Faculty Bibliography

Little is known about ecstasy/MDMA use among Asian American and Pacific Islander populations. Research is important because AAPIs face unique cultural factors that may influence use. We estimated the prevalence and correlates of lifetime ecstasy/MDMA use based on a representative sample of US AAPI adults aged ≥18 from the 2015-2020 National Survey on Drug Use and Health. An estimated 5.1% of AAPI adults used ecstasy in their lifetime. Compared to males, females had higher odds of use (aOR = 1.45, 95% CI: 1.08-1.98). Compared to those aged 18-25, those aged 26-34 were at increased odds for use (aOR = 1.99, 95% CI: 1.30-3.06), while those aged ≥50 were at lower odds for use. Lifetime use of other substances including cannabis (aOR = 28.4, 95% CI: 17.1-47.2), ketamine (aOR = 10.9, 95% CI: 1.63-73.4), LSD (aOR = 3.82, 95% CI: 1.98-7.37), cocaine (aOR = 3.77, 95% CI: 2.54-5.59), psilocybin (aOR = 3.29, 95% CI: 1.75-6.16), prescription opioids (aOR = 2.43, 95% CI: 1.44-4.09), and prescription stimulants (aOR = 1.96, 95% CI: 1.29-2.99) were associated with increased odds of ecstasy/MDMA use. We estimated that over 1 in 20 AAPI adults have ever used ecstasy/MDMA. Variations by age, sex, family income, substance type, and mental health service utilization emphasize the need for targeted public health strategies.

RATIONALE & OBJECTIVE/OBJECTIVE:Despite substantial growth in the population of older adults with kidney disease, there remains a lack of evidence to guide clinical care for this group. The Kidney Disease and Aging Research Collaborative (KDARC) conducted a Delphi study to build consensus on research priorities for clinical geriatric nephrology. STUDY DESIGN/METHODS:Asynchronous modified Delphi study. SETTING & PARTICIPANTS/METHODS:Clinicians and researchers in the US and Canada with clinical experience and/or research expertise in geriatric nephrology. OUTCOME/RESULTS:Research priorities in geriatric nephrology. ANALYTICAL APPROACH/METHODS:In the first Delphi round, participants submitted free-text descriptions of research priorities considered important for improving the clinical care of older adults with kidney disease. Delphi moderators used inductive content analysis to group concepts into categories. In the second and third rounds, participants iteratively reviewed topics, selected their top 5 priorities, and offered comments used to revise categories. RESULTS:Among 121 who were invited, 57 participants (47%) completed the first Delphi round and 48 (84% of enrolled participants) completed all rounds. After 3 rounds, the 5 priorities with the highest proportion of agreement were: 1) Communication and Decision-Making about Treatment Options for Older Adults with Kidney Failure (69% agreement), 2) Quality of Life, Symptom Management, and Palliative Care (67%), 3) Frailty and Physical Function (54%), 4) Tailoring Therapies for Kidney Disease to Specific Needs of Older Adults (42%), and 5) Caregiver and Social Support (35%). Health equity and person-centricity were identified as cross-cutting features that informed all topics. LIMITATIONS/CONCLUSIONS:Relatively low response rate and limited participation by private practitioners and older clinicians and researchers. CONCLUSIONS:Experts in geriatric nephrology identified clinical research priorities with the greatest potential to improve care for older adults with kidney disease. These findings provide a roadmap for the geriatric nephrology community to harmonize and maximize the impact of research efforts.

