@article {11523, title = {A Novel Metric for Developing Easy-to-Use and Accurate Clinical Prediction Models: The Time-cost Information Criterion.}, journal = {Medical Care}, volume = {59}, year = {2021}, pages = {418-424}, abstract = {

BACKGROUND: Guidelines recommend that clinicians use clinical prediction models to estimate future risk to guide decisions. For example, predicted fracture risk is a major factor in the decision to initiate bisphosphonate medications. However, current methods for developing prediction models often lead to models that are accurate but difficult to use in clinical settings.

OBJECTIVE: The objective of this study was to develop and test whether a new metric that explicitly balances model accuracy with clinical usability leads to accurate, easier-to-use prediction models.

METHODS: We propose a new metric called the Time-cost Information Criterion (TCIC) that will penalize potential predictor variables that take a long time to obtain in clinical settings. To demonstrate how the TCIC can be used to develop models that are easier-to-use in clinical settings, we use data from the 2000 wave of the Health and Retirement Study (n=6311) to develop and compare time to mortality prediction models using a traditional metric (Bayesian Information Criterion or BIC) and the TCIC.

RESULTS: We found that the TCIC models utilized predictors that could be obtained more quickly than BIC models while achieving similar discrimination. For example, the TCIC identified a 7-predictor model with a total time-cost of 44 seconds, while the BIC identified a 7-predictor model with a time-cost of 119 seconds. The Harrell C-statistic of the TCIC and BIC 7-predictor models did not differ (0.7065 vs. 0.7088, P=0.11).

CONCLUSION: Accounting for the time-costs of potential predictor variables through the use of the TCIC led to the development of an easier-to-use mortality prediction model with similar discrimination.

}, keywords = {Bayesian Information Criterion, Methodology}, issn = {1537-1948}, doi = {10.1097/MLR.0000000000001510}, author = {Lee, Sei J and Alexander K Smith and Ramirez-Diaz, Ledif G and Kenneth E Covinsky and Gan, Siqi and Chen, Catherine L and W John Boscardin} } @article {9512, title = {Chronic disease burden predicts food insecurity among older adults.}, journal = {Public Health Nutrition}, volume = {21}, year = {2018}, pages = {1737-1742}, abstract = {

OBJECTIVE: Increased out-of-pocket health-care expenditures may exert budget pressure on low-income households that leads to food insecurity. The objective of the present study was to examine whether older adults with higher chronic disease burden are at increased risk of food insecurity.

DESIGN: Secondary analysis of the 2013 Health and Retirement Study (HRS) Health Care and Nutrition Study (HCNS) linked to the 2012 nationally representative HRS.

SETTING: USA.

SUBJECTS: Respondents of the 2013 HRS HCNS with household incomes <300 \% of the federal poverty line (n 3552). Chronic disease burden was categorized by number of concurrent chronic conditions (0-1, 2-4, >=5 conditions), with multiple chronic conditions (MCC) defined as >=2 conditions.

RESULTS: The prevalence of food insecurity was 27{\textperiodcentered}8 \%. Compared with those having 0-1 conditions, respondents with MCC were significantly more likely to report food insecurity, with the adjusted odds ratio for those with 2-4 conditions being 2{\textperiodcentered}12 (95 \% CI 1{\textperiodcentered}45, 3{\textperiodcentered}09) and for those with >=5 conditions being 3{\textperiodcentered}64 (95 \% CI 2{\textperiodcentered}47, 5{\textperiodcentered}37).

CONCLUSIONS: A heavy chronic disease burden likely exerts substantial pressure on the household budgets of older adults, creating an increased risk for food insecurity. Given the high prevalence of food insecurity among older adults, screening those with MCC for food insecurity in the clinical setting may be warranted in order to refer to community food resources.

}, keywords = {Chronic conditions, Comorbidity, Food insecurity}, issn = {1475-2727}, doi = {10.1017/S1368980017004062}, author = {Jih, Jane and Stijacic-Cenzer, Irena and Hilary K Seligman and W John Boscardin and Thu T Nguyen and Christine S Ritchie} } @article {8678, title = {Rates of Recovery to Pre-Fracture Function in Older Persons with Hip Fracture: an Observational Study.}, journal = {J Gen Intern Med}, volume = {32}, year = {2017}, month = {2017 Feb}, pages = {153-158}, abstract = {

BACKGROUND: Knowledge about expected recovery after hip fracture is essential to help patients and families set realistic expectations and plan for the future.

OBJECTIVES: To determine rates of functional recovery in older adults who sustained a hip fracture based on one{\textquoteright}s previous function.

DESIGN: Observational study.

