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Caring for a partner with dementia poses significant emotional burden and high care demands, but changes in impacts before and after dementia onset is unclear.Examine changes in depressive symptoms and hours of care provided by caregivers through the course of their partners' cognitive decline.Retrospective, observational study using household survey data from 2000-2016 Health and Retirement Study and count models to evaluate older individuals' (ages ≥51 y) depressive symptoms (measured using the shortened Center for Epidemiologic Studies Depression Scale) and weekly caregiving in the 10 years before and after their partners' dementia onset (identified using Telephone Interview Cognitive Status screening). Relationships were examined overall and by sex and race.We identified 8298 observations for 1836 older caregivers whose partners developed dementia. From before to after partners' dementia onset, caregivers' mean (SD) depressive symptoms increased from 1.4 (1.9) to 1.9 (2.1) ( Plt;0.001) and weekly caregiving increased from 4.4 (19.7) to 20.8 (44.1) ( Plt;0.001) hours. Depressive symptoms and caregiving hours were higher for women compared with men. Depressive symptoms were higher for Blacks compared with Whites, while caregiving hours were higher for Whites. The expected count of caregivers' depressive symptoms and caregiving hours increased by 3% ( Plt;0.001) and 9% ( P =0.001) before partners' dementia onset and decreased by 2% ( Plt;0.001) and 1% ( P =0.63) following partners' dementia onset. No differences observed by sex or race.Depressive symptoms and instrumental burdens for caregivers increase substantially before the onset of dementia in partners. Early referral to specialty services is critical.

Non-Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non-Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset.We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee-for-service claims. Using the Hurd algorithm (a regression-based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use.We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p-value0.001. 23.8% of non-Hispanic Black versus 31.4% of non-Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education.Lower diagnosis rates of dementia among non-Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia-related outcomes among non-Hispanic Black Americans.

To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65.Health and Retirement Study survey data (1998-2018).We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensity-weighted pre- and post-Medicare eligibility cohorts. A regression discontinuity design compared the self-reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility.Not applicable.A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage-point decrease in the probability of informal care received for stroke patients (p = 0.003) but not in the other acute care cohorts. Men had a 16.8 percentage-point decrease (p = 0.002) in the probability of any care receipt.Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode-based reimbursement models that alter professional rehabilitative care intensity.

Objective Electronic health records (EHRs) have become a common data source for clinical risk prediction, offering large sample sizes and frequently sampled metrics. There may be notable differences between hospital-based EHR and traditional cohort samples: EHR data often are not population-representative random samples, even for particular diseases, as they tend to be sicker with higher healthcare utilization, while cohort studies often sample healthier subjects who typically are more likely to participate. We investigate heterogeneities between EHR- and cohort-based inferences including incidence rates, risk factor identifications/quantifications, and absolute risks. Materials and methods This is a retrospective cohort study of older patients with type 2 diabetes using EHR from New York University Langone Health ambulatory care (NYULH-EHR, years 2009–2017) and from the Health and Retirement Survey (HRS, 1995–2014) to study subsequent cardiovascular disease (CVD) risks. We used the same eligibility criteria, outcome definitions, and demographic covariates/biomarkers in both datasets. We compared subsequent CVD incidence rates, hazard ratios (HRs) of risk factors, and discrimination/calibration performances of CVD risk scores. Results The estimated subsequent total CVD incidence rate was 37.5 and 90.6 per 1000 person-years since T2DM onset in HRS and NYULH-EHR respectively. HR estimates were comparable between the datasets for most demographic covariates/biomarkers. Common CVD risk scores underestimated observed total CVD risks in NYULH-EHR. Discussion and conclusion EHR-estimated HRs of demographic and major clinical risk factors for CVD were mostly consistent with the estimates from a national cohort, despite high incidences and absolute risks of total CVD outcome in the EHR samples.

