Mortality among elderly receiving long-term care: a longitudinal cohort study

BACKGROUND AND AIMS: To investigate mortality, determinants of mortality, and time until death among elderly subjects receiving public long-term care. METHODS: This study comprises 626 respondents (age: 65-98 years). Data were collected for two cohorts (2001 and 2002). Cox regression analysis was used to identify determinants of mortality. Those who died and those who did not die were compared by, for example, demographic data and activities of daily living (ADL). RESULTS: The crude mortality rate was 9% in cohort 2001 and 14% in cohort 2002 in the first year, and 23% in cohort 2001 and 18% in cohort 2002 in the second year after decisions about care and service. Determinants of death were gender (men), severe cognitive impairment, co-morbidity, and high ADL scores. Regression analysis also showed that malignant tumors, respiratory, urinary and genito-urinary diseases were found to be significant predictors for mortality. CONCLUSIONS: The mortality rate was quite high, several diseases were common, and the need for help with ADL was wide-ranging. Results also showed that ADL scores, together with a measure of cognitive impairment, may be useful in identifying elderly subjects at high risk of mortality.     

Health care costs associated with hepatitis C: a longitudinal cohort study

BACKGROUND

Disease-specific estimates of medical costs are important for health policy decision making.

OBJECTIVE

To identify predictors of health care costs associated with hepatitis C virus (HCV) seropositivity across disease phases.

METHODS

HCV laboratory tests from the BC Centre for Disease Control were linked to administrative data pertaining to health services and drugs dispensed to estimate costs among case subjects and controls. The case group comprised HCV seropositive individuals (n=20,001), and the control group comprised single-tested, HCV seronegative persons (n=70,752) identified between January 1997 and December 2004. Subject observation time was assigned to the three following disease phases: initial phase (after diagnosis), late phase (late-stage liver disease) and predeath phase (12 months before death). Case subjects and controls were matched for age, sex and a propensity score within each phase to determine the net cost attributable to HCV seropositivity, and were adjusted for demographic and clinical factors.

RESULTS

Costs increased with disease progression, with hospitalization being the highest cost component in all phases. Initial and late phase net costs (2005 Canadian dollars) were $1,850 and $6,000 per patient per year, respectively. Costs among case subjects were driven by age, comorbidities, mental illness, illicit drug use and HIV coinfection. While predeath case subject and control costs were virtually the same, costs were high and case subjects died at a younger age.

CONCLUSION

HCV seropositivity is associated with increased medical costs driven by viral sequelae and medicosocial vulnerabilities (ie, mental illness, illicit drug use and HIV coinfection). Cost mitigation and health outcome improvements will require broad-based prevention programming to reduce vulnerabilities and HCV treatment to prevent disease progression, respectively.     

Transition: a future promise for children and adolescents with special health care needs and disabilities

Transitions are a part of everyone's life experience. Most young people with special health care needs and disabilities (SHCN/D) become independent partners in adult society, but some need deliberate guidance and support. This latter group is growing in number. Through a new consensus statement from the American Academy of Pediatrics and the U.S. Federal Government (Healthy People 2010), society is recognizing the need to assist young people with SHCN/D in attaining their potential in adulthood. This article discusses the growing number of young people with SHCN/D, their desires for their transition, the definition and areas of transition that should be addressed, and the key elements of successful transition programs. The article ends with a suggested list of actions a health care professional can undertake to foster a successful transition and a selected list of helpful resources for health professionals, families, and young people with SHCN/D.     

The longitudinal urban cohort ageing study (LUCAS): study protocol and participation in the first decade

Background

Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling frail older adults.

