Journal of the American Geriatrics Society最新文献_第9页

Pain management inequities by demographic and geriatric-related variables in older adult inpatients 按人口统计学和老年病学相关变量划分的老年住院患者疼痛管理不平等现象。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-12 DOI: 10.1111/jgs.19076

Aksharananda Rambachan MD, MPH, Torsten B. Neilands PhD, Leah Karliner MD, MAS, Kenneth Covinsky MD, MPH, Margaret Fang MD, MPH, Tung Nguyen MD

Background

Pain is ubiquitous, yet understudied. The objective of this study was to analyze inequities in pain assessment and management for hospitalized older adults focusing on demographic and geriatric-related variables.

Methods

This was a retrospective cohort study from January 2013 through September 2021 of all adults 65 years or older on the general medicine service at UCSF Medical Center. Primary exposures included (1) demographic variables including race/ethnicity and limited English proficiency (LEP) status and (2) geriatric-related variables including age, dementia or mild cognitive impairment diagnosis, hearing or visual impairment, end-of-life care, and geriatrics consult involvement. Primary outcomes included (1) adjusted odds of numeric pain assessment versus other assessments and (2) adjusted opioids administered, measured by morphine milligram equivalents (MME).

Results

A total of 15,809 patients were included across 27,857 hospitalizations with 1,378,215 pain assessments, with a mean age of 77.8 years old. Patients were 47.4% White, 26.3% with LEP, 49.6% male, and 50.4% female. Asian (OR 0.75, 95% CI 0.70–0.80), Latinx (OR 0.90, 95% CI 0.83–0.99), and Native Hawaiian or Pacific Islander (OR 0.77, 95% CI 0.64–0.93) patients had lower odds of a numeric assessment, compared with White patients. Patients with LEP (OR 0.70, 95% CI 0.66–0.74) had lower odds of a numeric assessment, compared with English-speaking patients. Patients with dementia, hearing impairment, patients 75+, and at end-of-life were all less likely to receive a numeric assessment. Compared with White patients (86 MME, 95% CI 77–96), Asian patients (55 MME, 95% CI 46–65) received fewer opioids. Patients with LEP, dementia, hearing impairment and those 75+ years old also received significantly fewer opioids.

Conclusion

Older, hospitalized, general medicine patients from minoritized groups and with geriatric-related conditions are uniquely vulnerable to inequitable pain assessment and management. These findings raise concerns for pain underassessment and undertreatment.

背景介绍疼痛无处不在，但研究却不足。本研究旨在分析住院老年人疼痛评估和管理中的不平等现象，重点关注人口统计学和老年医学相关变量：这是一项回顾性队列研究，从 2013 年 1 月到 2021 年 9 月，研究对象是加州大学旧金山分校医疗中心普通内科服务中所有 65 岁或以上的成年人。主要暴露因素包括：（1）人口统计学变量，包括种族/民族和英语水平有限（LEP）状态；（2）老年病相关变量，包括年龄、痴呆或轻度认知障碍诊断、听力或视力障碍、临终关怀和老年病咨询参与。主要结果包括：（1）数字疼痛评估与其他评估的调整几率；（2）以吗啡毫克当量（MME）衡量的调整后阿片类药物用量：共有 15,809 名患者接受了 27,857 次住院治疗，1,378,215 次疼痛评估，平均年龄为 77.8 岁。患者中 47.4% 为白人，26.3% 患有 LEP，49.6% 为男性，50.4% 为女性。与白人患者相比，亚裔（OR 0.75，95% CI 0.70-0.80）、拉丁裔（OR 0.90，95% CI 0.83-0.99）和夏威夷原住民或太平洋岛民（OR 0.77，95% CI 0.64-0.93）患者进行数字评估的几率较低。与讲英语的患者相比，有 LEP（OR 0.70，95% CI 0.66-0.74）的患者进行数字评估的几率较低。痴呆症患者、听力受损患者、75 岁以上患者和临终患者接受数字评估的几率都较低。与白人患者（86 MME，95% CI 77-96）相比，亚裔患者（55 MME，95% CI 46-65）接受阿片类药物治疗的比例较低。有语言障碍、痴呆症、听力障碍和 75 岁以上的患者接受阿片类药物治疗的次数也明显较少：结论：来自少数群体和患有老年病的住院老年普通内科病人特别容易受到不公平疼痛评估和管理的影响。这些发现引起了人们对疼痛评估不足和治疗不当的担忧。

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引用次数: 0

Commentary on the Health Resources and Services Administration Geriatrics Workforce Enhancement Program special supplement 对卫生资源和服务管理局老年医学劳动力增强计划特别补充的评论。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-10 DOI: 10.1111/jgs.19073