Over 6 million Americans have Alzheimer's Disease or Related Dementia (ADRD) but whether spikes in spending surrounding a new diagnosis reflect pre-diagnosis morbidity, diagnostic testing, or treatments for comorbidities is unknown.We used the 1998-2018 Health and Retirement Study and linked Medicare claims from older (≥65) adults to assess incremental quarterly spending changes just before versus just after a clinical diagnosis (diagnosis cohort, n = 2779) and, for comparative purposes, for a cohort screened as impaired based on the validated Telephone Interview for Cognitive Status (TICS) (impairment cohort, n = 2318). Models were adjusted for sociodemographic and health characteristics. Spending patterns were examined separately by sex, race, education, dual eligibility, and geography.Among the diagnosis cohort, mean (SD) overall spending was $4773 ($9774) per quarter - 43% of which was spending on hospital care ($2048). In adjusted analyses, spending increased by $8400 (p 0.001), or 156%, from $5394 in the quarter prior to $13,794 in the quarter including the diagnosis. Among the cohort in which impairment was incidentally detected using the TICS, adjusted spending did not change from just before to after detection of impairment, from $2986 before and $2962 after detection (p = 0.90). Incremental spending changes did not differ by sex, race, education, dual eligibility, or geography.Large, transient spending increases accompany an ADRD diagnosis that may not be attributed to impairment or changes in functional status due to dementia. Further study may help reveal how treatment for comorbidities is associated with the clinical diagnosis of dementia, with potential implications for Medicare spending.

BACKGROUND/OBJECTIVES Hypertension treatment reduces cardiovascular events. However, uncertainty remains about benefits and harms of deintensification or further intensification of antihypertensive medication when systolic blood pressure (SBP) is tightly controlled in older multimorbid patients, because of their frequent exclusion in trials. We assessed the association of hypertension treatment deintensification or intensification with clinical outcomes in older adults with tightly controlled SBP. DESIGN Longitudinal cohort study (2011-2013) with 9-month follow-up. SETTING U.S.-nationwide primary care Veterans Health Administration healthcare system. PARTICIPANTS Veterans aged 65 and older with baseline SBP

RESEARCH OBJECTIVE: Over 40 million older Americans rely on informal care (unpaid assistance for personal care such and instrumental support, including toileting, bathing, and shopping). Prior work illustrates 68–230% greater spending on post‐acute care after surgery for Medicare beneficiaries compared to older commercial insurance enrollees. Such enhanced access to post‐acute care may reduce the need for family and friend caregiving support for rehabilitation following acute medical events. While use of informal care is substantial among older Americans, little is known about informal support for patients after acute medical events, and how formal post‐acute care influences its use. STUDY DESIGN: We used 1998 to 2018 Health and Retirement Study (HRS) data to assess changes in weekly hours of informal care received by individuals experiencing acute events before and after Medicare eligibility. We created two similar cohorts of individuals near the Medicare eligibility age: pre‐Medicare, or individuals ages 59–66 and not covered by Medicare; and Medicare, or individuals ages 67–74. We used a threshold of 67, rather than 65, for the Medicare cohort to account for the two‐year lookback period used in HRS survey questions. The cohorts were matched using inverse probability treatment weights. A regression discontinuity design assessed three types of caregiving – the proportion of respondents receiving care, intensity of care among care recipients, and care intensity among all respondents – before and after Medicare eligibility. We estimated generalized linear models with a log link and gamma distribution that regressed informal care on Medicare status, a centered age variable, and an interaction between Medicare status and centered age. Sensitivity analyses included stratification by surgery type and by sex. POPULATION STUDIED: 4264 Health and Retirement Study participants near the age of Medicare eligibility in one of three self‐reported acute medical cohorts: stroke, heart surgery, or joint surgery. PRINCIPAL FINDINGS: Among near‐retirement individuals, 2031 (47.6%) had a stroke, 1038 (24.3%) underwent heart surgery, and 1038 (28.0%) underwent joint surgery. Of the 937 (22.3%) of patients who reported receiving care from an informal caregiver, average care measured 34.0 (SD: 49.2) weekly hours. Mean (SD) weekly informal caregiving hours were 7.5 (27.0) overall, and 12.1 (34.7), 3.8 (18.5), and 2.9 (14.1) for stroke, heart surgery, and joint surgery patients, respectively. In adjusted analyses, the proportion of stroke patients receiving informal care decreased from 39.5% to 28.6% (or by 28%) and the average weekly amount of care decreased from 21.0 to 10.3 hours (or 51%) after Medicare enrollment. Non‐significant decreases were observed for the other medical cohorts. There was a non‐significant average decrease of 22.8 hours (or 40%) in the intensity of care received by men after one of three events. CONCLUSIONS: Access to Medicare coverage was associated with a 51% reduction in informal care received by older Medicare stroke patients, potentially by increasing access to post‐acute services. IMPLICATIONS FOR POLICY OR PRACTICE: Post‐acute care is increasingly targeted for cost savings under Medicare policies, which may restrict access to post‐acute care and rehabilitation, impacting demand for informal care for older adults with stroke.

