Journal of the American Medical Directors Association最新文献

Objectives: To investigate the effect of preoperative muscle quality on functional outcomes after total hip arthroplasty (THA).

Design: Retrospective cohort study.

Setting and participants: We included 426 patients who underwent primary THA between 2015 and 2022 to evaluate the relationship between preoperative muscle quality and 1-year functional outcomes following THA.

Methods: The muscle cross-sectional area (CSA) and density at baseline were measured using preoperative computed tomography. The CSA was further divided based on muscle quality into intramuscular adipose tissue (IMAT), normal-density muscle (NDM), and low-density muscle (LDM) based on muscle density thresholds. According to their functional recovery, patients were classified into sufficient functional recovery [Harris hip score (HHS) ≥89] and insufficient functional recovery (HHS <89) groups based on their HHS at 1-year post THA. Propensity score matching was performed to balance the baseline characteristics of the patient groups, including age, sex, body mass index, HHS, University of California, Los Angeles activity scores, and gait speed. The preoperative muscle density, CSA, IMAT, NDM, and LDM of the gluteus maximus, gluteus medius, gluteus minimus, iliopsoas, and rectus femoris muscles were compared between the groups.

Results: Ninety matched pairs were analyzed following covariate adjustment using propensity scores. The insufficient group had significantly more IMAT in all muscles preoperatively than did the sufficient group (P < .05). In addition, the muscle density and NDM of the gluteus maximus, gluteus medius, and iliopsoas in the insufficient group were significantly worse than those in the sufficient group (P < .05). Conversely, the 2 groups showed no significant differences in LDM.

Conclusions and implications: Our results revealed that patients with a significantly higher IMAT prevalence and reduced NDM preoperatively were less likely to experience significant improvement after THA. Therefore, we propose that undergoing THA with good muscle quality represents the optimal timing for achieving higher functional recovery.

Objectives: This study investigated the role of patients' neighborhood socioeconomic status (SES) on the relationship between home health agency (HHA) care quality and health outcomes among home health care patients.

Design: Retrospective cohort study.

Setting and participants: We mainly used 2019 Outcome and Assessment Information Set data, Area Deprivation Index, and Quality of Patient Care Star Rating. We included Medicare beneficiaries (aged ≥ 65 years) who received home health care.

Methods: We used linear probability regression models to examine whether patients' neighborhood SES moderates the association between care quality of HHAs and health outcomes for 1,657,133 home health care patients.

Results: Our findings show that patients in neighborhoods with lower SES were more likely to use low-quality HHAs (lease disadvantaged neighborhoods: 11%, most disadvantaged neighborhoods: 15.2%). Our main model, adjusted by patient- and HHA-level characteristics, reveals patients living in socioeconomically disadvantaged neighborhoods (less disadvantaged: coefficient: -0.017, P < .001; more disadvantaged: coefficient: -0.035, P < .001; most disadvantaged: coefficient: -0.06, P < .001) and receiving care from low-quality HHAs (average-quality HHAs: coefficient: 0.037, P < .001; high-quality HHAs: coefficient: 0.062, P < .001) were less likely to remain in the community during their home health care. Furthermore, our study highlights that patients in the most disadvantaged neighborhoods encounter additional challenges in remaining at their homes and communities when they use low-quality HHAs.

Conclusions and implications: These findings highlight the need for targeted interventions and policy initiatives aimed at addressing disparities in care quality based on neighborhood SES. Efforts directed at enhancing the quality of care provided by HHAs and access to high-quality HHAs in socioeconomically disadvantaged neighborhoods could substantially impact health equity and outcomes for individuals in these settings.

Objectives: To evaluate the long-term effects of pay-for-performance (P4P) care in the geriatric population with newly diagnosed type 2 diabetes (T2D).

Design: Retrospective longitudinal cohort study.

Setting and participants: A total of 6607 propensity score-matched pairs of patients with newly diagnosed T2D who received either P4P care or standard care as identified from the National Health Insurance Research Database in Taiwan between January 1, 2000, and December 31, 2019.

Methods: Cox regression models were used to assess differences in risk of outcomes between P4P and non-P4P care. Primary outcomes and measures include all-cause mortality, hospital admissions due to cardiovascular events, dialysis initiation, severe hyperglycemia, and severe hypoglycemia. Multivariable Cox regression models were performed to calculate hazard ratios among and within groups.