Methods/design

In a 2-year stepped-wedge cluster randomised clinical trial with 6-monthly measurements, the chronic care model will be compared with usual care. The trial will be carried out among 35 primary care practices in two regions in the Netherlands. Per region, practices will be randomly allocated to four allocation arms designating the starting point of the intervention. Participants: 1200 community-dwelling older adults aged 65 or over and their primary informal caregivers. Primary care physicians will identify frail individuals based on a composite definition of frailty and a polypharmacy criterion. Final inclusion criterion: scoring 3 or more on a disability case-finding tool. Intervention: Every 6 months patients will receive a geriatric in-home assessment by a practice nurse, followed by a tailored care plan. Expert teams will manage and train practice nurses. Patients with complex care needs will be reviewed in interdisciplinary consultations. Evaluation: We will perform an effect evaluation, an economic evaluation, and a process evaluation. Primary outcome is quality of life as measured with the Short Form-12 questionnaire. Effect analyses will be based on the ??intention-to-treat?? principle, using multilevel regression analysis. Cost measurements will be administered continually during the study period. A cost-effectiveness analysis and cost-utility analysis will be conducted comparing mean total costs to functional status, care needs and QALYs. We will investigate the level of implementation, barriers and facilitators to successful implementation and the extent to which the intervention manages to achieve the transition necessary to overcome challenges in elderly care.

Discussion

This is one of the first studies assessing the effectiveness, cost-effectiveness and implementation process of the chronic care model for frail community-dwelling older adults.

Trial registration

The Netherlands National Trial Register NTR2160.     

Spirometry in an unselected group of 6-year-old children: the DARC birth cohort study

This study presents reference equations for spirometric parameters in 6-year-old children and evaluates the ability of spirometry to discriminate healthy children from children with asthma. Baseline spirometry and respiratory symptoms were assessed in 404 children participating in a longitudinal birth cohort study. Children with known asthma, possible asthma and a control group also performed bronchodilator measurements. At least two acceptable flow-volume curves at baseline were obtained by 368/404 children (91%). The two best values for FEV1 and FVC were within 5% of each other in 88% and 83% of children, respectively. Linear regression analyses for 242 children included in the reference population demonstrated height to be the main predictor of all spirometric indices except FEV1/FVC. FEV1, FEV75, and FVC correlated reasonably to anthropometric data in contrast to flow parameters. Gender differences were found for FEV1, FVC, and FEV75, but not for flow parameters. Asthma was diagnosed in 25/404 children. Baseline lung function in healthy children and children with asthma overlapped, although asthmatic children could be discriminated to some extent. Bronchodilator tests showed a difference in Delta FEV1(mean) between healthy children and children with asthma (3.1% vs. 6.1%, P < 0.05). At a cut-off point of Delta FEV1 = 7.8%, bronchodilator tests had a sensitivity of 46% and a specificity of 92% for current asthma. Spirometry including bronchodilator measurements was demonstrated to be feasible in 6-year-old children and reference values were determined. Spirometry aids the diagnosis of asthma in young children, but knowledge on sensitivity and specificity of these measurements is a prerequisite.     

Non-valvular atrial fibrillation and cognitive decline: a longitudinal cohort study

OBJECTIVES: non-valvular atrial fibrillation (NVAF) is an established risk factor for thromboembolism and stroke. Small cross-sectional studies suggest associations between NVAF, silent cerebral infarction and decreased cognitive function. We compared change in cognitive function between patients with recent onset NVAF and controls 12 and 36 months after baseline assessment, and examined the impact of anti-thrombotic therapy. DESIGN: prospective longitudinal cohort study with follow-up at 12 and 36 months. SETTING: Sunderland and South Tyneside, North East of England. Participants: community-dwelling men and women aged over 60 with recently identified NVAF or in sinus rhythm, matched for age, sex and general practice (N = 362, 174 NVAF, 188 sinus rhythm). Participants were stratified for use of anti-thrombotic therapy. MEASUREMENTS: assessment included stroke risk factors and a comprehensive battery of neuropsychological tests. RESULTS: at 3 years, 74 cases and 86 controls remained, giving an attrition rate for cases (59%) versus controls (52%); p = 0.15. Analysis of change in cognitive function between baseline and follow-up at 12 and 36 months revealed no clinically important differences between cases and controls, nor between subgroups on aspirin, warfarin or neither. Age and other confounders did not influence the results. CONCLUSIONS: there was no association between overall cognitive decline and NVAF after 3 years' follow-up, nor any apparent effect of anti-thrombotic therapy. This is consistent with our baseline results, but conflicts with previous studies. Cognitive decline is probably multifactorial and any influence of NVAF was not identified in this study.     

