Search

This study is based on data for individuals with a history of stroke taken from the NIA-sponsored Longitudinal Study of Aging (LSOA), 1984-1990. It provides information on the factors predicting survival and changes in disability and activity limitations in this cohort with stroke or cerebrovascular accident over the period of two years, 1984 to 1986. The results indicate that individuals who were less than 80 years old had higher chances of survival and were likely to show reduced activity limitations and disabilities. It was also observed that the individuals who were in excellent health were more likely to survive despite a history of stroke. Individuals with severe activity limitations had a very low incidence of survival over the two-year period. Further, the results of this study support the contention that the increased use of health care resources in the form of visits to physicians, hospitals, and nursing homes results in improved survival and lower disability and activity limitations among the elderly. Key Words: Longitudinal Study of Aging, Health-related quality of life, Geriatric care

Objective: The differential muscarinic receptor selectivity could cause selective antimuscarinics to offer advantages over nonselective agents with respect to adverse effects. The objective was to examine the comparative risk of falls/fractures and all‐cause hospitalizations among older adults with dementia and overactive bladder (OAB) using nonselective and selective antimuscarinics Methods/Design: A retrospective cohort study design was conducted among older patients with dementia and OAB using incident antimuscarinics. The primary exposure was classified as nonselective (oxybutynin, tolterodine, trospium, and fesoterodine) and selective (solifenacin and darifenacin). Cox proportional‐hazards regression using inverse probability of treatment weighting (IPTW) evaluated the risk of falls/fractures and all‐cause hospitalizations within 6 months of nonselective and selective antimuscarinic use. Results: The study cohort consisted of 13,896 (76.9%) nonselective and 4,179 (23.1%) selective antimuscarinic incident users. The unadjusted falls/fractures rate was 27.14% (3,772) for nonselective and 24.55% (1,026) for selective users (p‐value< 0.01). The unadjusted all‐cause hospitalizations rate was 24.14% (3,354) for nonselective and 21.58% (902) for selective users (p‐value <0.01). The IPTW models did not find a significant difference in the risk of falls/fractures (Hazard Ratio [HR] 1.03; 95% Confidence Interval [CI] 0.99–1.07) and risk of all‐cause hospitalizations (HR 1.04; 95% CI 0.99–1.08) between nonselective and selective antimuscarinics. Several sensitivity analyses corroborated the main findings. Conclusions: The study did not find a differential risk of falls/fractures and all‐cause hospitalizations in older adults with dementia and OAB using nonselective and selective antimuscarinics. More research is needed to understand the role of pharmacodynamics and pharmacokinetics in the safety profile of antimuscarinics in dementia. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the extent of documentation of asthma control and severity and associated characteristics among pediatric asthma patients in office-based settings. Methods: This cross-sectional study utilized data from the 2012–2015 National Ambulatory Medical Care Survey (NAMCS). Patients aged 6–17 years with a diagnosis of asthma were included. Weighted descriptive analysis examined the extent of documentation and uncontrolled asthma; while logistic regression evaluated associated characteristics. Results: Overall, there were 2.47 million (95% confidence interval, 95% CI: 2.04–2.90) average annual visits with asthma as a primary diagnosis. Asthma control and severity was documented in only 36.1% and 33.8% of the visits, respectively. An established patient (odds ratio, OR = 3.81), Hispanic ethnicity (OR = 2.10), chronic sinusitis (OR = 5.59), and visits in the Northeast (OR = 2.12) and Midwest (OR = 2.25) regions had higher odds of documented asthma control status, whereas undocumented asthma severity (OR = 0.02), and visits in spring (OR = 0.34), had lower odds. Osteopathic doctors (OR = 0.18), visits in the Northeast region (OR = 0.23), chronic sinusitis (OR = 0.08), and undocumented asthma control status (OR = 0.03) had lower odds of documented asthma severity, whereas visits in spring (OR = 3.88) and autumn (OR = 3.32) had higher odds. Moderate/severe persistent asthma (OR = 15.35) had higher odds of uncontrolled asthma (as compared to intermittent asthma), while visits in the summer (OR = 0.14) had lower odds. Conclusion: The findings of this study suggest a critical need to increase the documentation of asthma severity and control to improve quality of asthma care in children. [ABSTRACT FROM AUTHOR]