ImportanceOlder adults vary widely in age at diagnosis and duration of type 2 diabetes, but treatment often ignores this heterogeneity.ObjectivesTo investigate the associations of diabetes vs no diabetes, age at diagnosis, and diabetes duration with negative health outcomes in people 50 years and older.Design, Setting, and ParticipantsThis cohort study included participants in the 1995 through 2018 waves of the Health and Retirement Study (HRS), a population-based, biennial longitudinal health interview survey of older adults in the US. The study sample included adults 50 years or older (n = 36 060) without diabetes at entry. Data were analyzed from June 1, 2021, to July 31, 2022.ExposuresThe presence of diabetes, specifically the age at diabetes diagnosis, was the main exposure of the study. Age at diagnosis was defined as the age when the respondent first reported diabetes. Adults who developed diabetes were classified into 3 age-at-diagnosis groups: 50 to 59 years, 60 to 69 years, and 70 years and older.Main Outcomes and MeasuresFor each diabetes age-at-diagnosis group, a propensity score–matched control group of respondents who never developed diabetes was constructed. The association of diabetes with the incidence of key outcomes—including heart disease, stroke, disability, cognitive impairment, and all-cause mortality—was estimated and the association of diabetes vs no diabetes among the age-at-diagnosis case and matched control groups was compared.ResultsA total of 7739 HRS respondents developed diabetes and were included in the analysis (4267 women [55.1%]; mean [SD] age at diagnosis, 67.4 [9.9] years). The age-at-diagnosis groups included 1866 respondents at 50 to 59 years, 2834 at 60 to 69 years, and 3039 at 70 years or older; 28 321 HRS respondents never developed diabetes. Age at diagnosis of 50 to 59 years was significantly associated with incident heart disease (hazard ratio [HR], 1.66 [95% CI, 1.40-1.96]), stroke (HR, 1.64 [95% CI, 1.30-2.07]), disability (HR, 2.08 [95% CI, 1.59-2.72]), cognitive impairment (HR, 1.30 [95% CI, 1.05-1.61]), and mortality (HR, 1.49 [95% CI, 1.29-1.71]) compared with matched controls, even when accounting for diabetes duration. These associations significantly decreased with advancing age at diagnosis. Respondents with diabetes diagnosed at 70 years or older only showed a significant association with the outcome of elevated mortality (HR, 1.08 [95% CI, 1.01-1.17]).Conclusions and RelevanceThe findings of this cohort study suggest that age at diabetes diagnosis was differentially associated with outcomes and that younger age groups were at elevated risk of heart disease, stroke, disability, cognitive impairment, and all-cause mortality. These findings reinforce the clinical heterogeneity of diabetes and highlight the importance of improving diabetes management in adults with earlier diagnosis.

Background New hypertension performance measures encourage more intensive treatment in older adults. Treatment intensification includes starting new medications and increasing the dose of old ones. Medication dose is particularly important to older adults, given their vulnerability to dose-related side effects. We previously validated a standardized measure of beneficial doses tested in hypertension trials, Hypertension Daily Dose (HDD). Aim of the study To test whether changes in treatment intensity using HDD was associated with systolic blood pressure (SBP) and patient characteristics. Methods Longitudinal study of all Veterans aged ≥65 years with a diagnosis of hypertension. We defined 3 groups of risk: 1) cardiovascular risk; 2) geriatric/frail; 3) low-risk (comparator). Using multinomial regression, we assessed the probability of deintensification, intensification, vs. stable treatment, according to SBP and group. Results Among 1,331,111 Veterans, 19.9% had deintensification, and 29.6% intensification. Deintensification decreased, while intensification increased, with SBP. Compared to low-risk patients, cardiovascular risk patients had 1.11 (95% CI 1.10-1.13) times the odds of intensifying, and geriatric/frail patients 1.45 (95%CI 1.43-1.47) times the odds of deintensifying. Discussion Patient-level HDD change was consistent with an expected association with cardiovascular risk and geriatric/frail conditions, suggesting that HDD can be used longitudinally to assess hypertension treatment modification in large health systems.

