Tag: pubmed

JAMA Netw Open. 2024 Sep 3;7(9):e2427610. doi: 10.1001/jamanetworkopen.2024.27610.

ABSTRACT

IMPORTANCE: Lack of a US dementia surveillance system hinders efforts to support and address disparities among persons living with Alzheimer disease and related dementias (ADRD).

OBJECTIVE: To review diagnosis and prescription drug code ADRD identification algorithms to develop and implement case definitions for national surveillance.

DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional study, a systematic literature review was conducted to identify unique International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and prescription drug codes used by researchers to identify ADRD in administrative records. Code frequency of use, characteristics of beneficiaries identified by codes, and expert and author consensus around code definitions informed code placement into categories indicating highly likely, likely, and possible ADRD. These definitions were applied cross-sectionally to 2017 to 2019 Medicare fee-for-service (FFS) claims and Medicare Advantage (MA) encounter data to classify January 2019 Medicare enrollees. Data analysis was conducted from September 2022 to March 2024.

EXPOSURES: ICD-10-CM and national drug codes in FFS claims or MA encounters.

MAIN OUTCOMES AND MEASURES: The primary outcome was counts and rates of beneficiaries meeting each case definition. Category-specific age, sex, race and ethnicity, MA enrollment, dual-eligibility, long-term care utilization, mortality, and rural residence distributions, as well as frailty scores and FFS monthly expenditures were also analyzed. Beneficiary characteristics were compared across categories, and age-standardized to minimize confounding by age.

RESULTS: Of the 60 000 869 beneficiaries included (50 853 806 aged 65 years or older [84.8%]; 32 567 891 female [54.3%]; 5 555 571 Hispanic [9.3%]; 6 318 194 non-Hispanic Black [10.5%]; 44 384 980 non-Hispanic White [74.0%]), there were 4 312 496 (7.2%) with highly likely ADRD, 1 124 080 (1.9%) with likely ADRD, and 2 572 176 (4.3%) with possible ADRD, totaling more than 8.0 million with diagnostic evidence of at least possible ADRD. These beneficiaries were older, more frail, more likely to be female, more likely to be dual-eligible, more likely to use long-term care, and more likely to die in 2019 compared with beneficiaries with no evidence of ADRD. These differences became larger when moving from the possible ADRD group to the highly likely ADRD group. Mean (SD) FFS monthly spending was $2966 ($4921) among beneficiaries with highly likely ADRD compared with $936 ($2952) for beneficiaries with no evidence of ADRD. Differences persisted after age standardization.

CONCLUSIONS AND RELEVANCE: This cross-sectional study of 2019 Medicare beneficiaries identified more than 5.4 million Medicare beneficiaries with evidence of at least likely ADRD in 2019 using the diagnostic case definition. Pending validation against clinical and other methods of ascertainment, this approach can be adopted provisionally for national surveillance.

PMID:39226058 | DOI:10.1001/jamanetworkopen.2024.27610

JAMA Netw Open. 2024 Sep 3;7(9):e2431073. doi: 10.1001/jamanetworkopen.2024.31073.

ABSTRACT

IMPORTANCE: Without knowledge of the degree of misattribution in racial and ethnic designations in data, studies run the risk of missing existing inequities and disparities and identifying others that do not exist. Further, accuracy of racial and ethnic designations is important to clinical care improvement efforts and health outcomes.

OBJECTIVE: To determine the error rate of racial and ethnic attribution in the electronic medical records (EMRs) across the 3 largest pediatric health systems in Michigan.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study collected race and ethnicity data from parents in outpatient clinics, emergency departments, and inpatient units at the 3 largest pediatric health systems in Michigan. A total of 1594 parents or guardians participated at health system A, 1537 at health system B, and 1202 at health system C from September 1, 2023, to January 31, 2024. Parent or guardian report of race and ethnicity for a child was used as the gold standard for comparison with the designation in the EMR.

EXPOSURE: Race and ethnicity designations in the EMR. Options for race designation across the health systems ranged from 6 to 49; options for ethnicity, from 2 to 10.

