minutes in the Irish patients and 6 hours and 10 minutes in the non-Irish patients. The overall length of stay in hospital post stroke was similar between the two population groups at an average of 19 days duration.

Conclusion

This study identifies disparities in acute stroke presentation between the Irish and non-Irish population presenting to an Irish hospital. This study demonstrated the importance of further research on a national scale to record the variability of strokes in different ethnic groups in order to adequately plan primary and secondary stroke care and provide targeted public health campaigns to remain inclusive to Ireland’s growing and increasingly diverse population.

150 ESTABLISHING A PFO PATHWAY FOR ACUTE STROKE PATIENTS WITH A POSITIVE BUBBLE STUDY

Background

A bubble study is performed routinely on patients under the age of 65 years of age with a confirmed diagnosis of either acute ischaemic stroke or TIA in order to assist with the presence of a Patent Foramen Ovale(PFO)/Atrial Septal Defect(ASD) as an aetiology for the stroke event. Historically, a referral letter would be written to a hospital who specialises in cardiac structural surgeries, requesting a review of a patient with a positive bubble study and acute stroke. Closure would typically exceed 9 months.

Methods

The Stroke RANP led out on the project as she performs all bubble studies in stroke survivors. A designated Cardiologist, who also works in a hospital where PFO closures takes place, is notified by the RANP or team about a positive bubble study and the images are reviewed. It is then decided if the patients requires a TOE or not. A 2-page PFO referral form was created which contains all relevant information.

Results

Stroke RANP performed 92 bubble studies between January 2021 and May 2022. There were 18 positive studies (20% positivity rate): 7 positive studies from January to August 2021 (pre-pathway) and 11 positive studies from September 2021 to May 2022 (post-pathway). 72% (5/7) of patients had a TOE performed following a positive bubble study result pre-pathway, whereas only 1 TOE was performed out of 11 cases (9%) post-pathway. The time from positive bubble study to closure time reduced from 9months on average to 3 months.

Conclusion

There was a 63% reduction in the number of TOEs being performed for patients with a positive bubble study with the introduction of this PFO pathway. Additionally, there was a 6-month reduction time from the positive bubble study result to closure. This pathway has improved patient outcomes for this young group of stroke survivors and assists with the reduction of further stroke events in the future.

160 A CLOSED-LOOP AUDIT EXAMINING THE USE OF PROPHYLACTIC ANTI-COAGULATION IN OLDER ADULTS ADMITTED TO A SPECIALIST GERIATRIC SERVICE

Background

Guidelines recommend prescription of Prophylactic Anticoagulation (PA) to all hospitalized older adults unless a contraindication exits. In many cases this does not happen at the time of admission increasing the risk of thromboembolic events. We aimed to assess the use of PA across the medicine for the geriatric service of a level 3 hospital (average daily census of service 120) then use quality improvement to achieve our goal of 95% prescription of prophylactic anticoagulation when appropriate.

Methods

Medication kardexes and clinical notes were reviewed to collect variables including age, length of stay, creatinine clearance, weight, mobility status, use and dose of antithrombotic medications and documentation of reason if not prescribed. Following initial data collection, cause and effect analysis was performed to identify reasons for under-prescription and small tests of change were conducted across 4 PDSA cycles before data collection was repeated.

Results

Initial data collection revealed that only 80% of older adults admitted to the service were receiving prophylactic anticoagulation. Cause and effect analysis identified many reasons for failure to prescribe PA including inadequate history taking, lack of clinician education and training, poor documentation, lack of handover between clinicians, failure to complete medication reconciliation on admission and lack of pharmacy support on some wards. Each of these contributory factors were addressed in turn. After a month of QI activities prescription of PA improved to 83% and by 3 months 98.1% (104/106) of patients were receiving PA with only 2 patients for whom PA was not prescribed without clear documentation of the reason.

Conclusion

Sustained quality improvement resulted in a culture change across our service improving rates of appropriate prescription of PA and raising the quality of care delivered to older adults. This model of quality improvement is now being replicated across our department to address other gaps in service delivery.

Sleep Quality in Family Caregivers and Matched Non-Caregiving Controls: The REGARDS Study

The high levels of stress experienced by family caregivers may affect their physical and psychological health, including their sleep quality. However, there are few population-based studies comparing sleep between family caregivers and carefully-matched controls. We evaluated differences in sleep and identified predictors of poorer sleep among the caregivers, in a comparison of 251 incident caregivers and carefully matched non-caregiving controls, recruited from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Incident caregivers and controls were matched on up to seven demographic and health factors (age, sex, race, education level, marital status, self-rated health, and self-reported serious cardiovascular disease history). Sleep characteristics were self-reported and included total sleep time, sleep onset latency, wake after sleep onset, time in bed, and sleep efficiency. Family caregivers reported significantly longer sleep onset latency, before and after adjusting for potential confounders, compared to non-caregiving controls (ps < 0.05). Depressive symptoms in caregivers predicted longer sleep onset latency, greater wake after sleep onset, and lower sleep efficiency. Longer total sleep time in caregivers was predicted by employment status, living with the care recipient, and number of caregiver hours. Employed caregivers and caregivers who did not live with the care recipient had shorter total sleep time and spent less time in bed than non-employed caregivers. Additional research is needed to evaluate whether sleep disturbances contributes to health problems among caregivers.