PARTICIPANTS: We identified subjects who sustained a hip fracture while enrolled in the nationally representative Health and Retirement Study (HRS) using linked Medicare claims. HRS interviews subjects every 2~years. Using information from interviews collected during the interview preceding the fracture and the first interview 6 or more months after the fracture, we determined the proportion of subjects who returned to pre-fracture function.

MAIN MEASURES: Functional outcomes of interest were: (1) ADL dependency, (2) mobility, and (3) stair-climbing ability. We examined baseline characteristics associated with a return to: (1) ADL independence, (2) walking one block, and (3) climbing a flight of stairs.

KEY RESULTS: A total of 733 HRS subjects >=65~years of age sustained a hip fracture (mean age 84 {\textpm} 7~years, 77~\% female). Thirty-one percent returned to pre-fracture ADL function, 34~\% to pre-fracture mobility function, and 41~\% to pre-fracture climbing function. Among those who were ADL independent prior to fracture, 36~\% returned to independence, 27~\% survived but needed ADL assistance, and 37~\% died. Return to ADL independence was less likely for those >=85~years old (26~\% vs. 44~\%), with dementia (8~\% vs. 39~\%), and with a Charlson comorbidity score >2 (23~\% vs. 44~\%). Results were similar for those able to walk a block and for those able to climb a flight of stairs prior to fracture.

CONCLUSIONS: Recovery rates are low, even among those with higher levels of pre-fracture functional status, and are worse for patients who are older, cognitively impaired, and who have multiple comorbidities.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Comorbidity, Dementia, Female, Geriatric Assessment, Hip Fractures, Humans, Longitudinal Studies, Male, Mobility Limitation, Recovery of Function, Walking}, issn = {1525-1497}, doi = {10.1007/s11606-016-3848-2}, author = {Victoria L. Tang and Rebecca L. Sudore and Irena Cenzer and W John Boscardin and Alexander K Smith and Christine S Ritchie and Margaret Wallhagen and Finlayson, Emily and Petrillo, Laura and Kenneth E Covinsky} } @article {8501, title = {One-Year Mortality After Hip Fracture: Development and Validation of a Prognostic Index.}, journal = {J Am Geriatr Soc}, volume = {64}, year = {2016}, month = {2016 09}, pages = {1863-8}, abstract = {

OBJECTIVES: To develop a prediction index for 1-year mortality after hip fracture in older adults that includes predictors from a wide range of domains.

DESIGN: Retrospective cohort study.

SETTINGS: Health and Retirement Study (HRS).

PARTICIPANTS: HRS participants who experienced hip fracture between 1992 and 2010 as identified according to Medicare claims data (N = 857).

MEASUREMENTS: Outcome measure was death within 1 year of hip fracture. Predictor measures were participant demographic characteristics, socioeconomic status, social support, health, geriatric symptoms, and function. Variables independently associated with 1-year mortality were identified, and best-subsets regression was used to identify the final model. The selected variables were weighted to create a risk index. The index was internally validated using bootstrapping to estimate model optimism.

RESULTS: Mean age at time of hip fracture was 84, and 76\% of the participants were women. There were 235 deaths (27\%) during the 1-year follow up. Five predictors of mortality were included in the final model: aged 90 and older (2 points), male sex (2 points), congestive heart failure (2 points), difficulty preparing meals (2 points), and not being able to drive (1 point). The point scores of the index were associated with 1-year mortality, with 0 points predicting 10\% risk and 7 to 9 points predicting 66\% risk. The c-statistic for the final model was 0.73, with an estimated optimism penalty of 0.01, indicating very little evidence of overfitting.

CONCLUSION: The prognostic index combines demographic, comorbidity, and function variables and can be used to differentiate between individuals at low and high risk of 1-year mortality after hip fracture.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Cause of Death, Cohort Studies, Comorbidity, Disability Evaluation, Female, Hip Fractures, Humans, Incidence, Longitudinal Studies, Male, Prognosis, Retrospective Studies, Risk Assessment, Survival Analysis, United States}, issn = {1532-5415}, doi = {10.1111/jgs.14237}, url = {http://www.ncbi.nlm.nih.gov/pubmed/27295578}, author = {Irena Cenzer and Victoria L. Tang and W John Boscardin and Christine S Ritchie and Margaret Wallhagen and Espaldon, Roxanne and Kenneth E Covinsky} } @article {8679, title = {Prevalence and Outcomes of Breathlessness in Older Adults: A National Population Study.}, journal = {J Am Geriatr Soc}, volume = {64}, year = {2016}, month = {2016 10}, pages = {2035-2041}, abstract = {

OBJECTIVES: To determine the prevalence and outcomes of breathlessness in older Americans.