Nina Tumosa PhD, Joan Weiss PhD, RN, CRNP, FAAN

<p>The Health Resources and Services Administration (HRSA) is committed to providing healthcare providers with the knowledge and skills to care for older adults and supports the training of the healthcare workforce through its Geriatrics Workforce Enhancement Program (GWEP) cooperative agreement program. The purpose of GWEP is to improve health outcomes for older adults by developing a healthcare workforce that maximizes patient and family engagement, and by integrating geriatrics and primary care. An infographic (Figure 1) shows the major components of GWEP, including education and training on patient-centered care and evaluation. Evaluation includes trainee satisfaction and increase in their knowledge and skills. Evaluation also measures the adoption of new knowledge, skills, and patient satisfaction with their healthcare. GWEP began in 2015 (44 awards). A second cohort of 48 awardees began in 2019. A third cohort (42 awards) begins in July of 2024.</p><p>GWEP recipients use multiple tools to manage and evaluate their IPET. These tools include (1) working within reciprocal partnerships; (2) using the age-friendly health system (AFHS) framework to promote age-friendly and dementia-capable care in primary care; (3) embracing innovations that lead to practice transformations; and (4) using process and patient outcome evaluation techniques. Examples of how these tools have been used by the second cohort of GWEP recipients are provided in this Special Supplement.</p><p>Geriatrics educators must focus on developing trainings and education that can be used nationally, as well as locally, to improve health and healthcare of older adults. Given the variability of sites that provide primary care to older adults, from self-care to nursing home care, and from in-home care services to hospice care, this is not an easy task. However, identifying and delivering this training and education content, and determining which educational modalities work best in any given site, are well worth that effort.</p><p>The examples of work described in this supplement show that the future of aging includes reasons to hope for ongoing increases in longevity with less disability, with the inclusion of the patient, family, and caregivers in this journey. GWEP will continue to work at reducing disability and maintaining autonomy to allow longer, fuller lives. This effort will have an impact on the long-term health of everyone as they age, if not now, then in the future.</p><p>The authors made equal contributions to this work, including concept and design, drafting, and revision of the manuscript for important intellectual content, and final review.</p><p>The authors report no conflicts of interest.</p><p>The activities described in this article were funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) grant number U1QHP28732.</p><p>The views expressed by Nina Tumosa and Joan Weiss in this article are solely the opinions

美国卫生资源与服务管理局（HRSA）致力于为医疗服务提供者提供护理老年人的知识和技能，并通过其老年医学劳动力增强计划（GWEP）合作协议项目支持对医疗服务劳动力的培训。GWEP 的目的是通过培养一支能最大限度提高患者和家属参与度的医疗保健队伍，并通过将老年医学与初级保健相结合，改善老年人的健康状况。信息图表（图 1）显示了 GWEP 的主要组成部分，包括以患者为中心的护理教育和培训以及评估。评估包括受训人员的满意度及其知识和技能的增长。评估还衡量新知识、新技能的采用情况以及患者对医疗服务的满意度。GWEP 始于 2015 年（44 个奖项）。第二批 48 名获奖者于 2019 年开始接受培训。第三批（42 名获奖者）于 2024 年 7 月开始。GWEP 获奖者使用多种工具来管理和评估他们的 IPET。这些工具包括：(1) 在互惠伙伴关系中开展工作；(2) 使用老年友好型医疗系统 (AFHS) 框架，在初级保健中推广老年友好型和痴呆症适应性护理；(3) 接受创新，实现实践转型；以及 (4) 使用流程和患者结果评估技术。本特别增刊将举例说明第二批 "全球老年医学教育项目"（GWEP）受助者是如何使用这些工具的。老年医学教育者必须注重开发可在全国和地方范围内使用的培训和教育，以改善老年人的健康和医疗保健。鉴于为老年人提供初级保健服务的场所多种多样，从自我护理到养老院护理，从居家护理服务到临终关怀，这项任务并非易事。本补编中介绍的工作实例表明，老龄化的未来包括希望不断延长寿命、减少残疾的理由，以及将病人、家庭和护理人员纳入这一旅程的理由。全球老年教育计划将继续致力于减少残疾和保持自主性，使人们能够活得更长、更充实。作者们对这项工作做出了同等的贡献，包括构思和设计、起草、修改手稿的重要思想内容以及最终审核。Nina Tumosa 和 Joan Weiss 在本文中表达的观点仅代表作者本人，并不一定反映美国卫生与公众服务部 (HHS) 或卫生资源与服务管理局 (HRSA) 的官方政策，提及 HHS 或 HRSA 也并不意味着美国政府的认可。

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引用次数: 0

Disparities in end-of-life care for minoritized racial and ethnic patients during terminal hospitalizations in New York State 纽约州少数种族和族裔病人在临终住院期间的临终关怀差异。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-10 DOI: 10.1111/jgs.19046

Miguel Cid MPH, Main Lin Quan Vega MD, Zhixin Yang MS, Jean Guglielminotti MD, PhD, Guohua Li MD, DrPH, May Hua MD, MS

Background

Racial and ethnic minorities often receive care at different hospitals than non-Hispanic white patients, but how hospital characteristics influence the occurrence of disparities at the end of life is unknown. The aim of this study was to determine if disparities in end-of-life care were present among minoritized patients during terminal hospitalizations, and if these disparities varied with hospital characteristics.