Results of Optimize: A Cluster Randomized Trial of Patient, Family, and Provider Education in Primary Care

Individuals with cognitive impairment frequently have multiple chronic conditions (MCC), increasing their risk for polypharmacy and associated adverse outcomes. Optimizing medications through deprescribing (reducing or stopping the use of inappropriate medications or medications unlikely to be beneficial) may improve outcomes for this population. Optimize was a pragmatic, 12-month cluster-randomized trial of deprescribing in primary care within a not-for-profit integrated delivery system. Participants were age 65+ with dementia or mild cognitive impairment (MCI), 2+ chronic conditions, and 5+ chronic medications. The intervention consisted of a deprescribing educational brochure for patients/caregivers, and Tip Sheets for primary care clinicians. Outcomes were the number of chronic medications and presence of potentially inappropriate medications (PIM). In total, 1,433 patients received, and 1,579 control clinic patients would have been eligible to receive, the intervention (N=3,012). After 6 months, mean estimates of chronic medications were 6.23 in the intervention group and 6.33 in the control group adjusting for baseline counts, age, and gender (p=0.13). Excluding those without complete 90 days follow-up increased the adjusted effect size to 0.14 (p=0.08). In sub-analyses of individuals with 7+ medications at baseline (N= 1,434), the adjusted effect size was 0.19 (p=0.07) at 6 months and 0.21 (p=0.045) when excluding those without complete 90 days’ follow-up. Change in proportions of PIM did not differ between intervention and control groups. An educational intervention for patients, caregivers and clinicians may prompt reductions in chronic medications. The relatively small effect size highlights the complexity of medication management for individuals with dementia or MCI and MCC.

COVID Challenges and Adaptations Among Home-Based Medical Practices: Lessons for an Ongoing Pandemic

Home-based primary care (HBPC) practices rapidly adapted to maintain care during the COVID-19 pandemic. This mixed-methods national online survey of HBPC practices probed responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Seventy-nine practices across 29 states were included in the analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices also pivoted to concurrent use of video visits. The top five practice challenges were: patient familiarity with telemedicine, patient and clinician anxiety, technical difficulties reaching patients, and supply shortages. Practices also described creative strategies to physically support the needs of patients. These findings illustrate the need to balance in-person and virtual care for this population, and attend to the emotional needs of patients and staff.

Intervention Design With Cognitively Impaired Populations: The Optimize Deprescribing Intervention

Older adults with cognitive impairment and multiple other chronic conditions often have polypharmacy which increases their risks of medication related cognitive effects, adverse drug events, hospitalization and death and leads to higher health care costs. Deprescribing, the process of reducing or stopping potentially inappropriate medications may improve outcomes for those older adults with cognitive impairment and multiple chronic conditions. The OPTIMIZE trial examined whether a primary care-based, patient- and family-centered intervention educating and activating patients, family members, and clinicians about deprescribing reduces numbers of chronic medications and potentially inappropriate medications for older adults with dementia or mild cognitive impairment and multiple chronic conditions. We explored the mechanisms of intervention effectiveness through post hoc qualitative stakeholder interviews and surveys with 15 patients, 7 family caregivers, and 28 clinicians. All stakeholder groups endorsed the acceptability of the intervention. Success of the intervention was affected by contextual factors including prior knowledge and openness to deprescribing, cognition and prognosis. Positive outcomes included patients and care partners scheduling specific appointments to discuss deprescribing and providers remembering to consider deprescribing in cognitively impaired older adults. Recollection of intervention materials was inconsistent over time but highest shortly after intervention delivery. The time required to mail intervention materials to patients prior to a scheduled appointment limited the reach of the intervention by excluding persons with rapidly scheduled appointments. Our work identifies key learnings in intervention roll out which can guide future translation of our intervention to other settings and other pragmatic intervention studies in this vulnerable population.

A qualitative analysis of family caregiver perspectives from the Caregiving Transitions Study

As people live longer, informal caregiving for family and friends is becoming increasingly common. Caregiver satisfaction with their role is now of greater importance to an increasing proportion of the U.S. population. Most research on caregivers has studied convenience samples, often restricted to caregivers of people with dementia. Various studies have examined the impact of caregiving on caregivers’ health but to our knowledge there are no qualitative studies of caregiving experiences from caregivers in population-based samples. This study investigated the impact of caregiving on participants who transitioned into a caregiving role while participating in a national population-based study. Participants were from the Caregiving Transitions Study, which is ancillary to the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study. We thematically analyzed responses from 150 caregivers providing care for multiple different conditions to an open-ended question asked at the time of enrollment and designed to encourage caregivers to share additional details about their caregiving experience. Four major themes were identified: cultural/family expectations; growth opportunities and reciprocity; stressors and challenges; and recommendations. Participants shared both positive and challenging experiences in their role as a family caregiver as well as the impact that these experiences had on their lives. Caregivers shared that one of the most important motivations for taking on this role was their sense of duty toward family. Caregivers also highlighted the positive impact of caregiving on their lives such as opportunities for personal growth, acquisition of new skills, and finding a sense of fulfillment and gratitude.