Thyroid function in short children born small-for-gestational age (SGA) before and during GH treatment

Context  Disturbances in thyroid function have been described in small-for-gestational age (SGA) children but the influence of prematurity is unclear. In addition, the effect of GH treatment on thyroid function has not been studied in short SGA children.
Objectives  To determine whether short SGA children have higher TSH levels compared to age-matched controls and evaluate the influence of gestational age. To investigate whether GH treatment alters thyroid function.
Patients  A total of 264 short SGA children (116 preterm), prepubertal and non-GH deficient.
Measurements  Serum FT4 and TSH at baseline and after 6, 12 and 24 months of GH treatment.
Results  Baseline mean TSH was higher in preterm short SGA children than in age-matched controls ( P <  0·05). Mean FT4 was not significantly different between short SGA children and controls. Baseline FT4 or TSH did not correlate with gestational age, or SDS for birth weight, birth length, height, body mass index, IGF-I or IGFBP-3. Mean FT4 decreased significantly during the first 6 months of GH treatment, but remained within the normal range. TSH did not change during treatment. The change in FT4 did not correlate with the change in height SDS during 24 months of GH treatment.
Conclusion  Preterm short SGA children have higher, although within the normal range, TSH levels than controls. The level of TSH does not correlate with gestational age, birth weight SDS or birth length SDS. FT4 decreases during GH treatment, but is neither associated with an increase in TSH nor does it affect the response to GH treatment. As these mild alterations in thyroid function do not appear clinically relevant, frequent monitoring of thyroid function during GH therapy is not warranted in short SGA children.     

Morbidity in HIV-1-infected individuals before and after the introduction of antiretroviral therapy: a longitudinal study of a population-based cohort in Uganda

Background

We compared morbidities in HIV‐1‐infected patients before and after the introduction of antiretroviral therapy (ART) in a rural Ugandan cohort followed from 1990 to 2008. ART was introduced in 2004.

Methods

Random‐effects Poisson regression models were used to estimate incidence rates of World Health Organization (WHO) stage‐defining diseases in HIV‐infected individuals aged 13 years or older with known seroconversion dates, and in an age‐stratified sample of HIV‐negative individuals.

Results

The most common morbid event was bacterial pneumonia, with an incidence of 7.4/100 person‐years (pyr) among 309 HIV seroconverters and 1.3/100 pyr among 348 HIV‐negative participants [hazard ratio (HR) 5.64; 95% confidence interval (CI) 3.6–8.8]. Among seroconverters, the incidence of the acquisition of any WHO stage‐defining disease rose from 14.4/100 pyr (95% CI 11.1–18.6) in 1990–1998 to 46.0/100 pyr (95% CI 37.7–56.0) in 1999–2003. Following the introduction of ART, the incidence among seroconverters declined to 36.4/100 pyr (95% CI 27.1–48.9) in 2004–2005 and to 28.3/100 pyr (95% CI 21.2–37.8) in 2006–2008. At the individual level, a higher rate of acquiring any WHO stage‐defining disease was independently associated with lower CD4 cell count, longer duration of HIV infection and older age. In addition, individuals who had been on ART for longer than 12 months had a substantially lower rate of any WHO stage disease than those not yet on ART (adjusted HR 0.35; 95% CI 0.2–0.6).

Conclusion

Morbidity in HIV‐positive participants decreased following the introduction of ART, and this decline was more marked with increasing duration on ART. The benefits of decreased HIV‐related morbidity from ART lend support to urgent efforts to ensure universal access to early diagnosis of HIV infection and to ART, especially in rural Africa.     