Methods

We identified hospitalizations where a patient died in New York State, 2016–2018. Using multilevel logistic regression, we examined whether documented end-of-life care (do-not-resuscitate status (DNR), palliative care (PC) encounter) differed by race and ethnicity, and whether these disparities differed based on receiving care in hospitals with varying characteristics (Black or Hispanic-serving hospital; teaching status; bed size; and availability of specialty palliative care).

Results

We identified 143,713 terminal hospitalizations in 188 hospitals. Across all hospitals, only Black patients were less likely to have a PC encounter (adjusted odds ratio (aOR) 0.83 [0.80–0.87]) or DNR status (aOR 0.91 [0.87–0.95]) when compared with non-Hispanic White patients, while Hispanic patients were more likely to have DNR status (aOR 1.07 [1.01–1.13]). In non-teaching hospitals, all minoritized groups had decreased odds of PC (aOR 0.80 [0.76–0.85] for Black, aOR 0.91 [0.85–0.98] for Hispanic, aOR 0.93 [0.88–0.98] for Others), while in teaching hospitals, only Black patients had a decreased likelihood of a PC encounter (aOR 0.88 [0.82–0.93]). Also, Black patients in a Black-serving hospitals were less likely to have DNR status (aOR 0.80 [0.73–0.87]). Disparities did not differ based on whether specialty PC was available (p = 0.27 for PC encounter, p = 0.59 for DNR status).

Conclusion

During terminal hospitalizations, Black patients were less likely than non-Hispanic White patients to have documented end-of-life care. This disparity appears to be more pronounced in non-teaching hospitals than in teaching hospitals.

背景：与非西班牙裔白人患者相比，少数种族和少数族裔患者通常在不同的医院接受治疗，但医院特征如何影响临终关怀差异的发生尚不清楚。本研究旨在确定在临终住院期间，少数族裔患者在临终护理方面是否存在差异，以及这些差异是否随医院特征而变化：我们确定了 2016-2018 年纽约州患者死亡的住院情况。利用多层次逻辑回归，我们研究了记录在案的临终关怀（拒绝复苏状态（DNR）、姑息治疗（PC））是否因种族和民族而异，以及这些差异是否因在具有不同特征的医院（黑人或西班牙裔服务医院；教学状态；床位规模；以及是否提供专业姑息治疗）接受治疗而异：我们在 188 家医院中发现了 143713 例临终住院病例。在所有医院中，与非西班牙裔白人患者相比，只有黑人患者不太可能遇到 PC（调整赔率比 (aOR) 0.83 [0.80-0.87] ）或 DNR 状态（aOR 0.91 [0.87-0.95]），而西班牙裔患者更有可能遇到 DNR 状态（aOR 1.07 [1.01-1.13]）。在非教学医院，所有少数族裔群体发生 PC 的几率都有所下降（黑人的 aOR 为 0.80 [0.76-0.85]，西班牙裔的 aOR 为 0.91 [0.85-0.98]，其他族裔的 aOR 为 0.93 [0.88-0.98]），而在教学医院，只有黑人患者发生 PC 的几率有所下降（aOR 为 0.88 [0.82-0.93]）。此外，在为黑人服务的医院中，黑人患者出现 DNR 状态的可能性较低（aOR 0.80 [0.73-0.87]）。差异并不因是否有专科 PC 而异（P = 0.27 for PC encounter，P = 0.59 for DNR status）：结论：在临终住院期间，黑人患者比非西班牙裔白人患者更不可能获得有记录的临终关怀。这种差异在非教学医院似乎比教学医院更为明显。

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引用次数: 0

Sex differences in patterns of potentially inappropriate prescribing and adverse drug reactions in hospitalized older people: Findings from the SENATOR trial 住院老年人潜在不当处方和药物不良反应模式的性别差异：SENATOR 试验结果。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-09 DOI: 10.1111/jgs.19071

Denis O'Mahony MD, Alfonso J. Cruz-Jentoft MD, Adalsteinn Gudmundsson MD, Roy L. Soiza MD, Mirko Petrovic PhD, Antonio Cherubini MD, Stephen Byrne PhD, Paula Rochon MD

Background

Older women experience more adverse drug reactions (ADRs) than older men. However, the underlying basis for this sex difference is unclear. Sex (biological status) and/or gender (sociocultural constructs) influences on patterns of inappropriate prescribing in multimorbid older adults may be one reason for this ADR sex difference. In this secondary analysis, we examined whether incident ADR sex differences could be related to concurrent sex differences in potentially inappropriate prescribing.