256 USE OF PROTON PUMP INHIBITORS ON SPECIALIST GERIATRICS UNITS

Background

Proton Pump Inhibitors (PPIs) prescriptions have increased more than 100% in the past decade. Prior research estimates that only a third of PPI prescriptions are appropriate in older adults. Geriatric patients have increased rates of polypharmacy and adverse drug events. PPIs are associated with significant harms including a higher fracture risk, increased risk of infection and vitamin and electrolyte abnormalities. We aimed to examine the PPI prescribing practice in a Specialist Geriatric Unit (SGU), identify patterns of inappropriate use and reduce inappropriate prescriptions.

Methods

Medical records, kardexes and prescriptions were reviewed for 66 patients admitted in the Special Geriatric Units between April and May 2021. Variables included gender, age, ordinary residence (nursing home or home) and diagnosis on admission. PPI indication was grouped according to symptoms, OGD in the last year, H. Pylori testing in last year and reason/diagnosis leading to PPI prescription. Name and dose of PPI, route of administration and duration of treatment were noted.

Results

38 patients (57.6%) were on a PPI. The mean age was 81.7 years. 79% of the patients were on the PPI at the time of hospital admission. Over 85% of the patients on PPI had no OGD or H. Pylori testing in the last year. Only 42% had a diagnosis justifying the use of PPI (only 25% of whom had their diagnosis confirmed by appropriate investigations). 90% of the patients were on PPI for more than a year.

Conclusion

Inappropriate use of PPIs remains common in the Specialist Geriatric Units. PPI prescriptions need to be optimized so as to reduce harmful effects on geriatric patients. Following a multifaceted PPI deprescribing intervention repeat audit is now planned.

105 COVID-19 IN OLDER ADULTS: INPATIENT OUTCOMES IN A LEVEL 3 IRISH HOSPITAL

Background

COVID-19 has proved devastating in older persons. Previous studies reveal a mortality rate of 31% for hospitalised patients over 70.1 We examine outcomes for older COVID patients in our hospital.

Methods

We conducted a Hospital In Patient Enquiry Scheme review for patients coded as COVID-19 between 19/03/2020–19/02/2021 (n = 674). Older adults were defined as those aged over 65 years at time of admission. Age, sex, length of stay and survival were collected. Data was collated by ‘wave’: (Wave 1 n = 294, 2 n = 105, 3 n = 275). We reviewed whether patients had a CT pulmonary angiogram (CTPA) on the National Integrated Medical Imaging System.

Results

42.3% of COVID patients in our hospital were older persons (n = 285). This remained stable throughout the pandemic (Wave 1 44.2%, Wave 2 44.7%, Wave 3 39.3%). Mean length of stay was 19.7 days for older adults vs 7.4 for those under 65. Older persons had a higher mortality rate at 30.9% vs 3.6%. Overall incidence of PE was low at 1.9% (1.1% in older persons). However, the likelihood of a CTPA being positive for those over 65 was much higher at 42.9% vs 17.9%. While there was improvement in mortality rates in older persons from Wave 1 (31.5%) to 2 (19.1%), our data showed a significant rise in mortality in Wave 3 (35.2%). This compares to a different pattern in younger people, with mortality rates by wave at 6.7%, 0% and 1.7%.

Conclusion

In a large Irish cohort of patients hospitalised with COVID-19, 42.3% were older adults. Length of hospital stay was 3 times longer and mortality was 10 times higher than patients under 65. Older adults were also more likely to have a positive CTPA. Further study is needed to evaluate the long term effects of COVID-19 in our older population.

Reference

Zerah et al, Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2021 Feb 25; 76 (3): e4–e12.

"I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

Skilled Home Health Care Agency Perspectives on Communication With Physicians: A National Survey

BACKGROUND: Communication is important in the care of older adults receiving skilled home health care (SHHC). In a prior national survey, physicians viewed communication and care coordination with SHHC agencies as dismal. The views of SHHC personnel (Registered Nurses, Licensed Practical Nurses, Physical Therapists, Occupational Therapists, and Speech-Language Pathologists) on this issue have not been well studied. OBJECTIVE: To determine the effectiveness of communication between SHHC personnel and physicians who order SHHC services. METHODS: A nationally representative mailed survey of personnel from SHHC agencies identified through the 2016 Home Health Compare data set from the Centers of Medicare and Medicaid Services. RESULTS: 263 of 2000 surveys returned (13.2% response rate). Responding agencies were mainly proprietary (75.3%) and urban-based (83.7%). Most agencies were in the South (38.8%); 28.3% Midwest, 22.9% West, 12.1% Northeast. Only 62.2% of SHHC personnel completing start of care visits (n=202) reported being able to contact a physician when needed. The most common strategies used to contact physicians are phone (76.0%) and fax (11.2%). The greatest barriers to communication are having to communicate through a third party (64.9%) and a perception by SHHC personnel that “Physicians [are] not interested in communicating with SHHC Personnel” (45.1%). Failed communication resulted in delayed orders (70.8%) and sending a patient to the emergency room (37.1%). IMPLICATIONS: SHHC agency personnel experience significant barriers in communicating with physicians. Modes of communication remain rudimentary, and there are serious consequences of failed communication.