MAIN OUTCOMES AND MEASURES: Matching occurred in 3 stages. First, the exact racial and ethnic designations made by parents for their child were compared with what was found in the EMR. Second, for any child whose parent selected more than 1 racial category or for whom more than 1 appeared in the EMR, the designation of a minoritized racial group was used for matching purposes. Third, starting with the product of stage 2, racial designations were combined or collapsed into 6 (health systems A and C) or 5 (health system B) designations.

RESULTS: A total of 4333 survey responses were included in the analysis. The greatest error rate across the health systems occurred with the exact match of parental report of racial designation with the EMR, which ranged from 41% to 78% across the health systems. Improvement in the matching rate for each health system occurred with consolidation of race options provided. Differences between the health systems narrowed at the final consolidation to varying from 79% to 88% matching. Ethnicity matching between the EMR and the parental report ranged from 65% to 95% across the health systems. Missing race or ethnicity data in the EMR was counted as a nonmatch. Rates of missing racial data varied across the health systems from 2% to 10%. The health system with the greatest number of options for race and ethnicity had the highest error rates.

CONCLUSIONS AND RELEVANCE: Although there will always be some misattribution of race and ethnicity in the EMR, the results of this cross-sectional study suggest that significant error in these data may undermine strategies to improve care. It is unclear whether those in an organization who determine the number of potential categories are the same persons who use those data to investigate potential disparities and inequities.

PMID:39226057 | DOI:10.1001/jamanetworkopen.2024.31073

JAMA Netw Open. 2024 Sep 3;7(9):e2431180. doi: 10.1001/jamanetworkopen.2024.31180.

ABSTRACT

IMPORTANCE: Determining the influence of race and ethnicity on change in cognitive test performance has significant implications for clinical practice and research in populations at risk for Alzheimer disease.

OBJECTIVE: To evaluate the significance of race and ethnicity in predicting longitudinal cognitive test performance and to develop models to support evidence-based practice.

DESIGN, SETTING, AND PARTICIPANTS: This prognostic study included baseline and 24-month follow-up data that were obtained from the Health and Aging Brain Study-Health Disparities (HABS-HD) study, an ongoing longitudinal observational study of aging and dementia in a multiracial, multiethnic cohort. Participants included community-dwelling adults and elders living in the Dallas and Fort Worth metropolitan area who were Hispanic and non-Hispanic adults older than the age of 50 years and were cognitively unimpaired.

EXPOSURE: The primary exposure of interest was time, measured in months.

MAIN OUTCOMES AND MEASURES: Demographic variables included age, sex, education, and race and ethnicity. Cognitive domains included attention and working memory, processing speed, language, memory, and executive functioning. Linear regression models predicted follow-up performance from baseline performance and demographic variables for 13 commonly used neuropsychological tests. Follow-up testing was the primary outcome for all domains. Raw scores from 13 standardized tests were used for analyses.

RESULTS: This study included 799 adults who were cognitively unimpaired (352 Hispanic individuals [44.1%]; 447 non-Hispanic individuals [55.9%]; 524 female [65.6%]; mean [SD] age, 65.4 [8.1] years). In the regression models, all 13 follow-up scores were significantly predicted from their respective baseline scores and demographic variables. Baseline performance and education were the most consistent predictors of follow-up scores, contributing to all 13 models. Age was significantly associated with follow-up in 11 models, and sex was significant in 5 models. Race and ethnicity contributed to 10 of 13 models, with Hispanic participants predicted to have poorer follow-up scores than their non-Hispanic White counterparts on each test.

CONCLUSIONS AND RELEVANCE: In this longitudinal study of cognitive change in Hispanic and non-Hispanic older adults who were cognitively unimpaired, standardized regression-based models were influenced by multiple demographic variables, including race and ethnicity. These findings highlight the importance of including race and ethnicity in such cognitive change models. This ability to accurately predict cognitive change is expected to become increasingly important as clinical practice and clinical trials need to become more diverse and culturally appropriate in this burgeoning global medical and societal crisis.