BACKGROUND:Tobacco use continues to take the lives of many, and targeted interventions can counter this health burden. One possible target population is patients who have had a smoking-related diagnosis, as they may have a greater drive to quit. OBJECTIVE:To assess whether patients with previous cardiac or pulmonary conditions directly attributable to smoking have greater rates of abstinence post-discharge from hospitalization in the CHART-NY trial. DESIGN/METHODS:CHART-NY was a randomized comparative effectiveness trial comparing a more intensive versus a less intensive smoking cessation intervention after hospital discharge. We divided the 1618 CHART-NY participants into a smoking-related history group of 597 and a nonsmoking-related history group of 1021 based on cardiac or pulmonary conditions in a retrospective chart review. We conducted chi-squared analyses on baseline characteristics. Using follow-up survey data, we conducted chi-squared analyses on abstinence outcomes and made logistic regression models for the predictive value of smoking-related conditions on abstinence. PARTICIPANTS/METHODS:A total of 1059 and 1084 participants in CHART-NY who completed both 2- and 6-month follow-up surveys respectively. MAIN MEASURES/METHODS:Self-reported 30-day abstinence at 2- and 6-month follow-up and survey data for baseline characteristics. KEY RESULTS/RESULTS:Those abstinent at 6-month follow-up were more likely to have a smoking-attributable history (OR = 1.40, 95% CI 1.09-1.81). When stratified based on intervention, only the intensive counseling group was significant (OR = 1.53, 95% CI 1.08-2.17). The regression model using a smoking-related comorbidity score was significant at 6 months (OR = 1.29, p = 0.03), and the multivariate logistic regression model analyzing each smoking-related condition separately demonstrated significance for myocardial infarction at 6 months (OR = 1.66, p = 0.03). CONCLUSIONS:People who smoke who have experienced smoking-related conditions may be more likely to benefit from smoking cessation interventions, especially intensive telephone-based counseling. Multiple conditions had an additive effect in predicting long-term abstinence after intervention, and myocardial infarction had the greatest predictive value.

IMPORTANCE/UNASSIGNED:The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness. OBJECTIVE/UNASSIGNED:To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded. INTERVENTION/UNASSIGNED:A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff. MAIN OUTCOME AND MEASURES/UNASSIGNED:The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months. RESULTS/UNASSIGNED:There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03424109.

Inner strength, one's internal process of moving through challenging circumstances, has not been described in persons living with mild cognitive impairment (MCI). This qualitative study used the Listening Guide methodology to explore experiences of inner strength in persons newly diagnosed with MCI. We analyzed 36 joint and individual semi-structured interviews with nine participants with MCI and nine care partners. Analytic poems represented three themes explaining inner strength experiences. In the foundational theme, Me with MCI, participants reconfigured their sense of self. The theme Vacillating between Seeking Relief and Dwelling in Challenge illustrated adjusting to life with MCI. The theme You Get through It characterized inner strengths including perseverance, optimism, accepting MCI, and seeking help. Each participant's inner strength profile was unique and impacted by cognitive impairment, and therefore benefitted from support. Though limited by homogeneity, this study highlights Listening Guide utility and has implications for strengths-based interventions and nursing practice.

OBJECTIVE:Examine the relationship between race and ethnicity and area-level social deprivation and Medicare home health care (HHC) agency quality for seriously ill older adults receiving HHC. METHODS:A linear probability fixed effects model analyzed the association between patient-level predictors and HHC agency quality (star-rating), controlling for neighborhood level fixed effects. Linear mixed regression modeled the relationship between area-level social deprivation and receiving care from a high-quality HHC agency. An interaction term between race and social deprivation index quartiles examined whether racial disparities in accessing high-quality HHC agencies depended on the level of neighborhood social deprivation. RESULTS:< .001). The effect of race on access to high-quality HHC persisted regardless of the level of neighborhood social deprivation. CONCLUSIONS:For people living with serious illness, living in areas with higher social deprivation is associated with lower-quality HHC. Patient race and ethnicity has a consistent effect reducing access to high-quality HHC agencies, regardless of neighborhood. Future research must investigate ways to improve access to high-quality HHC for racial and ethnic historically marginalized populations who are seriously ill, especially in areas of high social deprivation. This includes understanding what policies, organizational structures, or care processes impede or improve access to high-quality care.