Self-Reported Uptake of Clinical Preventive Services by Vision Impairment Status

Disease prevention is central to healthy aging. People with vision impairment are more likely than those without to report barriers to accessing health care and have unmet health care needs. We examined the association between functional vision impairment and preventive care uptake among adults aged 65 years and older in the 2016 and 2018 Behavioral Risk Factor Surveillance System (BRFSS) survey. The outcome of interest was being up-to-date with the recommended core clinical preventive services, as defined by Healthy People 2020: influenza and pneumococcal vaccination, and colorectal cancer screening for men, with the addition of breast cancer screening for women. Self-reported vision impairment was defined as blindness or serious difficulty seeing, even when wearing glasses. In models adjusted for sociodemographic characteristics (including age), access to care, and health/functional status, there was no difference in the odds of reporting being up-to-date with the recommended core preventive services among men with vision impairment compared to those without (odds ratio [OR]=0.90, 95% confidence interval [CI]=0.8-1.01); however, men with vision impairment were 0.82 times (95% CI=0.71-0.94) less likely than those without to report being up-to-date with colorectal cancer screening. Women with vision impairment were less likely than those without to report being up-to-date with the recommended core preventive services (OR=0.77, 95% CI=0.69-0.87); among the different services, the odds were lowest for reporting breast and colorectal cancer screening. These findings suggest that to achieve higher rates of preventive care uptake, especially cancer screening, older adults with vision impairment may be a special group to target.

Caring for Older Adults with Vision Impairment and Dementia: Data from the National Study of Caregiving

We examined caregiving relationships for individuals with vision impairment (VI) and dementia, using 2011 National Health and Aging Trends Study (NHATS) data, a survey of Medicare beneficiaries, linked to the National Study of Caregiving, a survey of family/unpaid helpers to NHATS participants. VI was defined as self-reported blindness or difficulty recognizing someone across the street, watching television or reading newspaper print. Dementia was defined as probable dementia based on survey-report or AD8 criteria. Caregiving outcomes included: (1) hours of care provided in the last month and (2) number of valued activities affected by caregiving. Among 1,196 caregivers, 617 assisted older adults without dementia or VI (D-/VI-), 298 with dementia but without VI (D+/VI-), 143 without dementia but with VI (D-/VI+), and 138 with dementia and VI (D+/VI+). In fully-adjusted regression models, caregivers of older adults D+/VI+ spent twice as many hours (IRR=2.0; 95%CI: 1.5-2.7) providing care than caregivers of older adults D-/VI-; however, caregivers of adults D+/VI- and those providing to older adults D-/VI+ spent 1.5-times more hours (95% CI=1.2-1.7; 95% CI=1.1-2.0, respectively). Additionally, caregivers of older adults D+/VI+ reported 4 times as many valued activities were affected (95%CI=2.8-5.6) then caregivers of those D-/VI-, while caregivers of those D+/VI- reported 1.9-times (95% CI=1.3-2.8) and D-/VI+ 1.6-times (95% CI=1.1-2.3) more activities were affected. Our results suggest that caring for older adults with VI has similar demands as caring for older adults with dementia, but that these implications may be magnified when caring for older adults with both dementia and VI.

Enrolling Incident Caregivers and Matched Controls From a Nationwide Epidemiological Study

Participants in the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study were asked about family caregiving responsibilities at enrollment (2003-2007). Among the 88% of participants who were not caregivers at enrollment, 1,229 reported becoming caregivers before a follow-up interview 12 years later. The Caregiving Transitions Study screened these participants and enrolled 251 as incident caregivers. All reported 5 or more hours of care per week, provided assistance with at least one ADL or IADL, and were caregivers for at least 3 months before a 2nd blood sample was obtained in the REGARDS study. A total of 251 noncaregiving control participants who reported no caregiving responsibilities over this 12-year period were also enrolled. Each control was matched to a caregiver on age (+ 5 years), sex, race, other demographics, and baseline (pre-caregiving) health variables. Descriptive analyses confirm the unique comparability of the samples compared to previous caregiving studies.