PMID:39226056 | DOI:10.1001/jamanetworkopen.2024.31180

JAMA Netw Open. 2024 Sep 3;7(9):e2431183. doi: 10.1001/jamanetworkopen.2024.31183.

ABSTRACT

IMPORTANCE: Stroke treatment is exquisitely time sensitive. The door-in-door-out (DIDO) time, defined as the total time spent in the emergency department (ED) at a transferring hospital, is an important quality metric for the care of acute stroke. However, little is known about the contributions of specific process steps to delays and disparities in DIDO time.

OBJECTIVE: To quantify process steps and their association with DIDO times at transferring hospitals among patients with acute ischemic stroke (AIS).

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study analyzed patients in the American Heart Association Get With the Guidelines-Stroke registry with AIS presenting between January 1, 2019, to December 31, 2021, and transferred from the presenting hospital ED to another acute care hospital for evaluation of thrombolytics, endovascular therapy, or postthrombolytic care. Data were analyzed from July 8 to October 13, 2023.

EXPOSURES: Intervals of ED care of ischemic stroke: door-to-imaging and imaging-to-door times.

MAIN OUTCOMES AND MEASURES: The primary outcome was DIDO time. Multivariate generalized estimating equations regression models were performed to compare contributions of interval process times to explain variation in DIDO time, controlling for patient- and hospital-level characteristics.

RESULTS: Among 28 887 patients (50.5% male; mean [SD] age, 68.3 [14.8] years; 5.5% Hispanic, 14.7% non-Hispanic Black, and 73.2% non-Hispanic White), mean (SD) DIDO time was 171.4 (149.5) minutes, mean (SD) door-to-imaging time was 18.3 (34.1) minutes, and mean (SD) imaging-to-door time was 153.1 (141.5) minutes. In the model adjusting for door-to-imaging time, the following were associated with longer DIDO time: age 80 years or older (compared with 18-59 years; 5.97 [95% CI, 1.02-10.92] minutes), female sex (5.21 [95% CI, 1.55-8.87] minutes), and non-Hispanic Black race (compared with non-Hispanic White 10.09 [95% CI, 4.21-15.96] minutes). In the model including imaging-to-door time as a covariate, disparities in DIDO by age and female sex became nonsignificant, and the disparity by Black race was attenuated (2.32 [95% CI, 1.09-3.56] minutes).

CONCLUSIONS AND RELEVANCE: In this national cohort study of interhospital transfer of patients with AIS, delays in DIDO time by Black race, older age (≥80 years), and female sex were largely explained by the imaging-to-door period, suggesting that future systems interventions should target this interval to reduce these disparities. While existing guidelines and care resources heavily focus on reducing door-to-imaging times, further attention is warranted to reduce imaging-to-door times in the management of patients with AIS who require interhospital transfer.

PMID:39226055 | DOI:10.1001/jamanetworkopen.2024.31183

JAMA Netw Open. 2024 Sep 3;7(9):e2431427. doi: 10.1001/jamanetworkopen.2024.31427.

ABSTRACT

IMPORTANCE: Between 5% and 10% of breast cancer cases are associated with an inherited germline pathogenic or likely pathogenic variant (GPV) in a breast cancer susceptibility gene (BCSG), which could alter local and systemic therapy recommendations. Traditional genetic testing criteria misses a proportion of these cases.

OBJECTIVE: To evaluate the prevalence and clinicopathological associations of GPVs in 2 groups of BCSGs among an ethnically diverse cohort of women with newly diagnosed breast cancer.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study, conducted at 3 Montreal hospitals between September 2019 and April 2022, offered universal genetic counseling and testing to all women with a first diagnosis of invasive breast cancer. Women were offered an obligatory primary panel of BRCA1, BRCA2, and PALB2 (B1B2P2) and an optional secondary panel of 14 additional BCSGs. Eligible participants were women 18 years of age or older who received a diagnosis of a first primary invasive breast cancer not more than 6 months before the time of referral to the study. Data were analyzed from November 2023 to June 2024.