Results: The multivariable-adjusted model showed that patients with P4P care had a significantly lower risk of all-cause mortality [adjusted hazard ratio (aHR), 0.37; 95% CI, 0.35-0.39], stroke (aHR, 0.80 95% CI, 0.72-0.88), myocardial infarction (aHR, 0.57; 95% CI, 0.48-0.67), heart failure (aHR, 0.75; 95% CI, 0.69-0.81), and dialysis (aHR, 0.66; 95% CI, 0.53-0.82) compared with those not receiving P4P care. However, there were no significant differences in the risk of severe hyperglycemia (aHR, 0.92; 95% CI, 0.82-1.03) and severe hypoglycemia (aHR, 1.04; 95% CI, 0.92-1.17) between the 2 groups.

Conclusions and implications: This nationwide cohort study suggests that the P4P program may reduce the risk of cardiovascular events, dialysis needs, and mortality in older patients with T2D without increasing the risk of severe hypoglycemia. P4P may be an effective management strategy for older patients with T2D.

Objectives: Proton pump inhibitors (PPIs) are used to manage excess stomach acid production and provide gastroprotection from bleeding risk-increasing drugs (BRIDs). We aimed to determine the prevalence of potentially inappropriate PPI use in nursing homes and associated factors.

Design: Longitudinal cohort study using 8 years of electronic data.

Setting and participants: The study included 6439 permanent residents aged ≥65 years from 34 homes managed by 2 aged care providers in New South Wales.

Method: Continuous PPI use (>12 weeks) in the absence of long-term BRID (>30 days) use was deemed inappropriate overuse whereas long-term BRID use without concomitant PPI for gastroprotection was classified as inappropriate underuse. Binary logistic regression was used to determine factors associated with PPI overuse.

Results: Fifty-four percent of residents (n = 3478) received a PPI, with a median duration of 46 weeks, whereas 58.5% (n = 3770) were long-term BRID users. Four of 5 PPI users (83.6%, n = 2906) used PPIs for >12 weeks, and after accounting for BRID use, the prevalence of inappropriate PPI overuse was 27.1% (n = 944). PPI overuse was 4 times more likely in residents in provider A compared with residents in provider B [odds ratio (OR) 4.08, 95% CI 2.73-6.09]. The prevalence of PPI underuse was 38.5% (n = 1452).

Conclusions and implications: One in 4 PPI users exceeded the clinically recommended duration, whereas 2 in 5 long-term BRID users did not receive a PPI for gastroprotection. There is a pressing need for tailored interventions, such as medication reviews and deprescribing initiatives, to improve PPI prescribing.

Objectives: To investigate the prospective association between the risk of dementia and age-related macular degeneration (AMD) in patients with related visual disability (VD).

Design: A nationwide population-based cohort study used authorized data provided by the Korean National Health Insurance Service.

Setting and participants: A total of 1,788,457 individuals aged >50 years who participated in the Korean National Health Screening Program were enrolled.

Methods: From January 2009 to December 2019, participants were tracked for a diagnosis of dementia using registered diagnostic codes from claims data. Participants with VD were defined as those registered in a national disability registration established by the Korean government. The prospective association of AMD and related VD with new-onset dementia was investigated using a multivariate-adjusted Cox proportional hazard model adjusted for age, sex, body mass index, income level, systemic comorbidities, psychiatric diseases, and behavioral factors.

Results: During the average follow-up period of 9.7 ± 2.16 years, 4260 of 21,384 participants in the AMD cohort and 137,166 of 1,662,319 participants in the control cohort were newly diagnosed with dementia, respectively. Participants diagnosed with AMD showed a higher risk of new-onset dementia than those in the control group in the fully adjusted model [hazard ratio (HR) 1.11, 95% CI 1.07-1.14]. The risk of dementia was higher in participants diagnosed with AMD and associated VD (HR 1.28, 95% CI 1.15-1.43) compared to those without VD (HR 1.09, 95% CI 1.06-1.13).