Design and Setting

A retrospective secondary analysis of sex differences in the prevalence of potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs), and ADRs among the 1537 participants (47.2% female, median [IQR] age 78 [72–84] years) was undertaken in the SENATOR clinical trial database, conducted in six large European medical centers.

Participants and Methods

We looked specifically for male/female differences relating to PIMs and PPOs (defined by STOPP/START version 2 criteria) identified within 48 h of acute hospitalization. We also assessed sex differences for ADRs identified at 14 days from admission or discharge, whichever came first. ADRs were assessed by blinded endpoint adjudication panel consensus.

Results

During hospitalization, significantly more females experienced ≥1 ADR compared to males (28% and 21%, respectively; odds ratio 1.40, 95% CI 1.10–1.78, p < 0.005). Nine of the 11 STOPP-criteria PIMs showing a significant sex difference occurred more often in females. Of the four START-criteria PPOs showing a significant sex difference, all occurred more often in females. Some sex-associated PIMs reflect higher prevalence of related conditions in older women.

Conclusion

We conclude that specific STOPP-criteria PIMs and START-criteria PPOs were identified more frequently in older women than older men during acute hospitalization, possibly contributing to higher ADR incidence in older women. Prescribers should appreciate sex differences in exposure to potentially inappropriate prescribing and ADR risk, given the preponderance of older women over older men in most clinical settings.

背景：老年女性比老年男性经历更多的药物不良反应（ADR）。然而，这种性别差异的根本原因尚不清楚。性别（生理状态）和/或性别（社会文化结构）对多病老年人不当处方模式的影响可能是造成这种 ADR 性别差异的原因之一。在这项二次分析中，我们研究了ADR性别差异是否与潜在不当处方的性别差异有关：我们在 SENATOR 临床试验数据库中对 1537 名参与者（47.2% 为女性，中位数[IQR]年龄为 78 [72-84] 岁）的潜在不当用药 (PIM)、潜在处方遗漏 (PPO) 和 ADR 发生率的性别差异进行了回顾性二次分析：我们专门研究了急性住院 48 小时内发现的 PIM 和 PPO（根据 STOPP/START 第 2 版标准定义）的男女差异。我们还评估了入院或出院（以先到者为准）14 天后发现的 ADR 的性别差异。ADR由盲法终点裁定小组一致评估：结果：在住院期间，发生≥1 例 ADR 的女性明显多于男性（分别为 28% 和 21%；几率比 1.40，95% CI 1.10-1.78，P 结论：我们得出结论，特定的 STOPP 临界值可用于评估 ADR：我们得出结论：在急性住院期间，老年女性比老年男性更频繁地发现特定的 STOPP 标准 PIMs 和 START 标准 PPOs，这可能是老年女性 ADR 发生率较高的原因之一。鉴于在大多数临床环境中，老年女性多于老年男性，因此处方者应了解潜在不当处方和 ADR 风险的性别差异。

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引用次数: 0

Postoperative use of sleep aids and delirium in older adults after major surgery: A retrospective cohort study 老年人大手术后使用助眠药物与谵妄：一项回顾性队列研究。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-09 DOI: 10.1111/jgs.19067

Su Been Lee BA, Chan Mi Park MD, MPH, Raisa Levin MS, Dae Hyun Kim MD, ScD

Background

Sleep aids are commonly prescribed to treat sleep disturbance, a modifiable risk factor for postoperative delirium in older patients. The use of melatonin receptor agonists in the postoperative period has been increasing. The comparative safety of melatonin receptor agonists, zolpidem, and temazepam remains uncertain.

Methods

This retrospective study included 22,083 patients ≥65 years old who initiated melatonin receptor agonists, zolpidem, or temazepam after major surgery in the Premier Healthcare Database 2009–2018. We performed propensity score-based overlap weighting and estimated the risk ratio (RR) and risk difference (RD) of postoperative delirium as the primary outcome and a composite of delirium or new antipsychotic initiation, pneumonia, and in-hospital mortality as secondary outcomes.

Results

The mean age of the study population was 78 (SD, 7) years and 50% were female. There was no significant difference in the risk of postoperative delirium among patients treated with melatonin receptor agonists (3.4%, reference group), zolpidem (2.9%; RR [95% CI], 0.9 [0.7–1.2]; RD [95% CI] per 100 persons, −0.3 [−1.1 to 0.6]), and temazepam (3.1%; 0.9 [0.7–1.1]; RD [95% CI] per 100 persons, −0.5 [−1.2 to 0.3]). The risks of delirium or new antipsychotic initiation, pneumonia, and in-hospital mortality were also similar among all groups.