Self-Reported Health and Well-Being Across Heterogeneous Groups of Caregivers

Using the Caregiving Transitions Study (CTS) we compared the effects of caregiving on self-reported health and well-being in caregivers reporting providing dementia care, different levels of strain and amount of care provided. Caregivers (n-251) were 65% female, 36% African American and had a mean age of 71.8 years. A quarter of CGs reported being under a lot of strain and 47% provided care for persons with dementia. Dementia CGs (n=117) provided more hours of care per week (49.7 versus 37.7, p=0.001), more commonly reported high strain (36.8% versus 15.7%, p<0.03) and were more than twice as likely as non-dementia caregivers to report that caregiving interfered with taking care of their own health (33.9% versus 15.4%, p=0.003). Additional results will be reported on how these factors of dementia caregiving, level of strain, and hours of care affect well-being including perceived stress, treatment burden, depressive symptoms and health-related quality of life.

Are all homebound older adults frail?

Seven million adults in the United States are homebound and suffer the negative, powerful synergies of multiple chronic conditions, functional impairment, social stressors, and limited social capital. The prevalence of frailty in this vulnerable homebound population is unknown. Using representative data from the National Health and Aging Trends study (NHATS) study linked to Medicare claims (n=4756) we sought to assess the prevalence of frailty in the homebound population (n=361). Among the homebound, 68.5% met the frailty criteria compared to 12.3% of the non-homebound population. The frail homebound had lower educational attainment, were more likely to live alone, self-reported poorer health and more chronic physical and mental health conditions than the non-frail homebound (p<0.05 for all). Frail homebound older adults utilized more health services utilization than non-frail homebound and were twice as likely to be hospitalized (49.8% versus 28.0%, p=0.004).

Physical Frailty, Cognitive Impairment, and Healthcare Utilization in Linked Cohort and Claims Data

Accurate prediction of healthcare utilization is an important issue for Medicare managed care organizations. We hypothesized that physical frailty and cognitive impairment increase the risk of healthcare utilization in older adults receiving Medicare coverage, independent of age and multimorbidity. We used the marginal means/rates model to investigate the association between baseline cognitive impairment with/without frailty (using the physical frailty phenotype), vs. frailty alone, in NHATS and the number of incident non-ER-related hospitalizations and emergency room (ER) visits within 12 months in linked Medicare claims data (N=3,915). After covariate adjustment, physical frailty alone was predictive of both non-ER-related hospitalizations (HR=1.77; p=0.012) and ER visits (HR=1.75; p<0.001). Cognitive impairment with or without frailty was only associated with ER visits (HR=1.53, p=0.002; HR=1.30, p=0.001). Our findings support the value of physical frailty and cognitive impairment assessment above and beyond multimorbidity to improve the prediction of care utilization for vulnerable subgroups of Medicare beneficiaries.

DESIGNING FAMILY CAREGIVER STUDIES THAT BALANCE STRESS PROCESS AND HELPING RELATIONSHIP PERSPECTIVES

Family caregiving is often characterized as a chronically stressful situation, and stress process models have been the dominant conceptual foundation underlying caregiving studies for decades. Recently, this perspective has been augmented with more positive views that emphasize potentially healthy and prosocial aspects of caregiving. Replicated findings from population-based studies show that caregivers have lower mortality rates than noncaregivers, consistent with the more balanced conceptual approach. The Caregiving Transitions Study is investigating 251 participants who transitioned into a caregiving role at some point between two blood samples taken 10 years apart in a national epidemiological study and 251 matched controls. Preliminary analyses confirm that caregiving leads to increased psychological distress. Ongoing analyses are examining changes in inflammatory biomarkers, health status, and positive aspects of caregiving. Findings will be examined alongside our recent meta-analysis of convenience samples that found caregiving to have small and inconsistent relationships with biomarkers of inflammation and immunity.

A benefit-harm analysis of adding basal insulin vs. sulfonylurea to metformin to manage type II diabetes mellitus in people with multiple chronic conditions

OBJECTIVES

The benefits and harms of diabetes treatments need to be carefully weighed in people with type II diabetes mellitus (DM) and multiple chronic conditions (MCCs). Our objective was to quantitatively assess the benefits and harms of the addition of basal insulin (insulin) vs. sulfonylurea (SU) to metformin in people with DM and MCCs.

STUDY DESIGN AND SETTING

Data inputs into the benefit-harms analysis included (1) baseline risks of patient-centered outcomes (death, myocardial infarction, stroke, severe hypoglycemia, diarrhea, nausea) from cohorts and trials; (2) treatment effects for the addition of insulin vs. SU from a network meta-analysis; and (3) patient preference survey for outcome weights. Statistical analysis calculated the probability that adding insulin has greater benefits than harms, when compared with an SU, overall and by prespecified subgroups.

RESULTS

Including the six outcomes, the probability of net benefit for insulin compared with SU was similar, across subgroups by age and diabetes duration (probability range, using conditional logit weights: 0.44-0.56). Adding patient preferences for treatment burden associated with insulin injections shifted the probability to favor SU over insulin (probability range, using conditional logit weights: 0.01-0.12).

CONCLUSION

In people with DM and MCCs, we demonstrated incomplete evidence to conclude if basal insulin or SU should be added in people with DM and MCCs on metformin alone. The benefit-harm balance was sensitive to treatment preferences, that is., perceived treatment burden, indicating the importance of shared-decision making in caring for people with MCCs who are at high risk for experiencing harms associated with diabetes management.