Key Points Question Can the intensity of hypertension treatment by total dose burden for older patients be accurately quantified using only health system administrative pharmacy fill data? Findings In this cross-sectional study, dose intensity measured using pharmacy data in a national health care system was highly correlated with dose intensity documented in clinical notes by using a new algorithm that can be applied to an individual patient on any given day. Meaning This study suggests that intensity of hypertension treatment can be measured using pharmacy data at a more detailed level than using medication counts or blood pressure alone for quality comparison or as a research tool., Importance Simple measures of hypertension treatment, such as achievement of blood pressure (BP) targets, ignore the intensity of treatment once the BP target is met. High-intensity treatment involves increased treatment burden and can be associated with potential adverse effects in older adults. A method was previously developed to identify older patients receiving intense hypertension treatment by low BP and number of BP medications using national Veterans Health Administration and Medicare Part D administrative pharmacy data to evaluate which BP medications a patient is likely taking on any given day. Objective To further develop and validate a method to more precisely quantify dose intensity of hypertension treatment using only health system administrative pharmacy fill data. Design, Setting, and Participants Observational, cross-sectional study of 319 randomly selected older veterans in the national Veterans Health Administration health care system who were taking multiple BP-lowering medications and had a total of 3625 ambulatory care visits from July 1, 2011, to June 30, 2013. Measure development and medical record review occurred January 1, 2017, through November 30, 2018, and data analysis was conducted from December 1, 2019, to August 31, 2020. Main Outcomes and Measures For each BP-lowering medication, a moderate hypertension daily dose (HDD) was defined as half the maximum dose above which no further clinical benefit has been demonstrated by that medication in hypertension trials. Patients’ total HDD was calculated using pharmacy data (pharmacy HDDs), accounting for substantial delays in refills (>30 days) when a patient’s pill supply was stretched (eg, cutting existing pills in half). As an external comparison, the pharmacy HDDs were correlated with doses manually extracted from clinicians’ visit notes (clinically noted HDDs). How well the pharmacy HDDs correlated with clinically noted HDDs was calculated (using C statistics). To facilitate interpretation, HDDs were described in association with the number of medications. Results A total of 316 patients (99.1%) were male; the mean (SD) age was 75.6 (7.2) years. Pharmacy HDDs were highly correlated (r = 0.92) with clinically noted HDDs, with a mean (SD) of 2.7 (1.8) for pharmacy HDDs and 2.8 (1.8) for clinically noted HDDs. Pharmacy HDDs correlated with high-intensity, clinically noted HDDs ranging from a C statistic of 92.8% (95% CI, 92.0%-93.7%) for 2 or more clinically noted HDDs to 88.1% (95% CI, 85.5%-90.6%) for 6 or more clinically noted HDDs. Conclusions and Relevance This study suggests that health system pharmacy data may be used to accurately quantify hypertension regimen dose intensity. Together with clinic-measured BP, this tool can be used in future health system–based research or quality improvement efforts to fine-tune, manage, and optimize hypertension treatment in older adults., This cross-sectional study develops and validates a method to more precisely quantify dose intensity of hypertension treatment using only health system administrative pharmacy fill data.

The epidemiology of diabetes (DM) and subsequent development of cardiovascular disease (CVD) is well-studied. Less is known about the development/course of DM in adults with preexisting CVD. We hypothesized that incidence of DM in these adults varies by age. We analyzed waves 1993-2014 of the Health and Retirement Study, a nationally-representative health survey. Our study sample included adults ≥50 years (n=27,650) not having CVD or DM at entry. Age of CVD-onset was defined as age when respondent first reported CVD diagnosis. We classified adults who developed CVD into 3 age of CVD-onset groups (years): 50-59, 60-69, ≥70. For each group, we constructed a propensity-score-matched control group of respondents not having CVD. We compared risk of developing DM for each age of CVD-onset group and its matched control. Of all respondents, 683 developed CVD at 50-59 years, 1,609 at 60-69, and 3,253 at ≥70; 22,105 never developed CVD. Adults diagnosed with CVD at 50-59 years had substantial increased risk of DM: incidence risk ratio (IRR) 1.5 (1.1, 2.0). CVD diagnosis at 60-69 years also had increased risk of DM: IRR 1.2 (1.0, 1.5). CVD diagnosis at ≥70 years had no increased risk of DM: IRR 1.1 (0.9, 1.4). (Figure) Age of CVD diagnosis differentially impacts the risk of subsequent development of DM in middle-age and older adults. The relationship between DM and CVD is complex, with the role of prevalent CVD on DM incidence/course incompletely understood. Disclosure C. Cigolle: None. C. Blaum: None. J. Szymonifka: None. M. Kabeto: None. J. Ha: None. J. Zhong: None. Funding National Institutes of Health (AG054467-01)

