To What Extent Do Local Nursing Home Prescribing Patterns Relate to Psychotropic Prescribing in Assisted Living?

ObjectiveIn nursing homes (NHs), psychoactive medication use has received notable attention, but less is known about prescribing in assisted living (AL). This study examined how antipsychotic and antianxiety medication prescribing in AL compares with NHs.DesignObservational, cross-sectional AL data linked to publicly reported NH measures.Setting and ParticipantsRandom sample of 250 AL communities and the full sample of 3371 NHs in 7 states.MethodsWe calculated the percentage of residents receiving antipsychotics and antianxiety medications. For each AL community, we calculated the distance to NHs in the state. Linear models estimated the relationship between AL prescribing and that of the closest and farthest 5 NHs, adjusting for AL characteristics and state fixed effects.ResultsThe prescribing rate of potentially inappropriate antipsychotics (i.e., excluding for persons with recorded schizophrenia and Tourette syndrome) and of antianxiety medications (excluding for those on hospice) in AL was 15% and 21%, respectively. Unadjusted mean antipsychotic prescribing rates were nominally higher in AL than NHs (14.8% vs 14.6%; P = .056), whereas mean antianxiety prescribing was nominally lower in AL (21.2% vs 22.6%; P = .032). In adjusted analyses, AL rates of antipsychotic use were not associated with NH rates. However, being affiliated with an NH was associated with a lower rate of antipsychotic use [b = −0.03; 95% confidence interval (CI) −0.50 to −0.001; P = .043], whereas antianxiety rates were associated with neighboring NHs’ prescribing rates (b = 0.43; 95% CI 0.16–0.70; P = .002).Conclusions and ImplicationsThis study suggests reducing antipsychotic medication use in NHs may influence AL practices in a way not accounted for by local NH patterns. And, because antianxiety medications have not been the focus of national campaigns, they may be more subject to local prescribing behaviors. It seems advantageous to consider prescribing in AL when efforts are implemented to change NH prescribing, as there seems to be related influence whether by affiliation or region.     

Defining the Core Skills and Activities of the Attending Physician in Post-Acute and Long-Term Care

The American Board of Post-Acute and Long-Term Care Medicine (ABPLM) contracted with a psychometric firm to perform a 3-phase Job Analysis following best practices. Literature was reviewed, a task force of subject matter experts was convened, a survey was developed and sent via Survey Monkey to attending physicians practicing in post-acute and long-term care settings (PALTC). The task force refined a comprehensive list of the tasks, knowledge, and medical knowledge needed in the role of attending physician in PALTC. These items were written as statements and edited until consensus was reached on their accuracy, conciseness, and lack of overlap. Task statements described distinct, identifiable, and specific practice-related activities relevant across multiple care settings. Knowledge statements described previously acquired information considered necessary to effectively perform such tasks. The survey consisted of 260 items, including 21 demographic questions, 115 task statements, 73 knowledge statements, and 72 medical knowledge statements. The survey was disseminated via e-mail invitations to Society for Post-Acute and Long-Term Care (AMDA) members and through an online link available through ABPLM’s website. A total of 389 respondents participated. Survey data were analyzed with statistical analysis software SPSS. For each task and knowledge statement, an Overall Task Rating and Knowledge Rating were developed by combining the importance rating weighted at 65% and (for task) the frequency rating or (for knowledge) the cognitive level weighted at 35%. One task statement and 1 medical knowledge statement had a mean importance rating lower than 2.5 and were dropped from further review, resulting in a final count of 114 task, 73 knowledge, and 71 medical knowledge statements (258 total). The results of this Job Analysis highlight the unique and specific nature of medical care provided by attending physicians across a range of PALTC settings. These findings lay a foundation for Focused Practice Designation or Subspecialty in PALTC and changes in practice and policy.     

A global agenda for older adult immunization in the COVID-19 era: A roadmap for action

Given our global interconnectedness, the COVID-19 pandemic highlights the urgency of building a global system that can support both routine and pandemic/epidemic adult immunization. As such, a framework to recommend vaccines and build robust platforms to deliver them to protect the rapidly expanding demographic of older adults is needed. Adult immunization as a strategy has the broad potential to preserve and improve medical, social, and economic outcomes, including maintaining functional ability that benefits older adults, their families, communities, and countries. While we will soon have multiple vaccines against COVID-19, we must recognize that we already have a variety of vaccines against other pathogens that can keep adults healthier. They can prevent simultaneous co-infection with COVID-19, and may favorably impact- the outcome of a COVID-19 illness. Further, administering a vaccine against COVID-19 requires planning now to determine delivery strategies impacting how older adults will be immunized in a timely manner. A group of international experts with various backgrounds from health and aging disciplines met to discuss the evidence case for adult immunization and crucial knowledge gaps that must be filled in order to implement effective policies and programs for older adult immunization. This group, coming together as the International Council on Adult Immunization (ICAI), outlined a high-level roadmap to catalyze action, provide policy guidance, and envision a global adult immunization platform that can be adapted by countries to fit their local contexts. Further meetings centered around the value of adult immunization, particularly in the context of COVID-19. There was agreement that programs to deliver existing influenza, pneumococcal, herpes zoster vaccines, and future COVID-19 vaccines to over a billion older adults who are at substantially higher risk of death and disability due to vaccine-preventable diseases are more urgent than ever before. Here we present a proposed framework for delivering routine and pandemic vaccines. We call upon the global community and governments to prioritize action for integrating robust adult immunization programs into the public health agenda.     