Conclusions

Melatonin receptor agonists were not associated with a lower risk of postoperative delirium and other adverse outcomes compared with zolpidem and temazepam in older adults after major surgery.

背景：睡眠障碍是导致老年患者术后谵妄的一个可改变的风险因素，助眠剂是治疗睡眠障碍的常用处方。术后使用褪黑素受体激动剂的情况越来越多。褪黑素受体激动剂、唑吡坦和替马西泮的安全性比较仍不确定：这项回顾性研究纳入了 Premier Healthcare 数据库（2009-2018 年）中 22,083 名年龄≥65 岁、在大手术后开始使用褪黑素受体激动剂、唑吡坦或替马西泮的患者。我们进行了基于倾向评分的重叠加权，并估算了术后谵妄作为主要结局的风险比（RR）和风险差（RD），以及作为次要结局的谵妄或新的抗精神病药物启动、肺炎和院内死亡率的复合风险比（RR）和风险差（RD）：研究对象的平均年龄为 78（SD，7）岁，50% 为女性。使用褪黑素受体激动剂（3.4%，参照组）、唑吡坦（2.9%; RR [95% CI], 0.9 [0.7-1.2]; RD [95% CI] per 100 persons, -0.3 [-1.1 to 0.6]）和替马西泮（3.1%; 0.9 [0.7-1.1]; RD [95% CI] per 100 persons, -0.5 [-1.2 to 0.3]）。各组患者出现谵妄或开始使用新的抗精神病药物、肺炎和院内死亡的风险也相似：结论：与唑吡坦和替马西泮相比，褪黑素受体激动剂与老年人大手术后较低的术后谵妄风险和其他不良后果无关。

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引用次数: 0

Use of chronic care management service among Medicare beneficiaries in 2015–2019 2015-2019 年医疗保险受益人使用慢性病护理管理服务的情况。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-09 DOI: 10.1111/jgs.19066

Jieun Jang PhD, Ellen P. McCarthy PhD, MPH, Brianne Olivieri-Mui PhD, MPH, Sandra M. Shi MD, MPH, Chan Mi Park MD, MPH, Gahee Oh MD, MPH, Stephanie Denise M. Sison MD, MBA, Dae Hyun Kim MD, MPH, ScD

Background

The Centers for Medicare and Medicaid Services (CMS) introduced chronic care management (CCM) services in 2015 for patients with multiple chronic diseases. Few studies examine the utilization of CCM services by geographic region, sociodemographic, and clinical characteristics.

Methods

We used 2014–2019 Medicare claims data from a 5% random sample of fee-for-service beneficiaries aged 65 years or over. We included beneficiaries potentially eligible for CCM services because they had multiple chronic conditions (1,073,729 in 2015 and 1,130,523 in 2019). We calculated the proportion of potentially eligible beneficiaries receiving CCM service each year for the total population and by geographic region, sociodemographic, and clinical characteristics.

Results

The proportion of beneficiaries with two or more chronic conditions receiving CCM services increased from 1.1% in 2015 to 3.4% in 2019. The increase in CCM use was higher in the southern region, among dually eligible beneficiaries and beneficiaries with a greater burden of chronic conditions (2–5 conditions vs ≥10 conditions: 0.7% vs 2.0% in 2015; 2.1% vs 7.0% in 2019) and frailty (robust vs severely frail: 0.6% vs 3.3% in 2015; 1.9% vs 9.4% in 2019). Nearly one out of five recipients did not continue CCM service after the initial service.

Conclusion

We found that CCM service is being used by a very small fraction of eligible patients. Barriers and facilitators to more effective CCM adoption should be identified and incorporated into strategies that encourage more widespread use of this Medicare benefit.

背景：美国医疗保险和医疗补助服务中心（CMS）于 2015 年推出了针对多种慢性病患者的慢性病护理管理（CCM）服务。很少有研究按照地理区域、社会人口学和临床特征对 CCM 服务的使用情况进行研究：我们使用了 2014-2019 年医疗保险理赔数据，这些数据来自 65 岁或以上付费服务受益人的 5% 随机抽样。我们纳入了因患有多种慢性疾病而可能符合 CCM 服务条件的受益人（2015 年为 1,073,729 人，2019 年为 1,130,523 人）。我们计算了每年接受 CCM 服务的潜在合格受益人在总人口中所占的比例，并按地理区域、社会人口和临床特征进行了分类：有两种或两种以上慢性病的受益人接受 CCM 服务的比例从 2015 年的 1.1% 增加到 2019 年的 3.4%。在南部地区、双重资格受益人和慢性病负担较重的受益人中，使用 CCM 的比例增幅较大（2-5 种病症 vs ≥10 种病症：0.7% vs 2.0%；2-5 种病症 vs ≥10 种病症：0.7% vs 2.0%）：2015年为0.7% vs 2.0%；2019年为2.1% vs 7.0%）和体弱（体格健壮 vs 严重体弱：2015年为0.6% vs 3.3%；2019年为1.9% vs 9.4%）的受益人。近五分之一的接受者在首次服务后没有继续接受 CCM 服务：我们发现，只有极少数符合条件的患者使用了 CCM 服务。应找出更有效地采用 CCM 的障碍和促进因素，并将其纳入鼓励更广泛使用这一医疗保险福利的战略中。