SETTING: Community-dwelling older adults.

PARTICIPANTS: Individuals aged 70 and older in the nationally representative Health and Retirement Study (2008, follow-up through 2012) (N = 3,671; mean age 78).

MEASUREMENTS: Breathlessness was assessed by asking the question, "How often do you become short of breath while awake?" Responses of often or sometimes were considered to represent a level of breathlessness sufficient to warrant clinical attention. The prevalence of breathlessness is described overall and in subpopulations, then rates of associated symptoms, well-being, and health services use of participants who were breathless are compared with rates of those who were not. The risk of decline in activities of daily living (ADLs) and death through 2012 was estimated by creating a multivariable Cox proportional hazards model, adjusting for age, sex, race and ethnicity, and education.

RESULTS: Twenty-five percent of participants reported breathlessness. The prevalence of breathlessness was higher in certain subpopulations: chronic lung disease (63\%), multimorbidity (>=2 chronic conditions) (45\%), current smokers (38\%), heart disease (36\%), obesity (body mass index >=30.0 kg/m ) (33\%), and education less than high school (32\%). Breathlessness was associated with higher rates of depression, anxiety, and severe fatigue; lower ratings of well-being; and higher rates of clinic and emergency department visits and hospitalizations (all P < .001). Breathlessness predicted ADL decline over 5 years (adjusted hazard ratio (aHR) = 1.43, 95\% confidence interval (CI) = 1.22-1.68) and death (aHR 1.62, 95\% CI = 1.32-2.02).

CONCLUSION: One in four adults aged 70 and older in the United States experiences breathlessness, which is associated with lack of well-being, greater health services use, and a 40\% greater risk of worsened function and 60\% greater risk of death over the next 5 years.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Anxiety, Chronic disease, Comorbidity, depression, Dyspnea, Female, Geriatric Assessment, Hospitalization, Humans, Male, Prevalence, Proportional Hazards Models, Risk Assessment, Risk Factors, Symptom Assessment, United States}, issn = {1532-5415}, doi = {10.1111/jgs.14313}, author = {David C. Currow and Amy P Abernethy and Miriam J Johnson and Yinghui Miao and W John Boscardin and Christine S Ritchie} } @article {8506, title = {Self-Reported Hearing in the Last 2 Years of Life in Older Adults.}, journal = {J Am Geriatr Soc}, volume = {64}, year = {2016}, month = {2016 07}, pages = {1486-91}, abstract = {

OBJECTIVES: To assess the prevalence and correlates of self-reported hearing loss during the last 2 years of life.

DESIGN: Observational cohort study.

SETTING: The Health and Retirement Study (HRS), a longitudinal nationally representative cohort of adults aged 50 and older (2000-13).

PARTICIPANTS: Older adults (N = 5,895, mean age at death 78, 53\% female, 20\% nonwhite).

MEASUREMENTS: The HRS interview closest to death was used (mean 12.2 months before death). Participants rated their hearing (excellent, very good, good, fair, poor) and indicated whether they used hearing aids. The prevalence and correlates of fair and poor ratings are described, adjusted for age and sex.

RESULTS: Thirty-two percent (95\% confidence interval (CI) = 31-34\%) of all participants and 60\% (95\% CI = 57-64\%) of the 7\% of participants who used hearing aids rated their hearing as fair or poor. The prevalence of fair or poor hearing was highest in participants interviewed closest to death (29\% 19-24 months before death, 36\% 1-6 months before death, P for trend = .01). Correlates of fair or poor hearing during the last 2 years of life included age at death (50-59, 22\%; 60-69, 21\%; 70-79, 26\%; 80-89, 38\%; >=90, 50\%), sex (men 35\%, women 30\%), race and ethnicity (Hispanic 42\%, white 33\%), wealth (lowest quartile 38\%, highest quartile 27\%), history of heart disease (yes 38\%, no 27\%), activity of daily living dependence (yes 42\%, no 26\%), difficulty taking medications (yes 46\%, no 29\%), and probable dementia (yes 44\%, no 24\%).