Differences in the management and survival of metastatic colorectal cancer in Europe. A population-based study

BackgroundThe management regarding metastatic colorectal cancer throughout Europe is not well known.AimsTo draw a European comparison of the management and prognosis of metastatic colorectal cancers.MethodsFactors associated with chemotherapy administration were identified through logistic regressions. Net survival was estimated and crude probabilities of death related to cancer and other causes using a flexible cumulative hazard model.ResultsAmong the 13 227 patients with colorectal cancer diagnosed between 2010 and 2013 in cancer registries from 10 European countries, 3140 were metastatic. 62% of metastatic patients received chemotherapy. Compared to Spain, the related adjusted odds ratios ranged from 0.7 to 4.0 (P<0.001) according to country. The 3-year net survival by country ranged between 16% and 37%. The survival gap between countries diminished from 21% to 10% when adjusting for chemotherapy, age and sex. Geographical differences in the crude probability of death related to cancer were large for patients <70 or ≥80 years at diagnosis.ConclusionHeterogeneity in the application of European guidelines partly explain these differences. General health between populations, accessibility to a reference centre, or provision of health care could also be involved. Further population-based studies are warranted to disentangle between these possible explanations.     

Genome-wide association meta-analyses identified 1q43 and 2q32.2 for hip Ward's triangle areal bone mineral density

Aiming to identify genomic variants associated with osteoporosis, we performed a genome-wide association meta-analysis of bone mineral density (BMD) at Ward's triangle of the hip in 7175 subjects from 6 samples. We performed in silico replications with femoral neck, trochanter, and inter-trochanter BMDs in 6912 subjects from the Framingham heart study (FHS), and with forearm, femoral neck and lumbar spine BMDs in 32965 subjects from the GEFOS summary results. Combining the evidence from all samples, we identified 2 novel loci for areal BMD: 1q43 (rs1414660, discovery p = 1.20 × 10^− 8, FHS p = 0.05 for trochanter BMD; rs9287237, discovery p = 3.55 × 10^− 7, FHS p = 9.20 × 10^− 3 for trochanter BMD, GEFOS p = 0.02 for forearm BMD, nearest gene FMN2) and 2q32.2 (rs56346965, discovery p = 7.48 × 10^− 7, FHS p = 0.10 for inter-trochanter BMD, GEFOS p = 0.02 for spine BMD, nearest gene NAB1). The two lead SNPs rs1414660 and rs56346965 are eQTL sites for the genes GREM2 and NAB1 respectively. Functional annotation of GREM2 and NAB1 illustrated their involvement in BMP signaling pathway and in bone development. We also replicated three previously reported loci: 5q14.3 (rs10037512, discovery p = 3.09 × 10^− 6, FHS p = 8.50 × 10^− 3, GEFOS p = 1.23 × 10^− 24 for femoral neck BMD, nearest gene MEF2C), 6q25.1 (rs3020340, discovery p = 1.64 × 10^− 6, GEFOS p = 1.69 × 10^− 3 for SPN-BMD, nearest gene ESR1) and 7q21.3 (rs13310130, discovery p = 8.79 × 10^− 7, GEFOS p = 2.61 × 10^− 7 for spine BMD, nearest gene SHFM1). Our findings provide additional insights that further enhance our understanding of bone development, osteoporosis, and fracture pathogenesis.     

Characteristics of pediatric invasive pneumococcal diseases and the pneumococcal isolates in Suzhou,China before introduction of PCV13

BackgroundData on characteristics of invasive pneumococcal diseases (IPD) is limited in China. We aimed to understand the clinical features and explore the molecular characteristics of the pneumococcal isolates in China.MethodsSince 2010, we prospectively collected the pneumococcal isolates and the IPD patients’ demographic and clinical information in Suzhou University Affiliated Children’s Hospital (SCH). The antibiotic susceptibility, serotypes, genotypes of Streptococcus pneumoniae strains were identified by E-test, quellung reaction and/or multiplex PCR, and multi-locus sequence typing, respectively.ResultsDuring the period from January 2010 to December 2015, a total of 80 IPD patients were identified. They were diagnosed as meningitis (31.3%), septicemia (27.5%), pneumonia (21.3%) and others (20.0%). About half of them required vancomycin treatment, 42.5% were admitted to ICUs, 36.2% had complications and 6.2% were hospitalized for over 1 year. The most common serotypes of the pneumococcal isolates were serotypes 6B and 14, the coverage of PCV13 was 92.5%, and CC236s and CC199s were the most common clone complexes.ConclusionsPediatric IPD patients had severe clinical symptoms, demanded intensive treatment, suffered poor prognosis and substantial burden. The pneumococcal isolates’ serotype coverage of PCV13 vaccine was high, which leads to implication of PCV vaccine usage among children in China.     