RESULTS: Of 1017 referred patients, 805 were eligible and offered genetic counseling and testing, and 729 of those 805 (90.6%) consented to be tested. The median age at breast cancer diagnosis was 53 years (range, 23-91 years), and 65.4% were White and of European ancestry. Fifty-four GPVs were identified in 53 patients (7.3%), including 39 patients (5.3%) with B1B2P2 and 15 patients (2.1%) with 6 of the 14 secondary panel BCSGs (ATM, BARD1, BRIP1, CHEK2, RAD51D, and STK11). On multivariable analysis, clinical factors independently associated with B1B2P2-positive status included being younger than 40 years of age at diagnosis (odds ratio [OR], 6.83; 95% CI, 2.22-20.90), triple-negative breast cancer (OR, 3.19; 95% CI, 1.20-8.43), high grade disease (OR, 1.68; 95% CI, 1.05-2.70), and family history of ovarian cancer (OR, 9.75; 95% CI, 2.65-35.85). Of 39 B1B2P2-positive patients, 13 (33.3%) were eligible for poly(adenosine diphosphate-ribose) polymerase (PARP) inhibitors.

CONCLUSIONS AND RELEVANCE: In this cross-sectional universal genetic testing study of women with newly diagnosed invasive breast cancer, the prevalence of GPVs was 7.3%, with 5.3% of patients testing positive for B1B2P2. Among B1B2P2-women women, one-third were eligible for PARP inhibitors.

PMID:39226054 | DOI:10.1001/jamanetworkopen.2024.31427

JAMA Netw Open. 2024 Sep 3;7(9):e2431512. doi: 10.1001/jamanetworkopen.2024.31512.

ABSTRACT

IMPORTANCE: The emergence of acute neurological symptoms in children necessitates immediate intervention. Although low- and middle-income countries (LMICs) bear the highest burden of neurological diseases, there is a scarcity of diagnostic and therapeutic resources. Therefore, current understanding of the etiology of neurological emergencies in LMICs relies mainly on clinical diagnoses and verbal autopsies.

OBJECTIVE: To characterize the association of premortem neurological symptoms and their management with postmortem-confirmed cause of death among children aged younger than 5 years in LMICs and to identify current gaps and improve strategies to enhance child survival.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study was conducted between December 3, 2016, and July 22, 2022, at the 7 participating sites in the Child Health and Mortality Prevention Surveillance (CHAMPS) network (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa). Minimally invasive tissue sampling was performed at the CHAMPS sites with specimens from deceased children aged younger than 5 years. This study included deceased children who underwent a premortem neurological evaluation and had a postmortem-confirmed cause of death. Data analysis was performed between July 22, 2022, and January 15, 2023.

MAIN OUTCOMES AND MEASURES: Descriptive analysis was performed using neurological evaluations from premortem clinical records and from postmortem determination of cause of death (based on histopathology, microbiological testing, clinical records, and verbal autopsies).

RESULTS: Of the 2127 deaths of children codified during the study period, 1330 (62.5%) had neurological evaluations recorded and were included in this analysis. The 1330 children had a median age of 11 (IQR, 2-324) days; 745 (56.0%) were male and 727 (54.7%) presented with neurological symptoms during illness before death. The most common postmortem-confirmed neurological diagnoses related to death were hypoxic events (308 [23.2%]), meningoencephalitis (135 [10.2%]), and cerebral malaria (68 [5.1%]). There were 12 neonates with overlapping hypoxic events and meningoencephalitis, but there were no patients with overlapping meningoencephalitis and cerebral malaria. Neurological symptoms were similar among diagnoses, and no combination of symptoms was accurate in differentiating them without complementary tools. However, only 25 children (18.5%) with meningitis had a lumbar puncture performed before death. Nearly 90% of deaths (442 of 511 [86.5%]) with neurological diagnoses in the chain of events leading to death were considered preventable.