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引用次数: 0

Decline in use of high-risk agents for tight glucose control among older adults with diabetes in New York City: 2017–2022 纽约市老年糖尿病患者为严格控制血糖而使用高风险药物的减少情况：2017-2022 年。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-09 DOI: 10.1111/jgs.19060

Jeff Zhang MS, Rania Kanchi MPH, Sarah Conderino DrPH, MPH, Natalie K. Levy MD, Samrachana Adhikari PHD, Saul Blecker MD, Nichola Davis MD, Jasmin Divers PHD, Catherine Rabin BS, Mark Weiner MD, Lorna Thorpe PhD, MPH, John A. Dodson MD, MPH

Background

This study aimed to examine the prevalence of inappropriate tight glycemic control in older adults with type 2 diabetes and other chronic conditions in New York City, and to identify factors associated with this practice.

Methods

We conducted a retrospective cohort study using the INSIGHT Clinical Research Network. The study population included 11,728 and 15,196 older adults in New York City (age ≥ 75 years) with a diagnosis of type 2 diabetes, and at least one other chronic medical condition, in 2017 and 2022, respectively. The main outcome of interest was inappropriate tight glycemic control, defined as HbA1c <7.0% (<53 mmol/mol) with prescription of at least one high-risk agent (insulin or insulin secretagogue).

Results

The proportion of older adults with inappropriate tight glycemic control decreased by nearly 19% over a five-year period (19.4% in 2017 to 15.8% in 2022). There was a significant decrease in insulin (27.8% in 2017; 24.3% in 2022) and sulfonylurea (29.4% in 2017; 21.7% in 2022) medication prescription, and increase in use of GLP-1 agonists (1.8% in 2017; 11.4% in 2022) and SGLT-2 inhibitors (5.8% in 2017; 25.1% in 2022), among the total population. Factors associated with inappropriate tight glycemic control in 2022 included history of heart failure (adjusted odds ratio [aOR] 1.38), chronic kidney disease ([aOR] 1.93), colorectal cancer ([aOR] 1.38), acute myocardial infarction ([aOR] 1.28), “other” ([aOR] 0.72) or “unknown” ([aOR] 0.72) race, and a point increase in BMI ([aOR] 0.98).

Conclusions

We found an encouraging trend toward less use of high-risk medication strategies for older adults with type 2 diabetes and multiple chronic conditions. However, one in six patients in 2022 still had inappropriate tight glycemic control, indicating a need for continued efforts to optimize diabetes management in this population.

背景：本研究旨在调查纽约市患有 2 型糖尿病和其他慢性疾病的老年人中血糖控制不当的普遍程度，并确定与这种做法相关的因素：本研究旨在调查纽约市患有 2 型糖尿病和其他慢性疾病的老年人中血糖控制不当的普遍程度，并确定与这种做法相关的因素：我们利用 INSIGHT 临床研究网络开展了一项回顾性队列研究。研究人群包括纽约市 2017 年和 2022 年分别确诊为 2 型糖尿病和至少一种其他慢性疾病的 11728 名和 15196 名老年人（年龄≥ 75 岁）。主要研究结果是不适当的严格血糖控制，定义为 HbA1c 结果：血糖控制不当的老年人比例在五年内下降了近19%（2017年为19.4%，2022年为15.8%）。在所有人群中，胰岛素（2017 年为 27.8%；2022 年为 24.3%）和磺脲类药物（2017 年为 29.4%；2022 年为 21.7%）的处方明显减少，而 GLP-1 激动剂（2017 年为 1.8%；2022 年为 11.4%）和 SGLT-2 抑制剂（2017 年为 5.8%；2022 年为 25.1%）的使用有所增加。与 2022 年不适当严格控制血糖相关的因素包括：心力衰竭病史（调整后比值比 [aOR] 1.38）、慢性肾病（[aOR] 1.93）、结直肠癌（[aOR] 1.38）、急性心肌梗死（[aOR] 1.28）、"其他"（[aOR] 0.72）或 "未知"（[aOR] 0.72）种族，以及体重指数增加一个点（[aOR] 0.98）：我们发现，患有 2 型糖尿病和多种慢性疾病的老年人减少使用高风险药物治疗策略的趋势令人鼓舞。然而，在2022年，每六名患者中仍有一人血糖控制不当，这表明需要继续努力优化这一人群的糖尿病管理。