Conclusions and implications: A diagnosis of AMD was associated with an increased risk of all-cause dementia and its major subtypes. Close monitoring of cognitive function in patients with AMD, especially those with VD, may help in early detection of all-cause dementia, which could reduce the socioeconomic burden and improve the quality of life of patients.

Objectives: This study examined the association between care unit work environments in long-term care (LTC) homes and trends in care aides' job satisfaction and burnout (exhaustion, cynicism, reduced professional efficacy) from 2014 to early 2020.

Design: This was a retrospective longitudinal study using data from care aide surveys collected by the Translating Research in Elder Care research program over 3 periods: September 2014-May 2015 (T₁), May 2017-December 2017 (T₂), and September 2019-March 2020 (T₃).

Settings and participants: The study included 631 care aides from a stratified random sample of 84 LTC homes in 3 Canadian provinces, who participated in data collection at all 3 time points.

Methods: We used mixed-effects linear regression with a "time by work environment" interaction to assess whether work environment is associated with trends in job satisfaction (Michigan Organizational Assessment Questionnaire Job Satisfaction Subscale) and burnout (Maslach Burnout Inventory-General Survey). We standardized the outcomes using z-scores.

Results: Between T₁ and T₂, care aides in care units with less favorable work environments-characterized by less supportive leadership, weaker work culture, less effective team communication and feedback mechanisms, and insufficient structural resources and staffing-experienced a statistically significant decline in job satisfaction (B = -0.17, P < .01) and professional efficacy (B = -0.20, P < .01), along with an increase in exhaustion (B = 0.15, P < .05) and in cynicism (B = 0.27, P < .001). Those in more favorable work environments exhibited no statistically significant changes in these variables during the same period. Moreover, care aides in less favorable work environments continued to experience an increase in exhaustion from T₂ to T₃ (B = 0.16, P < .05).

Conclusions and implications: A positive work environment at the care unit level mitigated the deterioration in care aides' job satisfaction and burnout over the period studied. Targeted interventions to improve work environments show promise in sustaining the resilience of the care aide workforce.

Objectives: The main objective of this study was to measure the incidence of in-hospital adverse events in older adults presenting to the emergency department (ED) with an isolated traumatic hip fracture. The secondary objective was to identify the risk factors of adverse outcomes in those patients.

Design: Retrospective database analysis.

Setting and participants: Adults aged ≥65 years presenting to 1 of the 3 Quebec level 1 adult trauma centers' ED between 2003 and 2017 with an isolated hip fracture.

Methods: The main outcome was a composite of any adverse events defined as extended length of stay (LOS) >21 days, in-hospital complications (delirium, pressure ulcers, urinary tract infection, pneumonia, deep venous thrombosis, or pulmonary embolism), and mortality. Outcomes were also analyzed separately. Multivariable logistic regression modeling was used to identify factors associated with adverse events.

Results: We included 4569 patients (female: 74.8%; mean age: 83.7 years). Low energy mechanisms were the most frequent cause of injury (68.4%), and the median LOS was 13 days (interquartile range, 8-21). A total of 1829 patients (40.0%) suffered an in-hospital adverse event: extended LOS (n = 1106; 24.2%), death (n = 365, 8.0%), and ≥1 complications (n = 892, 19.5%). Risk factors of any in-hospital adverse event included aged ≥75 years [75-84 years: adjusted odds ratio (AOR), 1.44; 95% CI, 1.17-1.76; ≥85 years: AOR, 2.11; 95% CI, 1.72-2.58], male sex (AOR, 1.35; 95% CI, 1.17-1.56), cardiovascular disease (AOR, 1.47; 95% CI, 1.23-1.77), major cognitive disorder (AOR, 1.51; 95% CI, 1.26-1.80), and ≥2 comorbidities (AOR, 1.40; 95% CI, 1.02-1.93). Direct admission from ED to the operating room was associated with decreased risk of any adverse event (AOR, 0.87; 95% CI, 0.76-0.99).

Conclusions and implications: Two out of five patients presenting to a level-1 trauma center with an isolated hip fracture suffered from an adverse event. Aged ≥75 years, male sex, cardiovascular diseases, major cognitive disorder, and ≥2 comorbidities were significant risk factors. These factors may guide early identification of high-risk patients in the ED.