Mortality of rheumatoid arthritis in Japan: a longitudinal cohort study

OBJECTIVE: To determine the mortality risk of Japanese patients with rheumatoid arthritis, taking into account lifestyle and physical factors, including comorbidity. METHODS: 91 individuals with rheumatoid arthritis were identified during screening a cohort of 16 119 Japanese atomic bomb survivors in the period 1958 to 1966. These individuals and the remainder of the cohort were followed for mortality until 1999. Mortality risk of the rheumatoid patients was estimated by the Cox proportional hazards model. In addition to age and sex, lifestyle and physical factors such as smoking status, alcohol consumption, blood pressure, and comorbidity were included as adjustment factors for the analysis of total mortality and for analysis of mortality from each cause of death. RESULTS: 83 of the rheumatoid patients (91.2%) and 8527 of the non-rheumatoid controls (52.9%) died during mean follow up periods of 17.8 and 28.0 years, respectively. The age and sex adjusted hazard ratio for mortality in the rheumatoid patients was 1.60 (95% confidence interval, 1.29 to 1.99), p < 0.001. Multiple adjustments, including for lifestyle and physical factors, resulted in a similar mortality hazard ratio of 1.57 (1.25 to 1.94), p < 0.001. Although mortality risk tended to be higher in male than in female rheumatoid patients, the difference was not significant. Pneumonia, tuberculosis, and liver disease were significantly increased as causes of death in rheumatoid patients. CONCLUSIONS: Rheumatoid arthritis is an independent risk factor for mortality. Infectious events are associated with increased mortality in rheumatoid arthritis.     

Social network ties before and after retirement: a cohort study

Social networks are associated with individual’s health and well-being. Working life offers opportunities to create and maintain social networks, while retirement may change these networks. This study examined how the number of ties in social network changes across the retirement transition. The study population consisted of 2319 participants (84% women, mean age 63.2 years) from the Finnish Retirement and Aging study. Information about social network ties, including the number of ties in the inner, middle and outer circles of the social convoy model, was gathered using annual postal surveys before and after retirement. Three repeat surveys per participant covered the retirement transition and the post-retirement periods. Mean number of network ties was 21.6 before retirement, of which 5.6 were situated in the inner, 6.9 in the middle and 9.1 in the outer circle. The number of ties in the outer circle decreased by 0.67 (95% CI − 0.92, − 0.42) during the retirement transition period, but not during the post-retirement period (0.11, 95% CI − 0.33, 0.12) (interaction period * time, p = 0.006). The pattern of change in these ties did not differ by gender, occupational status, marital status, number of chronic diseases and mental health during the retirement transition period. The number of ties in the inner and middle circles overall did not decrease during these periods. The number of peripheral relationships decreased during the retirement transition but not after that, suggesting that the observed reduction is more likely to be associated with retirement rather than aging.     

Pituitary-ovarian function before, during and after the menopause: a longitudinal study

The excretion of FSH, LH, oestrogens and pregnanediol was monitored once weekly in urine samples collected from eight peri-menopausal women aged 44-55 years (median, 52 years). Observations were commenced between 5 and 15 weeks before the menopause and were continued for 22-30 weeks after final menstruation. Amenorrhoea of greater than 2 years duration in association with a persistent elevation in gonadotrophin output was considered proof of the post-menopausal state. No clear hormonal change occurred at the time of the menopause. During the peri-menopause there is a transition from the regular ovulatory cycles of pre-menopausal women to the unvarying high gonadotrophin and low oestrogen excretion which is generally regarded as being characteristic of post-menopausal women. In the group studied, post-menopausal levels of FSH and LH were common before and episodes of high oestrogen excretion were not uncommon after final menstruation. Menstrual failure appeared to occur spontaneously at some stage during the transition from the pre- to the post-menopausal state, and not to be associated with its conclusion. From the hormonal point of view the immediately post-menopausal period could not be distinguished from the long cycles of peri-menopausal women. This suggests that an endometrial rather than a hormonal event might determine the time at which menstruation stops during the menopausal transition.     