BACKGROUND:Home-based primary care (HBPC) is an important care delivery model for high-need older adults. Currently, target patient populations vary across HBPC programs, hindering expansion and large-scale evaluation. OBJECTIVES/OBJECTIVE:Develop and validate criteria that identify appropriate HBPC target populations. RESEARCH DESIGN/METHODS:A modified Delphi process was used to achieve expert consensus on criteria for identifying HBPC target populations. All criteria were defined and validated using linked data from Medicare claims and the National Health and Aging Trends Study (NHATS) (cohort n=21,727). Construct validation involved assessing demographics and health outcomes/expenditures for selected criteria. SUBJECTS/METHODS:Delphi panelists (n=29) represented diverse professional perspectives. Criteria were validated on community-dwelling Medicare beneficiaries (age above 70) enrolled in NHATS. MEASURES/METHODS:Criteria were selected via Delphi questionnaires. For construct validation, sociodemographic characteristics of Medicare beneficiaries were self-reported in NHATS, and annual health care expenditures and mortality were obtained via linked Medicare claims. RESULTS:Panelists proposed an algorithm of criteria for HBPC target populations that included indicators for serious illness, functional impairment, and social isolation. The algorithm's Delphi-selected criteria applied to 16.8% of Medicare beneficiaries. These HBPC target populations had higher annual health care costs [Med (IQR): $10,851 (3316, 31,556) vs. $2830 (913, 9574)] and higher 12-month mortality [15% (95% CI: 14, 17) vs. 5% (95% CI: 4, 5)] compared with the total validation cohort. CONCLUSIONS:We developed and validated an algorithm to define target populations for HBPC, which suggests a need for increased HBPC availability. By enabling objective identification of unmet demands for HBPC access or resources, this algorithm can foster robust evaluation and equitable expansion of HBPC.

OBJECTIVE:This analysis evaluated the validation results of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool for older adults. METHODS:We performed a subgroup analysis of older adults aged ≥65 (n = 184) from the TAPS tool validation study conducted in 5 primary care clinics. We compared the interviewer and self-administered versions of the TAPS tool at a cutoff of ≥1 for identifying problem use with a reference standard measure, the modified World Mental Health Composite International Diagnostic Interview. RESULTS:The mean age was 70.6 ± 5.9 years, 52.7% were female, and 49.5% were non-Hispanic Black. For identifying problem use, the self-administered TAPS tool had sensitivity of 0.91 (95% CI: 0.75-0.98) and specificity of 0.91 (95% CI: 0.85-0.95) for tobacco; sensitivity of 0.68 (95% CI: 0.45-0.86) and specificity of 0.88 (95% CI: 0.82-0.93) for alcohol; and sensitivity 0.86 (95% CI: 0.42-1.00) and specificity 0.94 (95% CI: 0.90-0.97) for cannabis. The interviewer-administered TAPS tool had similar results. We were unable to evaluate its performance for identifying problem use of individual classes of drugs other than cannabis in this population due to small sample sizes. CONCLUSIONS:While the TAPS had excellent sensitivity and specificity for identifying tobacco use among older adults, the results for other substances lack precision, and we were unable to evaluate its performance for prescription medications and individual illicit drugs in this sample. This analysis underlines the critical need to adapt and validate screening tools for unhealthy substance use, specifically for older populations who have unique risks.

BACKGROUND:Pre-injury frailty among older adults with trauma injuries is a predictor of increased morbidity and mortality. OBJECTIVES/OBJECTIVE:We sought to determine the relationship between frailty status and the care trajectories of older adult patients who underwent frailty screening in the emergency department (ED). METHODS:Using a retrospective cohort design, we pooled trauma data from a single institutional trauma database from August 2020 to June 2023. We limited the data to adults 65 years and older, who had trauma injuries and frailty screening at ED presentation (N = 2,862). The predictor variable was frailty status, measured as either robust (score 0), pre-frail (score 1-2), or frail (score 3-5) using the FRAIL index. The outcome variables were measures of clinical care trajectory: trauma team activation, inpatient admission, ED discharge, length of hospital stay, in-hospital death, home discharge, and discharge to rehabilitation. We controlled for age, sex, race/ethnicity, health insurance type, body mass index, Charlson Comorbidity Index, injury type and severity, and Glasgow Coma Scale score. We performed multivariable logistic and quantile regressions to measure the influence of frailty on post-trauma care trajectories. RESULTS:The mean (SD) age of the study population was 80 (8.9) years, and the population was predominantly female (64%) and non-Hispanic White (60%). Compared to those classified as robust, those categorized as frail had 2.5 (95% CI: 1.86-3.23), 3.1 (95% CI: 2.28-4.12), and 0.3 (95% CI: 0.23-0.42) times the adjusted odds of trauma team activation, inpatient admission, and ED discharge, respectively. Also, those classified as frail had significantly longer lengths of hospital stay as well as 3.7 (1.07-12.62), 0.4 (0.28-0.47), and 2.2 (95% CI: 1.71-2.91) times the odds of in-hospital death, home discharge, and discharge to rehabilitation, respectively. CONCLUSION/CONCLUSIONS:Pre-injury frailty is a predictor of clinical care trajectories for older adults with trauma injuries.