CONCLUSIONS AND RELEVANCE: In this cross-sectional study of children aged younger than 5 years, neurological symptoms were frequent before death. However, clinical phenotypes were insufficient to differentiate the most common underlying neurological diagnoses. The low rate of lumbar punctures performed was especially worrying, suggesting a challenge in quality of care of children presenting with neurological symptoms. Improved diagnostic management of neurological emergencies is necessary to ultimately reduce mortality in this vulnerable population.

PMID:39226053 | DOI:10.1001/jamanetworkopen.2024.31512

Invest Ophthalmol Vis Sci. 2024 Sep 3;65(11):2. doi: 10.1167/iovs.65.11.2.

ABSTRACT

PURPOSE: We aimed to examine the normative profile of crystalline lens power (LP) and its associations with ocular biometric parameters including age, axial length (AL), spherical equivalent refraction (SE), corneal radius (CR), lens thickness, anterior chamber depth, and AL/CR ratio among a cynomolgus monkey colony.

METHODS: This population-based cross-sectional Non-human Primate Eye Study recruited middle-aged subjects in South China. All included macaques underwent a detailed ophthalmic examination. LP was calculated using the modified Bennett’s formula, with biometry data from an autorefractometer and A-scan. SPSS version 25.0 was used for statistical analysis.

RESULTS: A total of 301 macaques with an average age of 18.75 ± 2.95 years were collected in this study. The mean LP was 25.40 ± 2.96 D. Greater LP was independently associated with younger age, longer AL, and lower SE (P = 0.028, P = 0.025, and P = 0.034, respectively). LP showed a positive correlation with age, SE, CR, AL, lens thickness, and anterior chamber depth, whereas no correlation was observed between LP and AL/CR ratio.

CONCLUSIONS: Our results suggested the LP distribution in the nonhuman primate colony and indicated that AL and SE strongly influenced the rate of LP. Therefore, this study contributed to a deeper understanding of the relative significance of the LP on the optics of the crystalline lens study.

PMID:39226049 | DOI:10.1167/iovs.65.11.2

Int J Pharm Pract. 2024 Sep 3:riae047. doi: 10.1093/ijpp/riae047. Online ahead of print.

ABSTRACT

OBJECTIVES: This study aimed to evaluate the knowledge of community pharmacists toward acute uncomplicated cystitis regarding diagnosis, referral, and conformity to guidelines of the chosen antibiotic and to identify the associated factors with the pharmacist’s knowledge.

METHODS: This was a descriptive cross-sectional survey using a questionnaire. Data was collected from 349 community pharmacies in upper southern Thailand between December 2021 and February 2022. Univariate logistic regression analysis was used to assess factors associated with an inappropriate diagnosis of acute uncomplicated cystitis. The variables with P-value < 0.2 were included in the multivariate model. The statistically significant level was set as P-value < 0.05.

KEY FINDINGS: Three hundred and forty-nine pharmacists from 349 community pharmacies were included. Approximately 65% and 69% of the participants had the knowledge to identify which patients should be considered for cystitis and which patients should be considered for acute uncomplicated cystitis. Ninety eight percentage of pharmacists could select the appropriate antibiotic for uncomplicated cystitis patients. The most prescribed antibiotics were ciprofloxacin (44.7%), norfloxacin (40.7%), and ofloxacin (10.3%). Inappropriate diagnosis was significantly related to age (P = 0.016) and role in the community pharmacy (P = 0.033).

CONCLUSION: The majority of participants had misconceptions about the differential diagnosis between complicated and uncomplicated cystitis. These were related to the community pharmacists’ advanced age. Continuous pharmacy education should be established to advocate rational antibiotic use, especially in a country where community pharmacists are legally allowed to dispense antimicrobials without a prescription.

PMID:39226048 | DOI:10.1093/ijpp/riae047

JAMA Pediatr. 2024 Sep 3. doi: 10.1001/jamapediatrics.2024.3274. Online ahead of print.

ABSTRACT

IMPORTANCE: Increased secure firearm storage can reduce youth firearm injury and mortality, a leading cause of death for children and adolescents in the US. Despite the availability of evidence-based secure firearm storage programs and recommendations from the American Academy of Pediatrics, few pediatric clinicians report routinely implementing these programs.