CONCLUSION: Self-reported hearing loss increases during the last 2 years of life and is associated with physical and social vulnerability.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, California, Demography, Female, Hearing aids, Hearing loss, Humans, Longitudinal Studies, Male, Middle Aged, Prevalence, Quality of Life, Risk Factors, Self Report, Vulnerable Populations}, issn = {1532-5415}, doi = {10.1111/jgs.14145}, url = {http://www.ncbi.nlm.nih.gov/pubmed/27341383}, author = {Christine S Ritchie and Yinghui Miao and W John Boscardin and Margaret Wallhagen} } @article {8224, title = {Discrimination in Healthcare Settings is Associated with Disability in Older Adults: Health and Retirement Study, 2008-2012.}, journal = {J Gen Intern Med}, volume = {30}, year = {2015}, note = {Export Date: 29 May 2015 Article in Press}, month = {2015 Oct}, pages = {1413-20}, publisher = {30}, abstract = {

BACKGROUND: As our society ages, improving medical care for an older population will be crucial. Discrimination in healthcare may contribute to substandard experiences with the healthcare system, increasing the burden of poor health in older adults. Few studies have focused on the presence of healthcare discrimination and its effects on older adults.

OBJECTIVE: We aimed to examine the relationship between healthcare discrimination and new or worsened disability.

DESIGN: This was a longitudinal analysis of data from the nationally representative Health and Retirement Study administered in 2008 with follow-up through 2012.

PARTICIPANTS: Six thousand and seventeen adults over the age of 50 years (mean age 67 years, 56.3 \% female, 83.1 \% white) were included in this study.

MAIN MEASURES: Healthcare discrimination assessed by a 2008 report of receiving poorer service or treatment than other people by doctors or hospitals (never, less than a year=infrequent; more than once a year=frequent). Outcome was self-report of new or worsened disability by 2012 (difficulty or dependence in any of six activities of daily living). We used a Cox proportional hazards model adjusting for age, race/ethnicity, gender, net worth, education, depression, high blood pressure, diabetes, cancer, lung disease, heart disease, stroke, and healthcare utilization in the past 2 years.

KEY RESULTS: In all, 12.6 \% experienced discrimination infrequently and 5.9 \% frequently. Almost one-third of participants (29 \%) reporting frequent healthcare discrimination developed new or worsened disability over 4 years, compared to 16.8 \% of those who infrequently and 14.7 \% of those who never experienced healthcare discrimination (p < 0.001). In multivariate analyses, compared to no discrimination, frequent healthcare discrimination was associated with new or worsened disability over 4 years (aHR = 1.63, 95 \% CI 1.16-2.27).

CONCLUSIONS: One out of five adults over the age of 50 years experiences discrimination in healthcare settings. One in 17 experience frequent healthcare discrimination, and this is associated with new or worsened disability by 4 years. Future research should focus on the mechanisms by which healthcare discrimination influences disability in older adults to promote better health outcomes for an aging population.

}, keywords = {Activities of Daily Living, Aged, Ageism, Aging, Disabled Persons, Female, Follow-Up Studies, Health Status, Humans, Longitudinal Studies, Male, Middle Aged, Retirement, Surveys and Questionnaires}, issn = {1525-1497}, doi = {10.1007/s11606-015-3233-6}, url = {http://www.scopus.com/inward/record.url?eid=2-s2.0-84924662760andpartnerID=40andmd5=4aaf0227e962a58fb0e6670d3d3c6bff}, author = {Stephanie E Rogers and Angela D Thrasher and Yinghui Miao and W John Boscardin} } @article {8229, title = {Increase in Disability Prevalence Before Hip Fracture.}, journal = {J Am Geriatr Soc}, volume = {63}, year = {2015}, note = {Times Cited: 0 0}, month = {2015 Oct}, pages = {2029-35}, publisher = {63}, abstract = {

OBJECTIVES: To establish the prevalence and correlates of disability during the 2 years before hip fracture.

DESIGN: Data from participants who experienced hip fracture in the Health and Retirement Study (HRS) with hip fracture identified using linked Medicare claims. Each participant was interviewed at varying time points in the 2 years before hip fracture. Disability was defined as self-report of the need for assistance in any activity of daily living (walking across the room, eating, bathing, dressing, using the toilet, transferring). Based on the timing between interview and hip fracture, prevalence of disability was calculated in the cohort as a whole over the 2 years before hip fracture and in subgroups defined according to demographic and clinical characteristics.

SETTING: The HRS is a nationally representative longitudinal study (1992-2010).

PARTICIPANTS: HRS participants aged >=65 with hip fracture (mean age at fracture 84, 77\% female).

RESULTS: The adjusted prevalence of disability was 20\% (95\% confidence interval (CI) = 14-25\%) 2 years before hip fracture, with little change until approximately 10 months before fracture, when it started to rise, reaching 44\% (95\% CI = 33-55\%) in the month before hip fracture. The prevalence of disability was highest in the last month before fracture for persons aged 85 and older (53\%) and for those with dementia (60\%).