Effect of prior vaccination on carriage rates of Streptococcus pneumoniae in older adults: A longitudinal surveillance study

IntroductionPneumococcus is a commensal of the upper respiratory tract and colonization is common in young children. Carriage studies have provided insights on vaccine effects in children and may also be useful for assessing vaccines in adults. However, culture based prevalence studies in older adults describe low colonization rates. Therefore, we assessed cumulative incidence of pneumococcal colonization in older adults using polymerase chain reaction (PCR) targeting the lytA gene and risk factors for carriage.Methods100 community-dwelling adults ≥65 years were enrolled the winter of 2015 and followed biweekly for 12 months. Medical, vaccination and illness history as well as nasopharyngeal (NP) and oropharyngeal (OP) samples were collected. Combined OP and NP were incubated in enrichment broth and screened using real-time lytA PCR. Samples from new colonization events (lytA PCR+) were cultured on gentamicin blood agar plates. Isolates identified by colony morphology as S. pneumoniae were serotyped using a multiplex combined immunoassay-PCR platform which classifies 96 serotypes. Cumulative incidence of pneumococcal carriage was calculated and risk factors for carriage assessed.ResultsThe cumulative incidence of colonization was 41% by PCR and 14% by culture. Monthly prevalence ranged from 0 to 17% by PCR and 1 to 4% by culture with peaks in the spring and fall. Demographics were similar between colonized and never colonized subjects although colonized were younger (72.4 vs. 75.0 years, P = 0.06). Vaccination with any pneumococcal vaccine before or during study period was associated with decreased risk of becoming colonized (p < 0.001) as was vaccination with either the 13-valent conjugated pneumococcal vaccine (PCV13) or 23-valent polysaccharide vaccine (PPSV23) (p < 0.001).ConclusionPneumococcal colonization in older adults as detected by lytA PCR is frequent and pneumococcal vaccination appears to be associated with decreased risk of carriage. Further study is needed to understand the biological significance of molecular detection of pneumococcus in adults.     

Benefits of flu vaccination for persons with diabetes mellitus: A review

Diabetes mellitus imposes a significant and increasing burden on society, with major consequences for human health, welfare and the economy worldwide. Persons with diabetes mellitus are at increased risk of developing severe complications after influenza virus infection and guidelines advise vaccination. The present evidence for influenza vaccine effectiveness in persons with diabetes mellitus is mainly based on observational studies with clinical endpoints like hospitalization and death, indicating a beneficial reduction of morbidity and mortality. Further supportive evidence comes from serological studies, in which persons with diabetes mellitus usually develop similar antibody levels after vaccination as healthy people. Observational studies may be prone to selection bias, and serological studies may not completely mirror vaccine effectiveness in the field. Although more controlled trials in persons with diabetes mellitus with laboratory-confirmed, influenza-specific outcomes would be desirable to better estimate the effect of vaccination, the currently available data justify routine influenza vaccination in persons with diabetes mellitus. As in this risk group, the use of influenza vaccine is far below target worldwide, efforts should be made to increase vaccination coverage.     

Impact of live attenuated influenza vaccination programme for healthy children in Northern Ireland: A comparison of seven influenza seasons, 2010/11–2016/17

Seasonal influenza vaccination for healthy children was introduced in Northern Ireland in the 2013/14 flu season, with an initial pilot year involving two specific cohorts, followed by rollout to all children aged 4–11 years in subsequent seasons. This study aimed to examine the impact of that programme on the burden of flu in primary care over the study period 2010/11–2016/17.Two routine indicators were used to measure impact – GP in-hour consultations and out-of-hour calls for influenza and influenza-like-illness (ILI). Analysis was conducted overall and stratified by age; rates in children under 14 years of age to measure direct impact and rates in individuals 14 years and over to measure indirect impact. Seven influenza seasons were included, three pre-programme seasons (2010/11–2012/13: phase 0), one pilot season (2013/14: phase 1), and three post-programme seasons (2014/15–2016/17: phase 2).High uptake of vaccination was observed from the programme introduction, with consistent uptake of over 50% in pre-school age groups and over 75% in primary school age groups. Statistically significant reductions were found in GP in-hours consultations and in out-of-hour calls in phase 2 compared to phase 0, both overall (GP in-hours RR 0.61, 95% CI 0.38–0.98, p = .040; out-of-hours RR 0.51, 95% CI 0.27–0.97, p = .041) and in the under 14 years group (GP in-hours RR 0.38, 95% CI 0.19–0.75, p = .006; out-of-hours RR 0.39, 95% CI 0.19–0.83, p = .014).Our results suggest that there have been reductions in the burden of flu in primary care settings overall and in children aged under 14 years in the seasons since the introduction of healthy children influenza vaccination. Further seasons should be added to subsequent analyses to strengthen this evidence.