Skin Punctures in Preterm Infants in the First 2 Weeks of Life

OBJECTIVE

The objective of this study was to investigate frequency and trends of skin punctures in preterm infants.

STUDY DESIGN

A prospective audit of preterm infants less than 35 weeks admitted over a 6-month period to a tertiary neonatal intensive care unit. Each skin puncture performed in the first 2 weeks of life was documented in a specifically designed audit sheet.

RESULTS

Ninety-nine preterm infants were enrolled. Infants born at < 32 weeks' gestation had significantly more skin punctures than infants > 32 weeks (median skin punctures 26.5 vs. 17, p-value < 0.05). The highest frequency of skin punctures occurred during the first week of life for infants > 28 weeks' gestation (medians 17.5 in 28-31 + 6 weeks' gestation, and 15 in > 32 weeks), and during the second week of life for those born at < 28 weeks (median 17.5). Infants with sepsis had more skin punctures (p-value < 0.001), but this was not significant on multivariate analysis. Median skin punctures in the second week of life were statistically higher in the sepsis group on multivariate analysis (odds ratio: 1.07, 95% confidence interval: 1.00-1.14, p = 0.041).

CONCLUSION

Frequency of skin punctures is influenced by gestational age and postnatal age. Skin punctures were not an independent risk factor for sepsis.

Factors Associated With Loss of Usual Source of Care Among Older Adults

PURPOSE

Access to a usual source of care (USC) is associated with better preventive health and chronic disease treatment. Although most older adults have a USC, loss of USC, and factors associated with loss of USC, have not previously been examined.

METHODS

We followed 7,609 participants of the National Health and Aging Trends Study annually for up to 6 years (2011-2016). Discrete time-to-event techniques and pooled logistic regression were used to identify demographic, clinical, and social factors associated with loss of USC.

RESULTS

Ninety-five percent of older adults reported having a USC in 2011, of whom 5% subsequently did not. Odds of losing a USC were higher among older adults with unmet transportation needs (adjusted odds ratio [aOR] 1.67), who moved to a new residence (aOR 2.08), and who reported depressive symptoms (aOR 1.40). Odds of losing a USC were lower for those who had ≥4 chronic conditions (vs 0-1; aOR 0.42) and with supplemental (aOR 0.52) or Medicaid (aOR 0.67) insurance coverage.

CONCLUSIONS

We identified factors associated with older adults' loss of a USC. Potentially modifiable factors, such as access to transportation and supplemental insurance, deserve further investigation to potentially assist older adults with continuous access to care.

Rates, Predictors, and Outcomes of Early and Late Recurrence After Stroke

Background and Purpose—

Few recent studies have investigated the rates and predictors of early and late stroke recurrence using prospective population–based methodology. We investigated recurrent stroke at 2 years in the North Dublin Population Stroke Study (NDPSS).

Methods—

Patients were ascertained from December 2005 to 2006 from overlapping community and hospital sources using hot and cold pursuit. Stroke recurrence, survival, and functional outcome were ascertained at 72 hours, 7 days, 28 days, 90 days, 1 year, and 2 years.

Results—

Of 567 patients, cumulative 2-year stroke recurrence rate was 10.8% and case fatality was 38.6%. Recurrence subtype was associated with initial stroke subtype ( P <0.001). On multivariable Cox regression, hyperlipidemia (adjusted hazard ratio, 3.32; P =0.005) and prior stroke (adjusted hazard ratio, 2.92; P =0.01) were independent predictors of 2-year recurrence in 28-day survivors.

Conclusions—

Despite rigorous ascertainment, recurrent stroke rates were lower in current study than in earlier studies. Our data suggest that large sample sizes may be needed for future secondary prevention trials in patients treated with modern preventive medications.

Falls and fractures 2 years after acute stroke: the North Dublin Population Stroke Study

BACKGROUND

Stroke patients are at increased risk of falls and fractures. The aim of this study was to determine the rate, predictors and consequences of falls within 2 years after stroke in a prospective population-based study in North Dublin, Ireland.

DESIGN

Prospective population-based cohort study.

SUBJECTS

567 adults aged >18 years from the North Dublin Population Stroke Study.

METHODS

Participants were enrolled from an Irish urban population of 294,592 individuals, according to recommended criteria. Patients were followed for 2 years. Outcome measures included death, modified Rankin Scale (mRS), fall and fracture rate.

RESULTS

At 2 years, 23.5% (124/522) had fallen at least once since their stroke, 14.2% (74/522) had 2 or more falls and 5.4% (28/522) had a fracture. Of 332 survivors at 2 years, 107 (32.2%) had fallen, of whom 60.7% (65/107) had 2 or more falls and 23.4% (25/107) had fractured. In a multivariable model controlling for age and gender, independent risk factors for falling within the first 2 years of stroke included use of alpha-blocker medications for treatment of hypertension (P = 0.02). When mobility measured at Day 90 was included in the model, patients who were mobility impaired (mRS 2-3) were at the highest risk of falling within 2 years of stroke [odds ratio (OR) 2.30, P = 0.003] and those functionally dependent (mRS 4-5) displayed intermediate risk (OR 2.02, P = 0.03) when compared with independently mobile patients.