INTRODUCTION: This study develops a measure of Alzheimer’s disease and Related Dementias (ADRD) using Medicare claims. METHODS: Validation resembles the approach of the American Psychological Association, including (i) content validity, (ii) construct validity, and (iii) predictive validity. RESULTS: We found that four items -- a Medicare claim recording ADRD 1-year ago, 2-years ago, 3-years ago, and a total stay of 6-months in a nursing home -- exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD. DISCUSSION: Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.

Objectives To compare the accuracy of and factors affecting the accuracy of self‐reported fall‐related injuries (SFRIs) with those of administratively obtained FRIs (AFRIs). Design Retrospective observational study Setting United States Participants Fee‐for‐service Medicare beneficiaries aged 65 and older (N=47,215). Measurements We used 24‐month self‐report recall data from 2000–2012 Health and Retirement Study data to identify SFRIs and linked inpatient, outpatient, and ambulatory Medicare data to identify AFRIs. Sensitivity and specificity were assessed, with AFRIs defined using the University of California at Los Angeles/RAND algorithm as the criterion standard. Logistic regression models were used to identify sociodemographic and health predictors of sensitivity. Results Overall sensitivity and specificity were 28% and 92%. Sensitivity was greater for the oldest adults (38%), women (34%), those with more functional limitations (47%), and those with a prior fall (38%). In adjusted results, several participant factors (being female, being white, poor functional status, depression, prior falls) were modestly associated with better sensitivity and specificity. Injury severity (requiring hospital care) most substantively improved SFRI sensitivity (73%). Conclusion An overwhelming 72% of individuals who received Medicare‐reimbursed health care for FRIs failed to report a fall injury when asked. Future efforts to address underreporting in primary care of nonwhite and healthier older adults are critical to improve preventive efforts. Redesigned questions—for example, that address stigma of attributing injury to falling—may improve sensitivity.

Caring for a partner with Alzheimer’s disease or related dementia (ADRD) can create tremendous care burdens. However, the extent to which onset of ADRD in a partner impacts caregiving intensity and emotional health, the relationship of increased care intensity to emotional health, and whether relationships vary across the older adult population, are less clear. We used 9 waves (years 2000-2016) of the nationally representative Health and Retirement Study dataset to examine the number of weekly caregiving hours provided and depressive symptoms for older (ages ≥51) individuals after partners' ADRD onset (measured with the Telephone Cognitive Interview Survey). We compared changes in outcomes from before to after partners' ADRD onset using zero-inflated negative binomial regression models, overall and among sub-populations with potential vulnerability to excess care burdens – women and racial/ethnic minorities. In our sample of 2,186 older Americans with 10,120 unique observations, we observed a 215% increase (p

Electronic health records (EHR) are an increasingly common data source for studying disease risks, having large sample sizes and frequently sampled clinical predictors/outcomes. In contrast to population-based cohorts, EHRs are not population-representative random samples, as subjects tend to be sicker, with higher healthcare utilization. We compared risk predictions of the same outcome (time to incident CVD) in the same population of interest (DM2 patients >50 years) using 2 data sources: waves 1993-2014 of the nationally representative Health and Retirement Survey (HRS) and 2009-2017 New Langone Health Epic data. In each dataset, we estimated the incidence rate (IR) of subsequent CVD in DM2 patients and adjusted hazard ratios (HR) of CVD risk factors using the Cox-regression model. The HRS sample included 2,739, of whom 423 developed CVD. The NYU-Epic sample included 9,179, of whom 1,264 developed CVD. The estimated subsequent CVD IRs were 28.5 (95% CI: 25.9-31.3) (HRS) and 67.1 (95% CI: 63.5-90.9) (NYU-Epic) per 1,000 person-years since DM2 onset. HR estimates were comparable between the datasets for most demographic covariates/biomarkers (Table). Our findings showed that the EHR sample was enriched with a higher proportion of sicker DM2 patients. Our study supports EHR use in DM2 research: EHR-based HR estimates of CVD risk factors have promise to be population-generalizable despite higher CVD IRs in the EHR samples. Disclosure J. Zhong: None. C. Blaum: None. J. Yu: None. R. Ferris: None. J. Ha: None. Y. Xia: None. M. Kabeto: None. C. Cigolle: None. Funding National Institute on Aging