Successful ageing trajectories at the end of life: a longitudinal population-based cohort study

BackgroundDespite the acknowledgment that successful ageing is a heterogeneous life-course process, present models of successful ageing are unable to accommodate decline at the end of life because of methodological and conceptual limitations. The present study aimed to address these limitations, identifying different trajectories of successful ageing at the end of life.MethodsThe Successful Ageing Index (SAI), which is a scale consisting of components identified by systematic reviews of layperson perspectives and operational definitions of successful ageing, was collected in a longitudinal population-based cohort study of individuals aged 75 years and older—the Cambridge City over-75s Cohort Study (CC75C). SAI scores were examined longitudinally with growth mixture modelling (GMM) to identify classes of participants with similar trajectories; in this model decedents’ (n=1015) last completed interview and up to four previous data collection waves before death were used. Classes identified by GMM were compared by means of logistic regression models.FindingsA three-class model was identified: a high-functioning, no decline (HN) class; a high-functioning, gradual decline (HG) class; and a low-functioning, steep decline (LS) class. Individuals in the HN class were significantly younger at death (88·3 years [SD 4·9]) than were those in the HG (89·9 [5·0], p<0·0001) and LS classes (90·5 [5·1], p<0·0001); were significantly younger at their last interview (82·9 years [3·6] vs 85·0 [4·2] in the HG class [p<0·0001] and 86·3 [4·7] in the LS class [p<0·0001]); consisted of more men (52% men vs 31% in the HG class [p<0·0001] and 22% in the LS class [p<0·0001]); and were more likely to be married (51% vs 24% in the HG class [p<0·0001] and 19% in the LS class [p=0·0001]).InterpretationSuccessful ageing trajectories at the end of life are heterogeneous; individuals can experience many different trajectories towards death. Methods used in this study provide novel insights into successful ageing at the end of life. The present study provides the methodological framework for future research, with important implications for policy and practice, as well as insights into the demographic characteristics of end of life trajectories.FundingNone.     

母体甲状腺功能紊乱或自身抗体阳性对围产期子代的影响:一项前瞻性队列研究

本文为一项大型前瞻性队列研究,从妊娠早期起即对受试者进行全面的生化检查,根据测定数据评估母体甲状腺功能紊乱和自体免疫对围产期结局(包括早产、出生体重和头围、分娩时胎位和围产期死亡率)的影响.本文即为该研究结果的报道.     

Mortality in adults with learning disabilities with and without a health check: a cohort study

BackgroundAnnual health checks in primary care were introduced in Wales in 2006, for adults with learning disability on the social services register. The health check includes screening for conditions such as diabetes, general health measures, and medication review. We aimed to compare mortality rates in individuals who have a health check and those with no record of having a health check in their medical records.MethodsWe stratified general practice records of 24 474 people with a learning disability in Wales by health check status (read code for a health check vs no health check). The Secure Anonymised Data Linkage databank was used to link general practitioner (GP) data and Office for National Statistics mortality data between Jan 1, 2005, and Dec 31, 2017. We used survival analysis (Cox's regression) to calculate unadjusted and adjusted (for age, sex, and comorbidity) mortality hazard ratios (HRs).FindingsOf the 24 474 people with a learning disability in Wales, 7542 (30·8%) had a confirmed health check and 16 932 (69·2%) had no record of a health check. Mortality rates were higher for people with a learning disability who have never received a health check than those who had received a health check (3·55 deaths per 1000 individuals per year in the non-health check group vs 2·08 deaths per 1000 individuals in the health check group). Among individuals with autism, mortality was lower among individuals who had a health check than those who had no check (HR 0·61, 95% CI 0·39–0·96; adjusted HR 0·53, 0·33–0·83 [adjusted for age and sex]). Among individuals with epilepsy, mortality was also lower among individuals who had a health check than those who had no check (HR 0·72, 0·64–0.81; adjusted HR 0·65, 0·58–0·74 [adjusted for age and sex]) and the same trend was observed among individuals with diabetes (HR 0·77, 0·64–0·92; adjusted HR 0·71, 0·60–0·84). The largest differences in mortality between individuals with and without a health check were observed among individuals aged 18-50 years (adjusted HR 0·46, 0·39–0·50 [adjusted for comorbidity and sex]), with a smaller difference in mortality identified among individuals aged older than 50 years at their first health check (adjusted HR 0·81, 0·72–0·90 [adjusted for comorbidity and sex]).InterpretationMortality is lower among people with learning disabilities who have health checks than those who do not. Our findings suggest that health checks provide long-term benefit, especially for younger people.FundingWelsh Assembly Government.