CONCLUSION

Greater attention to falls risk, fall prevention strategies and bone health in the stroke population are required.

Abstract W P351: Plasma Interleukin-6 and C-reactive Protein Are Associated With Acute Diffusion Hyperintensity After Transient Ischemic Attack

Background: In suspected TIA, DWI hyperintensity confirms the diagnosis of brain ischemia and identifies those with 3-fold risk of early recurrent stroke. However, immediate MRI is expensive and may not be available in many healthcare settings. A simple validated blood test to objectively support the diagnosis of cerebral ischaemia after transient symptoms might have utility in clinical practice. We hypothesised that blood markers of inflammation may be associated with abnormal DWI following TIA.

Methods: BIO-TIA was a multi-centre prospective study of consecutive patients with clinically-defined TIA, confirmed by a stroke physician. Phlebotomy and stroke protocol MRI were performed within 72 hours of symptoms. Patients with malignancy, active infection, trauma, surgery, definite transient non-ischaemic symptoms or recurrent stroke before phlebotomy/MRI were excluded. Plasma high-sensitivity CRP and interleukin-6 (IL-6) were measured by mass spectrometry.

Results: In 201 included patients, mean age was 68 years (59% male). Carotid stenosis was present in 26.4% and atrial fibrillation in 29.1%. Mean ABCD2 score was 4.2 (SD 1.3). Acute DWI hyperintensity was observed in 37.8% (76/201). Median hsCRP was 1.78mg/L in DWI-negative, compared with 3.01mg/L in DWI-positive TIA (p=0.04). Median IL-6 was 3.76pg/ml (DWI-negative) versus 4.91pg/ml (DWI-positive) (p=0.04). When the highest quartiles of CRP and IL-6 distributions were compared with quartiles 1-3, the prevalence of DWI hyperintensity was 61.5% (Q4) versus 32.9% (Q1-3) for CRP (p=0.001), and 56.4% (Q4) versus 34.9% [Q1-3) for IL-6 (p=0.02). Thresholds of 4.78mg/L for CRP or 6.21pg/ml for IL-6 had at least 80% specificity for identification of abnormal DWI signal. IL-6 was associated with CRP (rho 0.58), age (rho 0.36), and ABCD2 score (rho 0.18) and carotid stenosis (p≤0.01 for all), but not statin use.

Conclusion: Our preliminary findings require validation, but suggest that inexpensive, rapidly-measured blood markers are associated with acute DWI hyperintensity after TIA. If validated, blood markers may have utility to support the diagnosis of cerebral ischemia or select patients for early MRI.

Incidence, event rates, and early outcome of stroke in Dublin, Ireland: the North Dublin population stroke study

BACKGROUND AND PURPOSE

The World Health Organization has emphasized the importance of international population-based data for unbiased surveillance of stroke incidence and outcome. To date, few such studies have been conducted using recommended gold-standard ascertainment methods. We conducted a large, population-based stroke study in Dublin, Ireland.

METHODS

Using gold-standard ascertainment methods, individuals with stroke and transient ischemic attack occurring over a 12-month period (December 1, 2005-November 30, 2006) in North Dublin were identified. Disability was assessed using the modified Rankin score and stroke severity (<72 hours) by the National Institutes of Health Stroke Scale. Stroke-related deaths were confirmed by review of medical files, death certificates, pathology, and coroner's records. Crude and standardized (to European and World Health Organization standard populations) rates of incidence, risk factors, severity, and early outcome (mortality, case-fatality, disability) were calculated, assuming a Poisson distribution for the number of events.

RESULTS

Seven hundred one patients with new stroke or transient ischemic attack were ascertained (485 first-ever stroke patients, 83 recurrent stroke patients, 133 first-ever transient ischemic attack patients). Crude frequency rates (all rates per 1000 person-years) were: 1.65 (95% CI, 1.5-1.79; first-ever stroke), 0.28 (95% CI, 0.22-0.35; recurrent stroke), and 0.45 (95% CI, 0.37-0.53; first-ever transient ischemic attack). Age-adjusted stroke rates were higher than those in 9 other recent population-based samples from high-income countries. High rates of subtype-specific risk factors were observed (atrial fibrillation, 31.3% and smoking, 29.1% in ischemic stroke; warfarin use, 21.2% in primary intracerebral hemorrhage; smoking, 53.9% in subarachnoid hemorrhage; P<0.01 for all compared with other subtypes). Compared with recent studies, 28-day case-fatality rates for primary intracerebral hemorrhage (41%; 95% CI, 29.2%-54.1%) and subarachnoid hemorrhage (46%; 95% CI, 28.8%-64.5%) were greater in Dublin.

CONCLUSIONS

Using gold-standard methods for case ascertainment, we found high incidence rates of stroke in Dublin compared with those in similar high-income countries; this is likely explained in part by high rates of subtype-specific risk factors.