Objectives: To compare the racial/ethnic differences in treatment quality among youth with primary care provider- initiated versus mental health specialist-initiated care for major depressive disorders (MDD). Methods: A retrospective cohort study was conducted using the 2005--2007 Medicaid claims data from Texas. Youth aged 10--20 during the study period were identified if they had two consecutive MDD diagnoses and received either medications for MDD or psychotherapy. Patients who received ≥84 days of medications and/or ≥4 sessions of psychotherapy for MDD treatment during 4 months of follow-up were considered meeting the minimum adequacy of treatment. Results: The generalized linear multilevel model (MLM) analysis revealed that both Hispanics and Blacks were approximately 30% less likely to receive adequate treatment (Hispanics -- OR: 0.67; 95% CI: 0.6--0.8) (Blacks -- OR: 0.66; 95% CI: 0.6--0.8) and Hispanic children were 50% more likely to undergo MHrelated hospitalization (OR: 1.53; 95% CI: 1.1--2.2) compared to their White counterparts. The odds of meeting the minimum MDD treatment adequacy were comparable between pediatric MDD cases first identified by primary care providers (PCP-I) and psychiatrists (PSY-I) (PCP-I vs. PSY-I: OR: 0.97; 95% CI: 0.8--1.2), and slightly lower in those first identified by social workers/psychologists (SWP-I) as compared to PSY-I (SWP-I vs. PSY-I: OR: 0.81; 95% CI: 0.7--0.9). In all models, the interaction between race/ethnicity and type of provider who initiated MDD care was not statistically significant. Conclusions: Minority youths received less adequate MDD treatment compared to Whites. Hispanic children had the highest risk of having mental health-related hospitalization. The specialty of provider who initiated MDD care had limited impact on treatment quality and was not associated with the racial/ethnic variations in treatment completion and mental health-related hospitalizations. [ABSTRACT FROM AUTHOR]

Objective: To examine the association of geographic access to providers with racial/ethnic variations in treatment quality among youth with depression.Methods: The geographic access to providers who initiated the depression treatment was measured using the travel distance estimated based on Google Maps® and the provider density within a 5-mile radius of each patient residence. Depression treatment quality was measured as treatment engagement, defined as having ≥2 prescriptions or psychotherapy with 2-month following a new depression diagnosis, and treatment completion defined as having ≥8 sessions of psychotherapy within 12 weeks or received ≥84 days of continuous treatment with antidepressants within 114 days following the treatment initiation.Results: The results of multivariate logistic regression analysis have demonstrated that the travel distance to provider was only negatively associated with the treatment engagement of Hispanics (5.0 - 14.9 vs ≤ 4.9 miles: OR=0.74, 95% CI [0.54-0.88]; ≥15 vs ≤ 4.9 miles: OR=0.82, 95% CI [0.56-0.97]), while a higher mental health specialist density was only positively associated with the treatment engagement of Blacks (1.00-1.99 vs < 1.00: OR=1.63, 95% CI [1.03-4.51]; 2.00-4.99 vs < 1.0: OR=2.28, 95% CI [1.21-7.11]). Among those who have engaged in the treatment, travel distance was associated with a lower likelihood of treatment completion in all racial/ethnic groups.Limitations: The study did not account for types of transportation used by patients.Conclusion: Geographic access barriers had a negative association with treatment quality of pediatric depression. Minority children were more sensitive to the barriers than Whites. [ABSTRACT FROM AUTHOR]

