%0 Journal Article %J Journal of the American Geriatrics Society %D 2023 %T Can markers of disease severity improve the predictive power of claims-based multimorbidity indices? %A Rizzo, Anael %A Jing, Bocheng %A Boscardin, W John %A Shah, Sachin J %A Steinman, Michael A %K Hospitalization %K Medicare %K multimorbidity %K Patient Acuity %X

BACKGROUND: Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden.

METHODS: We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases.

RESULTS: Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (<0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers.

CONCLUSIONS: Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.

%B Journal of the American Geriatrics Society %V 71 %P 845-857 %G eng %N 3 %R 10.1111/jgs.18150 %0 Journal Article %J Journal of the American Geriatrics Society %D 2023 %T Development and validation of novel multimorbidity indices for older adults. %A Steinman, Michael A %A Jing, Bocheng %A Shah, Sachin J %A Rizzo, Anael %A Lee, Sei J %A Covinsky, Kenneth E %A Ritchie, Christine S %A Boscardin, W John %K claims data %K functional impairment %K multimorbidity %K prognostic models %X

BACKGROUND: Measuring multimorbidity in claims data is used for risk adjustment and identifying populations at high risk for adverse events. Multimorbidity indices such as Charlson and Elixhauser scores have important limitations. We sought to create a better method of measuring multimorbidity using claims data by incorporating geriatric conditions, markers of disease severity, and disease-disease interactions, and by tailoring measures to different outcomes.

METHODS: Health conditions were assessed using Medicare inpatient and outpatient claims from subjects age 67 and older in the Health and Retirement Study. Separate indices were developed for ADL decline, IADL decline, hospitalization, and death, each over 2 years of follow-up. We validated these indices using data from Medicare claims linked to the National Health and Aging Trends Study.

RESULTS: The development cohort included 5012 subjects with median age 76 years; 58% were female. Claims-based markers of disease severity and disease-disease interactions yielded minimal gains in predictive power and were not included in the final indices. In the validation cohort, after adjusting for age and sex, c-statistics for the new multimorbidity indices were 0.72 for ADL decline, 0.69 for IADL decline, 0.72 for hospitalization, and 0.77 for death. These c-statistics were 0.02-0.03 higher than c-statistics from Charlson and Elixhauser indices for predicting ADL decline, IADL decline, and hospitalization, and <0.01 higher for death (p < 0.05 for each outcome except death), and were similar to those from the CMS-HCC model. On decision curve analysis, the new indices provided minimal benefit compared with legacy approaches. C-statistics for both new and legacy indices varied substantially across derivation and validation cohorts.

CONCLUSIONS: A new series of claims-based multimorbidity measures were modestly better at predicting hospitalization and functional decline than several legacy indices, and no better at predicting death. There may be limited opportunity in claims data to measure multimorbidity better than older methods.

%B Journal of the American Geriatrics Society %V 71 %P 121-135 %G eng %N 1 %R 10.1111/jgs.18052 %0 Journal Article %J J Am Geriatr Soc %D 2023 %T Medication misuse and overuse in community-dwelling persons with dementia. %A Deardorff, W James %A Jing, Bocheng %A Growdon, Matthew E %A Yaffe, Kristine %A Boscardin, W John %A Boockvar, Kenneth S %A Steinman, Michael A %X

BACKGROUND: Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD.

METHODS: We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative.

RESULTS: Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively.

CONCLUSION: Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.

%B J Am Geriatr Soc %G eng %R 10.1111/jgs.18463 %0 Journal Article %J Innovation in Aging %D 2022 %T UNNECESSARY AND HARMFUL MEDICATION USE IN COMMUNITY DWELLING PERSONS WITH DEMENTIA %A Deardorff, W James %A Jing, Bocheng %A Growdon, Matthew %A Yaffe, Kristine %A Boockvar, Kenneth S %A Steinman, Michael A. %K community dwelling %K Medication %X Persons with dementia (PWD) often have multiple comorbidities which results in extensive medication use despite potentially limited benefit and increased risk of adverse events. Compared to the nursing home, little is known about medication overuse and misuse among the ~70% of PWD in the community. Therefore, we examined medication use from Medicare Part D prescriptions among 1,289 community-dwelling PWD aged ≥66 from the Health and Retirement Study. We classified medication overuse as over-aggressive treatment of chronic conditions (e.g., insulin/sulfonylurea use with hemoglobin A1c<7.5%) and medications inappropriate near the end of life. We classified medication misuse as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics) and problematic medications (using Beers and STOPP criteria). We describe the prevalence and patterns of different types of medication overuse/misuse. Frequently problematic medications included antipsychotics (9%), benzodiazepines (12%), and gabapentinoids (13%). Our findings highlight the burden of unnecessary/harmful medications among PWD and inform future deprescribing interventions. %B Innovation in Aging %V 6 %P 414 %G eng %N Suppl 1 %R 10.1093/geroni/igac059.1626 %0 Journal Article %J JAMA Surgery %D 2020 %T Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery %A Victoria L. Tang %A Jing, Bocheng %A W John Boscardin %A Ngo, Sarah %A Silvestrini, Molly %A Finlayson, Emily %A Kenneth E Covinsky %K Cognition %K Mortality %K Surgery %X More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults.To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery.Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery.Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy.Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors.Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55\%) were women, 99 (7\%) underwent abdominal aortic aneurysm repair, 686 (51\%) coronary artery bypass graft, and 556 (42\%) colectomy; 223 (17\%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29\% vs 13\%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21\% vs 14\%; aHR, 1.32; P = .05), the inability to walk several blocks (17\% vs 11\%; aHR, 1.64; P = .01), dementia (21\% vs 12\%; aHR, 1.91; P = .03), and depression (19\% vs 12\%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0\%; 1 factor: 16.2\%; 2 factors: 27.8\%).In this older adult cohort, 223 participants (17\%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling. %B JAMA Surgery %G eng %U https://jamanetwork.com/journals/jamasurgery/article-abstract/2762522 %9 Journal %R 10.1001/jamasurg.2020.0091