CONCLUSION: Care models for hip fracture need to consider not only the acute medical and surgical needs, but also the high level of need for supportive care and caregiver assistance that chronically disabled individuals require.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Dementia, Disability Evaluation, Disabled Persons, Educational Status, Female, Health Surveys, Hip Fractures, Humans, Income, Male, Mobility Limitation, Prevalence, United States}, issn = {1532-5415}, doi = {10.1111/jgs.13658}, author = {Irena Cenzer and W John Boscardin and Christine S Ritchie and Margaret Wallhagen and Kenneth E Covinsky} } @article {8746, title = {Subjective, Objective, and Observed Long-term Survival}, journal = {JAMA Internal Medicine}, volume = {175}, year = {2015}, month = {Jan-12-2015}, pages = {1986}, abstract = {Many professional guidelines recommend using life expectancy when considering diagnostic or treatment interventions in which the time to benefit may exceed patients{\textquoteright} survival.1 When subjected to such tests and treatments, these patients are put at risk for up-front harms with little chance of reaping benefits.2 Patients{\textquoteright} perceptions of prognosis are important. Clinicians who follow recommended guidelines may urge patients to change health routines to which they have become accustomed. Patients who underestimate their survival may choose to forego interventions that are likely to help them, while those who overestimate may choose to undergo interventions that are more likely to cause harm. However, little is known about how well older adults estimate their survival, the aim of this analysis. Methods We drew a sample of 64-, 69-, 74-, 79-, 84-, and 89-year-old participants in the 2000 wave of the Health and Retirement Study (HRS), a nationally representative, longitudinal, prospective cohort study of adults in the United States.3 Institutional review board approval for HRS was received from the University of California, San Francisco, Committee on Human Research. Informed consent was obtained by HRS at the time of the interview. Our variable of interest was participants{\textquoteright} subjective estimate of long-term survival, assessed by the question, {\textquotedblleft}What is the percent chance you will live to be x or more?{\textquotedblright} where x was 75, 80, 85, 90, 95, or 100 years old. Our sampling strategy ensured that all participants predicted survival across the same period. We calculated an objective estimate of life expectancy using the Lee life expectancy calculator.4 Observed survival was determined using mortality through 2010 (confirmed using the National Death Index). We compared participants{\textquoteright} subjective estimates to observed survival (using the C statistic) and the objective estimates (using a best-fit analysis). Participants were classified as underestimating or overestimating their survival if their estimate was more than 25 percentage points less or greater than the calculated prediction, respectively. Results A total of 2018 respondents of the specified ages were interviewed directly in the 2000 wave of the HRS, and our final sample included 1722 participants who had complete responses necessary for the calculator (56\% female, 88\% white). We combined the 84- and 89-year-olds because of the small number of respondents in each group. Overall, discrimination was moderate for participants{\textquoteright} subjective estimates of survival compared with observed survival (C statistic = 0.62; P < .001). The 64- and 69-year-olds were moderately able to estimate their survival (C statistic = 0.62 and 0.58, respectively; P < .001 for both), but older participants fared no better than chance (Table). Substantial dissimilarity was seen between participants{\textquoteright} subjective and the objective estimates of survival (Figure). Overall, 54.7\% of participants had estimates similar to the objective calculation; however, 32.7\% underestimated and 11.5\% overestimated. Underestimation was relatively similar across age groups, but overestimation increased significantly with age (Table) (P < .001). Discussion Our findings have important implications for clinicians. First, approximately half the time, participants accurately estimated survival compared with an objective clinical estimate, and when in error, they were more likely to underestimate than overestimate. Consequently, disclosing prognosis is not necessarily bad news. Second, because of the substantial dissimilarity between the subjective and objective estimates, patients may be hesitant to follow guideline recommendations to change long-standing regimens. Third, our findings make a case for using prognostic calculators, which were more accurate than participants{\textquoteright} subjective estimates and have been shown to be superior to clinician estimates.5 Fourth, participants in the HRS were willing to make an estimate of their survival and report it. Previous research suggests that older adults are generally willing to discuss long-term prognosis.6 Clinicians should solicit patients{\textquoteright} individual perception of prognosis and use this information as a starting point for further discussion, particularly among older patients who may be more prone to errors. Then, in conjunction with prognostic tools, they can begin to bridge the gap between subjective and objective estimates of survival.}, keywords = {Health Conditions and Status, Mortality, Older Adults, Self-reported health}, issn = {2168-6106}, doi = {10.1001/jamainternmed.2015.5542}, url = {http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2015.5542}, author = {Rafael D Romo and Sei J. Lee and Yinghui Miao and W John Boscardin} }