Key Points Question What are older adults’ risks of fall injuries in the periods surrounding hospitalization? Findings This retrospective cohort study using national survey and linked Medicare data observed spikes in older adult fall injury risk in the periods just before and after hospitalization. Risk increases were particularly pronounced for those who experienced an inpatient fall injury. Meaning These findings suggest that efforts to improve coordination of fall injury risk during care transitions into and out of the hospital are needed., This cohort study estimates the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization., Importance To date, measurement and treatment of older adult fall injury has been siloed within specific care settings, such as a hospital or within a nursing home or community. Little is known about changes in fall risk across care settings. Understanding the occurrence of falls across settings has implications for measuring and incentivizing high-value care across care settings. Objective To estimate the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization. Design, Setting, and Participants This cohort study is a longitudinal analysis of 12-month periods that include an anchor hospital stay using national data from 2006 to 2014. Participants included older (aged ≥65 years) Medicare fee-for-service beneficiaries from the Health and Retirement Study. Weekly fall injury rates were computed for 4 periods compared with the anchor hospitalization: at baseline (1-6 months before hospitalization), just before (

Importance Blood pressure (BP) targets are the main measure of high-quality hypertension care in health systems. However, BP alone does not reflect intensity of pharmacological treatment, which should be carefully managed in older patients. Objectives To develop and validate an electronic health record (EHR) data-only algorithm using pharmacy and BP data to capture intensive hypertension care (IHC), defined as 3 or more BP medications and BP less than 120 mm Hg, and to identify conditions associated with greater IHC, either through greater algorithm false-positive IHC, or by contributing clinically to delivering more IHC. Design, Setting, and Participants This cross-sectional study was conducted among 319 randomly selected patients aged 65 years or older receiving IHC from the Veterans Health Administration (VHA) from July 1, 2011, to June 30, 2013. Data were collected from a total of 3625 primary care visits. Data were analyzed from January 2017 to March 2020. Exposures Calibration and measurement of the algorithm for IHC (algorithm IHC). Main Outcomes and Measures For each primary care visit, the reference standard, clinical IHC, was determined by detailed review of free-text clinical notes. The correlation in BP medication count between the EHR-only algorithm vs the reference standard and the sensitivity and specificity of the algorithm IHC were calculated. In addition, presence vs absence of contributing conditions acting in combination with hypertension management were measured to examine incidence of IHC associated with contributing conditions, including an acute condition that lowered BP (eg, dehydration), another condition requiring a BP target lower than the standard 140 mm Hg (eg, diabetes), or the patient needing a BP-lowering medication for a nonhypertension condition (eg, β-blocker for atrial fibrillation) resulting in low BP. Results Among 319 patients with 3625 visits (mean [SD] age, 75.6 [7.2] years; 3592 [99.1%] men), 911 visits (25.1%) had clinical IHC by the reference standard. The algorithm for determining medication count was highly correlated with the reference standard (r = 0.84). Sensitivity of detecting clinical IHC was 92.2% (95% CI, 89.3%-95.1%), and specificity was 97.2% (95% CI, 96.1%-98.3%), suggesting that clinical IHC can be identified from routinely collected data. Only 75 visits (2.1%) were algorithm IHC false positives, 55 visits (1.5%) involved IHC with contributing conditions, and 125 visits (3.5%) involved either false-positive or IHC with contributing conditions. Among select contributing conditions, congestive heart failure (37 patients [5.2%]) was most associated with a prespecified combined false-positive or IHC with contributing conditions rate higher than 5%. Conclusions and Relevance These findings suggest that health system data can be used reliably to estimate IHC.