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引用次数: 0

Comment on Saving the profession of geriatric medicine: No shortage of good ideas 就拯救老年医学专业发表评论：不乏好点子

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-09 DOI: 10.1111/jgs.19070

Nancy E. Lundebjerg MPA, Mark A. Supiano MD, AGSF, Donna M. Fick PhD, RN, GCNS-BC, AGSF, FGSA, FAAN

The recommendations enumerated in the commentary from Dr. Gurwitz and Dr. Seligman, “Saving the Profession of Geriatric Medicine: No Shortage of Good Ideas,”¹ are in alignment with long-standing American Geriatrics Society (AGS) priorities² for achieving our mission and vision. We appreciate the citations to selected papers^3-7 that have been published on this topic. We were surprised, however, to find that decades of work by AGS,^8-19 individual geriatrics health professional leaders,^20-23 and other organizations^24-29 were not cited in the commentary. We are submitting this letter to ensure that readers of the Journal of the American Geriatrics Society (JAGS) have the historical context and knowledge of the work that AGS and others have done in service of advancing our collective vision for a future where all are able to maintain our health, safety, and independence as we age.

On a more personal note, we are inspired by the young people who are choosing a career in geriatrics.³⁰ We appreciate your enthusiasm, energy, and talent and we believe the future of our field is bright. As always, we invite our AGS members to share ideas for new approaches that would help us to advance our priorities and achieve our vision via [email protected].

All authors contributed to the manuscript.

The authors have no conflicts of interest to disclose.

There was no sponsor for this manuscript.

Gurwitz 博士和 Seligman 博士的评论文章 "拯救老年医学专业：不乏好点子 "1 与美国老年医学会（AGS）长期以来为实现我们的使命和愿景而优先考虑的事项2 一致。我们对引用已发表的有关这一主题的论文3-7 表示赞赏。然而，我们惊讶地发现，评论中并未引用 AGS、8-19 老年医学专业领导人20-23 以及其他组织24-29 数十年来所做的工作。我们提交这封信是为了确保《美国老年医学会杂志》（JAGS）的读者能够了解历史背景和知识，了解 AGS 和其他组织为推进我们的集体愿景所做的工作，即在未来，所有人都能够在年老时保持健康、安全和独立。我们一如既往地邀请 AGS 成员通过 [email protected] 分享有助于我们推进工作重点和实现愿景的新方法。

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引用次数: 0

Esophageal motor disorders across ages: A retrospective multicentric analysis 不同年龄段的食管运动障碍：回顾性多中心分析

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-08 DOI: 10.1111/jgs.19068

Andrea Pasta MD, Chiara Facchini MD, Francesco Calabrese MD, Giorgia Bodini MD, PhD, Nicola De Bortoli MD, PhD, Manuele Furnari MD, Amir Mari MD, PhD, Edoardo V. Savarino MD, PhD, Vincenzo Savarino MD, PhD, Pierfrancesco Visaggi MD, Patrizia Zentilin MD, PhD, Edoardo G. Giannini MD, PhD, Elisa Marabotto MD, PhD

Background

Age-related changes in the gastrointestinal system are common and may be influenced by physiological aging processes. To date, a comprehensive analysis of esophageal motor disorders in patients belonging to various age groups has not been adequately reported.

Methods

We conducted a retrospective assessment of high-resolution manometry (HRM) studies in a multicenter setting. HRM parameters were evaluated according to the Chicago Classification version 4.0. Epidemiological, demographic, clinical data, and main manometric parameters, were collected at the time of the examination. Age groups were categorized as early adulthood (<35 years), early middle-age (35–49 years), late middle-age (50–64 years), and late adulthood (≥65 years).

Results

Overall, 1341 patients (632, 47.0% male) were included with a median age of 55 years. Late adulthood patients reported more frequently dysphagia (35.2%) than early adulthood patients (24.0%, p = 0.035), early middle-age patients (21.0%, p < 0.0001), and late middle-aged patients (22.7%, p < 0.0001). Esophagogastric junction outflow obstruction was more prevalent in late adulthood (16.7%) than in early adulthood (6.1%, p = 0.003), and in early middle-age (8.1%, p = 0.001). Patients with normal esophageal motility were significantly younger (52.0 years) than patients with hypercontractile esophagus (61.5 years), type III achalasia (59.6 years), esophagogastric junction outflow obstruction (59.4 years), absent contractility (57.2 years), and distal esophageal spasm (57.0 years), in multivariate model (p < 0.0001).