Improved late survival and disability after stroke with therapeutic anticoagulation for atrial fibrillation: a population study

BACKGROUND AND PURPOSE

Although therapeutic anticoagulation improves early (within 1 month) outcomes after ischemic stroke in hospital-admitted patients with atrial fibrillation, no information exists on late outcomes in unselected population-based studies, including patients with all stroke (ischemic and hemorrhagic).

METHODS

We identified patients with atrial fibrillation and stroke in a prospective, population-based study in North Dublin. Clinical characteristics, stroke subtype, stroke severity (National Institutes of Health Stroke Scale), prestroke antithrombotic medication, and International Normalized Ratio (INR) at onset were documented. Modified Rankin Scale (mRS) score was measured before stroke and at 7, 28, and 90 days; 1 year; and 2 years after stroke.

RESULTS

One hundred seventy-five patients had atrial fibrillation-associated stroke and medication data at stroke onset (159 ischemic, 16 hemorrhagic); 17% of those with ischemic stroke were anticoagulated before stroke (27 of 159.) On multivariable analysis, therapeutic INR was associated with improved late survival after ischemic stroke (adjusted 2-year odds ratio for death=0.08; 95% CI, 0.01 to 0.78; P=0.03). This survival benefit persisted when patients with hemorrhagic stroke were included (2-year survival; 70.5% therapeutic INR, 14.3% nontherapeutic INR; log-rank P<0.001; odds ratio for death=0.27; 95% CI, 0.09 to 0.88; P=0.03). Admission INR was inversely correlated with early and late modified Rankin Scale score (2-year Spearman ρ=-0.65; P<0.0003). An INR of 2 to 3 at ischemic stroke onset was associated with greater early (72 hours to 28 days) modified Rankin Scale score improvement (P=0.04) and good functional outcome (modified Rankin Scale score=0 to 2) at 1 year (adjusted odds ratio=4.8; 95% CI, 1.45 to 23.8; P=0.04).

CONCLUSIONS

In addition to improving short-term outcome in selected hospital-treated patient groups, therapeutic anticoagulation may provide important benefits for long-term stroke outcomes in unselected populations.

Stroke associated with atrial fibrillation--incidence and early outcomes in the north Dublin population stroke study

BACKGROUND

Prospective population-based studies are important to accurately determine the incidence and characteristics of stroke associated with atrial fibrillation (AF), while avoiding selection bias which may complicate hospital-based studies.

METHODS

We investigated AF-associated stroke within the North Dublin Population Stroke Study, a prospective cohort study of stroke/transient ischaemic attack in 294,592 individuals, according to recommended criteria for rigorous stroke epidemiological studies.

RESULTS

Of 568 stroke patients ascertained in the first year, 31.2% (177/568) were associated with AF (90.4%, i.e. 160/177 ischaemic infarcts). The crude incidence rate of all AF-associated stroke was 60/100,000 person-years (95% CI = 52-70). Prior stroke was almost twice as common in AF compared to non-AF groups (21.9 vs. 12.8%, p = 0.01). The frequency of AF progressively increased across ischaemic stroke patients stratified by increasing stroke severity (NIHSS 0-4, 29.7%; 5-9, 38.1%; 10-14, 43.8%; >or=15, 53.3%, p < 0.0001). The 90-day trajectory of recovery of AF-associated stroke was identical to that of non-AF stroke, but Rankin scores in AF stroke remained higher at 7, 28 and 90 days (p < 0.001 for all).

DISCUSSION

AF-associated stroke occurred in one third of all patients and was associated with a distinct profile of recurrent, severe and disabling stroke. Targeted strategies to increase anticoagulation rates may provide a substantial benefit to prevent severe disabling stroke at a population level.

Pharmacoeconomics of lipid lowering therapy in Ireland

Increases in expenditure on medicines above the level of increases in health care are generally, a feature of all Western health systems. From the early 1990's, the average annual growth rate (AAGR) in pharmaceutical expenditure exceeded the AAGR in health among all the European member states 1. In Ireland, the expenditure on drugs, as a percentage of health care spending, was 7.1% in 1987 compared with 9.2% in 1997. The state expenditure on medicines increased from 165.8 million Pounds in 1993 to 278 million Pounds in 1998 representing an average increase of 11% each year. All the available evidence indicates that the expenditure on medicines will continue to show real growth, and take an increasing share of the total health care budget. Analysis shows that the main reasons driving such growth include those of "product mix"--the prescribing of newer, more expensive medicines, in addition to the 'volume effect' comprising growth in the number of tablets per prescription. These two factors account for 80% of the observed increase in drug cost 2. Six therapeutic classes accounted for 16 of the top 20 most expensive drugs prescribed under the GMS in 1998 3. These areas can be classified as follows: peptic ulcer disease, asthma, hypertension/cardiac failure, antidepressants, anti inflammatory and lipid lowering drugs. In this article we discuss the clinical evidence base, and the pharmacoeconomic implications of lipid lowering therapy in this country.