Older adults vary in age of onset and duration of diabetes (DM) but are treated similarly. We hypothesized that age of DM-onset has differential impact on distal outcome risk. 0057e analyzed waves 1993-2014 of the Health and Retirement Study, a nationally-representative health survey where we can study people before and after DM diagnosis for ∼ 20 years. Our sample included adults >50 years (n=27,975) without DM at entry. Age of DM-onset was defined as age when respondent first reported DM diagnosis. We classified adults who developed DM into 3 groups: 75. For each group, we constructed a propensity-score-matched control group of respondents who never develop DM. We compared risks of outcomes for each onset-age group and control: cardiac disease, stroke, mild disability (1-2 ADL/IADL dependencies), severe disability (>2 ADL/IADL dependencies), death. At 75; 21,994 never developed DM. Adults diagnosed with DM at Age of DM diagnosis differentially impacts key outcome risks in older adults and has more impact than duration. Findings reinforce clinical heterogeneity in DM and the focus to improve DM management in middle aged adults. Disclosure J. Zhong: None. J. Ha: None. C. Blaum: None. M. Kabeto: None. C. Cigolle: None.

OBJECTIVES: In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry, and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models. STUDY DESIGN: Longitudinal cohort study. METHODS: We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients, merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure, and low-density lipoprotein [LDL]). RESULTS: In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic blood pressure (–1.5 mm Hg for pharmacy-SMS and –1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic blood pressure) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years. CONCLUSIONS: Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.

Background The Community Healthy Activities Model Program for Seniors (CHAMPS) survey, summarized into weekly caloric expenditures, is a common physical activity (PA) assessment tool among older adults. Specific types of PA reported in the CHAMPS have not been systematically analyzed. We applied latent class analysis to identify the patterns of PA among sedentary older adults with diabetes reported in the CHAMPS survey. Methods Latent class models of PA were identified using the CHAMPS survey data reported by 115 individuals aged ≥60 years with type 2 diabetes whom volunteered for a clinical study of PA. Multinomial logistic regression was used to assess independent predictors of a specific latent class, including age, sex, and performance in physical function tests. Results Ninety-three percent of the participants were classified into 3 latent classes. Participants in latent class 1 (60.9%) primarily reported domestic-focused activities. Participants in latent class 2 and 3 (19.5% and 19.6%, respectively) reported domestic-focused activities, in addition to leisure-time physical activities and structured exercise activities. Latent class 1, with more women than men (73% vs.27%), had the lowest caloric expenditure, whereas class 3, with fewer women than men (28% vs. 72%), had the highest caloric expenditure (all p

Importance National injury surveillance systems use administrative data to collect information about severe fall-related trauma and mortality. Measuring milder injuries in ambulatory clinics would improve comprehensive outcomes measurement across the care spectrum. Objectives To assess a flexible set of administrative data–only algorithms for health systems to capture a greater breadth of injuries than traditional fall injury surveillance algorithms and to quantify the algorithm inclusiveness and validity associated with expanding to milder injuries. Design, Setting, and Participants In this longitudinal diagnostic study of 13 939 older adults (≥65 years) in the nationally representative Health and Retirement Study, a survey was conducted every 2 years and was linked to hospital, emergency department, postacute skilled nursing home, and outpatient Medicare claims (2000-2012). During each 2-year observation period, participants were considered to have sustained a fall-related injury (FRI) based on a composite reference standard of having either an external cause of injury (E-code) or confirmation by the Health and Retirement Study patient interview. A framework involving 3 algorithms withInternational Classification of Diseases, Ninth Revisioncodes that extend FRI identification with administrative data beyond the use of fall-related E-codes was developed: an acute care algorithm (head and face or limb, neck, and trunk injury reported at the hospital or emergency department), a balanced algorithm (all acute care algorithm injuries plus severe nonemergency outpatient injuries), and an inclusive algorithm (almost all injuries). Data were collected from January 1, 1998, through December 31, 2012, and statistical analysis was performed from August 1, 2016, to March 1, 2019. Main Outcomes and Measures Validity, measured as the proportion of potential FRI diagnoses confirmed by the reference standard, and inclusiveness, measured as the proportion of reference-standard FRIs captured by the potential FRI diagnoses. Results Of 13 939 participants, 1672 (42.4%) were male, with a mean (SD) age of 77.56 (7.63) years. Among 50 310 observation periods, 9270 potential FRI diagnoses (18.4%) were identified; these were tested against 8621 reference-standard FRIs (17.1%). Compared with the commonly used method of E-coded–only FRIs (2-year incidence, 8.8% [95% CI, 8.6%-9.1%]; inclusion of 51.5% [95% CI, 50.4%-52.5%] of the reference-standard FRIs), FRI inclusion was increased with use of the study framework of algorithms. With the acute care algorithm (2-year incidence, 12.6% [95% CI, 12.4%-12.9%]), validity was prioritized (88.6% [95% CI, 87.4%-89.8%]) over inclusiveness (62.1% [95% CI, 61.1%-63.1%]). The balanced algorithm showed a 2-year incidence of 14.6% (95% CI, 14.3%-14.9%), inclusion of 65.3% (95% CI, 64.3%-66.3%), and validity of 83.2% (95% CI, 81.9%-84.6%). With the inclusive algorithm, the number of potential FRIs increased compared with the E-code–only method (2-year incidence, 17.4% [95% CI, 17.1%-17.8%]; inclusion, 68.4% [95% CI, 67.4%-69.3%]; validity, 75.2% [95% CI, 73.7%-76.6%]). Conclusions and Relevance The findings suggest that use of algorithms withInternational Classification of Diseases, Ninth Revisioncodes may increase inclusion of FRIs by health care systems compared with E-codes and that these algorithms may be used by health systems to evaluate interventions and quality improvement efforts.