Conclusion

The rate of esophageal motor disorders is higher in older patients, in particular esophagogastric junction outflow obstruction and hypercontractile esophagus. Future prospective studies are necessary to confirm our results and to find tailored strategies to improve clinical outcomes.

背景：胃肠道系统与年龄有关的变化很常见，可能受到生理衰老过程的影响。迄今为止，关于不同年龄段患者食管运动障碍的全面分析尚未得到充分报道：我们在一个多中心环境中对高分辨率测压（HRM）研究进行了回顾性评估。根据芝加哥分类 4.0 版对 HRM 参数进行了评估。检查时收集了流行病学、人口统计学、临床数据和主要测压参数。年龄组被划分为成年早期（结果：共纳入 1341 名患者（632 人，47.0% 为男性），中位年龄为 55 岁。成年晚期患者（35.2%）比成年早期患者（24.0%，P = 0.035）、中年早期患者（21.0%，P 结论：成年晚期患者的食道运动障碍发生率高于中年早期患者：老年患者的食管运动障碍发生率较高，尤其是食管胃交界处流出道梗阻和食管过度收缩。今后有必要进行前瞻性研究，以证实我们的结果，并找到改善临床结果的针对性策略。

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引用次数: 0

Medicare expenditures among spouses of persons with dementia 痴呆症患者配偶的医疗保险支出。

IF 4.3 2区医学 Q1 GERIATRICS & GERONTOLOGY

Journal of the American Geriatrics Society

Pub Date : 2024-07-08 DOI: 10.1111/jgs.19074

Bailey C. Ingraham PhD, Douglas Barthold PhD, Norma B. Coe PhD, Paul Fishman PhD

Background

Spouses of persons living with dementia face intense strains on their well-being compared with similarly aged adults and spouses of partners with no dementia. This strain can impact spouses' health and healthcare needs, and therefore affect their healthcare utilization and expenditures.

Methods

Using data from the Health and Retirement Study linked with Medicare claims, we matched dyads of spouses and their partners with dementia (SPWD) to a comparison group of similar spouses and their partners with no dementia (SPWND). We then examined Medicare expenditures for spouses in the 5 years following their partner's dementia onset month using a two-part regression model.

Results

SPWD cumulative total Medicare expenditures were, on average, $60,043 in the 5 years post dementia onset, compared to $56,068 for SPWND. This difference ($3974, 95% CI = [−$3,199; $11,477]) was not significant. However, there were significant differences in the 5th year's total expenditures (+$2,748 [$321; $5,447]), driven by inpatient expenditures ($1,562 [$22; $3,277]).

Conclusions

Despite the differences in partner's dementia status, we found no significant difference in the 5-year cumulative Medicare expenditures between SPWD and SPWND. Compared to previous studies, we likely captured an earlier stage of dementia more consistently for a broader population which may be less straining on spouses. Further research should examine patterns of expenditures in later years and around critical timepoints in caregiving, such as partner transitions to formal long-term care settings and death, to better understand healthcare expenditures for spouses of persons living with dementia.

背景：与年龄相仿的成年人和没有痴呆症的伴侣的配偶相比，痴呆症患者的配偶面临着巨大的压力。这种压力会影响配偶的健康和医疗保健需求，从而影响他们的医疗保健使用和支出：我们利用健康与退休研究（Health and Retirement Study）中与医疗保险（Medicare）报销单相关联的数据，将患有痴呆症的配偶及其伴侣（SPWD）与无痴呆症的类似配偶及其伴侣（SPWND）的对比组进行配对。然后，我们使用一个由两部分组成的回归模型，对配偶在其伴侣痴呆症发病月份之后 5 年内的医疗保险支出进行了研究：结果：在痴呆症发病后的 5 年中，SPWD 的累积医疗保险总支出平均为 60,043 美元，而 SPWND 为 56,068 美元。这一差异（3974 美元，95% CI = [-3199 美元；11477 美元]）并不显著。然而，第 5 年的总支出（+2,748 美元 [321 美元；5,447 美元]）却有显著差异，这主要是由住院支出（1,562 美元 [22 美元；3,277 美元]）造成的：尽管伴侣的痴呆状态不同，但我们发现 SPWD 和 SPWND 的 5 年累计医疗保险支出没有显著差异。与之前的研究相比，我们可能更一致地捕捉到了更广泛人群中痴呆症的早期阶段，这可能会减轻配偶的压力。为了更好地了解痴呆症患者配偶的医疗支出情况，进一步的研究应该考察晚年以及护理过程中关键时间点的支出模式，如伴侣转入正规长期护理机构和死亡。

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引用次数: 0