OBJECTIVE: To compare the effectiveness of an electronic health record (EHR) documentation template (nudge) and the nudge plus facilitation (ie, clinic support to implement the program; nudge+) at promoting delivery of a brief evidence-based secure firearm storage program (SAFE Firearm) that includes counseling about secure firearm storage and free cable locks during all pediatric well visits.

DESIGN, SETTING, AND PARTICIPANTS: The Adolescent and Child Suicide Prevention in Routine Clinical Encounters (ASPIRE) unblinded parallel cluster randomized effectiveness-implementation trial was conducted from March 14, 2022, to March 20, 2023, to test the hypothesis that, relative to nudge, nudge+ would result in delivery of the firearm storage program to an additional 10% or more of the eligible population, and that this difference would be statistically significant. Thirty pediatric primary care clinics in 2 US health care systems (in Michigan and Colorado) were included, excluding clinics that were not the primary site for participating health care professionals and a subset selected at random due to resource limitations. All pediatric well visits at participating clinics for youth ages 5 to 17 years were analyzed.

INTERVENTIONS: Clinics were randomly assigned in a 1:1 ratio to receive either the nudge or nudge+.

MAIN OUTCOMES AND MEASURES: Patient-level outcomes were modeled to estimate the primary outcome, reach, which is a visit-level binary indicator of whether the parent received both components of the firearm storage program (counseling and lock), as documented by the clinician in the EHR. Secondary outcomes explored individual program component delivery.

RESULTS: A total of 47 307 well-child visits (median [IQR] age, 11.3 [8.1-14.4] years; 24 210 [51.2%] male and 23 091 [48.8%] female) among 46 597 children and 368 clinicians were eligible to receive the firearm storage program during the trial and were included in analyses. Using the intention-to-treat principle, a higher percentage of well-child visits received the firearm storage program in the nudge+ condition (49%; 95% CI, 37-61) compared to nudge (22%; 95% CI, 13-31).

CONCLUSIONS AND RELEVANCE: In this study, the EHR strategy combined with facilitation (nudge+) was more effective at increasing delivery of an evidence-based secure firearm storage program compared to nudge alone.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04844021.

PMID:39226027 | DOI:10.1001/jamapediatrics.2024.3274

J Racial Ethn Health Disparities. 2024 Sep 3. doi: 10.1007/s40615-024-02161-3. Online ahead of print.

ABSTRACT

BACKGROUND: The study was conducted to investigate the relationship between pregnancy-related anxiety levels of primiparae living in an ethnic region and their readiness for postnatal hygienic care of newborns.

METHOD: The study conducted between February and May 2023 included 201 “18-40-year-old primiparae” who lived in an ethnic region and volunteered to participate in the study. The population of the study consisted of all pregnant women who presented to the Gynecology and Obstetrics Clinic, Pregnancy Outpatient Clinic of a city hospital. The “Pregnant Women Personality and Obstetric Characteristics Form,” “Pregnant Women’s Readiness for Newborn Hygienic Care Scale,” and “Spielberg State-Trait Anxiety Inventory” were used as data collection tools.

RESULTS: The mean age of the 201 primiparae participating in the study was 26.11 ± 3.05 years. Although 71.1% of them felt confident about baby care before the baby was born, 95.5% needed help with baby care after birth. Their readiness for stress and newborn hygienic care was at a “medium” level. There was a statistically significant negative relationship between the scores they obtained from the Pregnant Women’s Readiness for Newborn Hygienic Care Scale and Spielberg State-Trait Anxiety Inventory (p = 0.011; r = – 0.180).

CONCLUSIONS: The participating primiparae experienced moderate levels of anxiety, and the increase in their anxiety levels negatively affected their readiness for the hygienic care of their newborn babies. Thus, when primiparae are provided with healthy newborn care, their anxiety levels should.

PMID:39225966 | DOI:10.1007/s40615-024-02161-3