OBJECTIVE To describe the prevalence of physical function limitations among a nationally representative sample of adults with prediabetes. RESEARCH DESIGN AND METHODS We performed a cross-sectional analysis of 5,991 respondents ≥53 years of age from the 2006 wave of the Health and Retirement Study. All respondents self-reported physical function limitations and comorbidities (chronic diseases and geriatric conditions). Respondents with prediabetes reported no diabetes and had a measured glycosylated hemoglobin (HbA1c) of 5.7–6.4%. Descriptive analyses and logistic regressions were used to compare respondents with prediabetes versus diabetes (diabetes history or HbA1c ≥6.5%) or normoglycemia (no diabetes history and HbA1c RESULTS Twenty-eight percent of respondents ≥53 years of age had prediabetes; 32% had mobility limitations (walking several blocks and/or climbing a flight of stairs); 56% had lower-extremity limitations (getting up from a chair and/or stooping, kneeling, or crouching); and 33% had upper-extremity limitations (pushing or pulling heavy objects and/or lifting >10 lb). Respondents with diabetes had the highest prevalence of comorbidities and physical function limitations, followed by those with prediabetes, and then normoglycemia (P < 0.05). Compared with respondents with normoglycemia, respondents with prediabetes had a higher odds of having functional limitations that affected mobility (odds ratio [OR] 1.48), the lower extremities (OR 1.35), and the upper extremities (OR 1.37) (all P < 0.01). The higher odds of having lower-extremity limitations remained after adjusting for age, sex, and body mass index (OR 1.21, P < 0.05). CONCLUSIONS Comorbidities and physical function limitations are prevalent among middle-aged and older adults with prediabetes. Effective lifestyle interventions to prevent diabetes must accommodate physical function limitations.

Summary Misclassified causes of failures are a common phenomenon in competing risks survival data such as cancer mortality. We propose new estimating equations for a semiparametric proportional hazards (PH) model with misattributed causes of failures. Unlike other methods, the estimator does not require any parametric assumptions on baseline cause-specific hazard rates. It is shown that the estimators for regression coefficients are consistent and asymptotically normal. Simulation results support the theoretical analysis in finite samples. The methods are applied to analyze prostate cancer survival.

Several authors have indicated that incorrectly classified cause of death for prostate cancer survivors may have played a role in the observed recent peak and decline of prostate cancer mortality. Motivated by the suggestion we studied a competing risks model where other cause of death may be misattributed as a death of interest. We first consider a naive approach using unconstrained nonparametric maximum likelihood estimation (NPMLE), and then present the constrained NPMLE where the survival function is forced to be monotonic. Surprising observations were made as we studied their small-sample and asymptotic properties in continuous and discrete situations. Contrary to the common belief that the non-monotonicity of a survival function NPMLE is a small-sample problem, the constrained NPMLE is asymptotically biased in the continuous setting. Other isotonic approaches, the supremum (SUP) method and the Pooled-Adjacent-Violators (PAV) algorithm, and the EM algorithm are also considered. We found that the EM algorithm is equivalent to the constrained NPMLE. Both SUP method and PAV algorithm deliver consistent and asymptotically unbiased estimator. All methods behave well asymptotically in the discrete time setting. Data from the Surveillance, Epidemiology and End Results (SEER) database are used to illustrate the proposed estimators.