Objective: To examine patient and provider characteristics associated with the use of pediatric psychotropic polypharmacy.Methods: A retrospective study was conducted on children with psychiatric disorder diagnosis and treatment using the 2013-2015 claims data from a Pediatric Medicaid Managed Care Plan. Psychotropic polypharmacy was defined as the receipt of ≥2 psychotropic medications from different drug classes concurrently for ≥60 days. Stratified logistic regression analyses based on the number of prescribers involved in the treatment, i.e. single prescriber (SP) and multiple prescribers (MP) were conducted to determine the risk factors associated with multiclass psychotropic polypharmacy. The Fairlie decomposition method was used to test the difference in receipt of psychotropic polypharmacy between patients with and without a psychiatrist visit.Results: A total of 24,147 children and adolescents met the inclusion criteria. The prevalence of psychotropic polypharmacy was 20.09%. In addition to patients' demographics, diagnoses, number of comorbid psychiatric disorders (MP only), and the number of prescribers involved in the treatment (MP only), patients with a psychiatrist involved in the treatment had 5.3 times and 3.6 times higher odds of receiving psychotropic polypharmacy in SP and MP groups respectively (SP: OR = 5.32; 95% CI 4.62-6.14 & MP: OR = 3.57; 95% CI 3.20-3.99). Only a quarter of the prescribing practice variation between psychiatrists and PCPs was explained by the observed need factors.Conclusions: Pediatric psychotropic polypharmacy may be necessary and justified as it is mainly prescribed by the best-trained providers. [ABSTRACT FROM AUTHOR]

Background: Atypical antipsychotics are used as monotherapy or as augmentation therapy for management of late-life depression. However, little is known about utilization pattern of atypical antipsychotics in depression in the elderly.Objective: The objective of this study was to examine the prescribing practices and predictors of atypical antipsychotics and augmentation therapy in elderly outpatient visits with depression.Methods: This retrospective cross-sectional study used the National Ambulatory Medical Care Survey (NAMCS) and outpatient department component of the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2010 and 2011. The study included elderly (age ≥ 65years) outpatient visits with depression. Descriptive weighted analysis was performed to determine the prescribing practices of atypical antipsychotics and multivariable logistic regression analyses were performed to determine the factors associated with the prescription of atypical antipsychotics and augmentation therapy in outpatient visits.Results: According to the national surveys, there were about 22 million outpatent visits for depression during the study period; atypical antipsychotics were prescribed in 3.53% (95% CI, 2.02-5.04) of the visits. Among depression patients who were using antidepressants, 4.86% (95% CI, 3.07-6.04) used as an augmentation therapy. Multivariable regression analysis revealed that Hispanics (odds ratio [OR] = 0.33; 95% CI, 0.12-0.90) were associated with decreased likelihood of antipsychotic prescription, whereas personality disorder and obsessive compulsive disorder (OR = 10.23; 95% CI, 2.80-37.40) were associated with increased likelihood of prescribing antipsychotics. For augmentation therapy, Hispanics (OR = 0.06; 95% CI, 0.02-0.24) and primary physicians (OR = 0.24; 95% CI, 0.09-0.69) were associated with decreased likelihood; and obsessive compulsive disorder and personality disorder (OR = 7.56; 95% CI, 1.75-32.69) were associated with increased likelihood of antipsychotic prescription.Conclusion: Less than 4% of the elderly visits with depression were prescribed atypical antipsychotics. Both clinical and demographic factors contribute to antipsychotic prescribing in elderly patients with depression. [ABSTRACT FROM AUTHOR]

Patients with chronic liver disease (CLD) have frequent exposure to Clostridium difficile infection (CDI) risk factors but the incidence and aetiology of CDI on this population is poorly understood. The aim of this study was to assess the incidence, disease presentation and outcomes of CDI in patients with underlying CLD. The Health Care and Utilization Project National Inpatient Sample (HCUP-NIS) 2009 dataset was used to identify patients with CLD who developed CDI along with matched non-CLD patients with CDI. Using the NIS dataset, the incidence rate of CDI was 189.4/10 000 discharges in CLD patients vs. 83.7/10 000 discharges in the non-CLD matched cohort (P < 0.001). Compared with non-CLD, comorbidity-matched controls with CDI, CLD patients with CDI had higher likelihood of in-hospital mortality (8.8% vs. 18.6%, P < 0.001), increased length of stay by 1.19 days (P < 0.001) and increased total costs by $8632 (P < 0.001). In separate analyses using a tertiary case database of hospitalised patients in Houston, Texas (2006-2016) with CLD and CDI (n = 41) compared with patients with CDI but not CLD (n = 111), CLD patients had significantly higher Charlson comorbidity index (P < 0.0001) but similar risk factors for CDI and CDI-related disease presentation compared with non-CLD patients. In conclusion, CDI-related risk factors were almost universally present in the CLD population. CDI resulted in worse outcomes in this population. [ABSTRACT FROM AUTHOR]