Consideration Of Life Expectancy Research Articles

Public Health Impact and Cost-Effectiveness Analysis of 4-Component Meningococcal Serotype B Vaccination for Infants in France.

In France, meningococcal serogroup B (MenB) is the most common serogroup causing invasive meningococcal disease (IMD) in infants and young children. Our objective was to illustrate the impact of model choices on health outcomes and the cost-effectiveness of infant vaccination with the multicomponent meningococcal serogroup B vaccine (4CMenB) versus no vaccine in France. A previously published dynamic transmission-based cost-effectiveness model was adapted for the French context using updated, French-specific demographic, epidemiological, and cost data. IMD incidence and long-term sequelae were derived through analysis of French healthcare and surveillance databases. A collective perspective over a 100-year time horizon was adopted, with a discount rate of 2.5%, reduced to 1.5% after the first 30 years. Deterministic and probabilistic sensitivity and scenario analyses were performed. In the base case analysis, infant vaccination with 4CMenB avoided 3101 MenB IMD cases in infants aged <1 year (-54%) and 6845 cases in all age groups (-21%). The estimated incremental cost-effectiveness ratio was €316,272/quality-adjusted life-year (QALY) but was highly sensitive to the types of sequelae included, MenB incidence, vaccine effectiveness parameters, and consideration of life-expectancy in IMD survivors (range: €65,272/QALY to €493,218/QALY). Using economic models compliant with French methodology guidelines, 4CMenB does not seem cost-effective; however, results are sensitive to model choices and 4CMenB immunization is an effective strategy to prevent MenB IMD cases and to improve quality of life and economic burden associated with MenB IMD treatment, especially with regard to long-term sequelae.

Midterm Outcomes of Elective Endovascular Aortic Repair in Octogenarians: When Is It Too Old?

Introduction: Endovascular aortic repair outcomes in octogenarians remain unclear. We aim to investigate whether the results for octogenarians differ from those of the younger population in elective endovascular aortic repair. Materials and Methods: From January 2013 to January 2022, 313 patients were treated with elective endovascular aortic repairs. Patient demographics and perioperative and postoperative features were obtained from the hospital database. The primary goals were to explore the early mortality rates of patients aged 80 years and older and compare them with those under 80. The secondary goal was to analyze the comorbid factors. Results: A total of 245 patients were under 80 years old, and 68 patients were 80 years and older. The early mortality rate was 2.94% in the octogenarians and 0.81% in the rest, and there was no significant difference between the two (p = 0.24). However, being 80 years and older led to a significantly lower survival probability at the five-year follow-ups. The American Society of Anesthesiologists’ score was found to help predict late mortality risk and patient selection for elective endovascular aortic repair. Conclusion: As octogenarians are fragile and sensitive to complications, patient selection, careful consideration of life expectancy, and clinical assessment are key to repair. Furthermore, age should not be an independent exclusion criterion in the endovascular aortic repair treatment decision. Keywords: Aortic Aneurysm, Abdominal; Endovascular Procedure; Octogenarians.

Updated recommendations regarding the management of older patients with breast cancer: a joint paper from the European Society of Breast Cancer Specialists (EUSOMA) and the International Society of Geriatric Oncology (SIOG)

Breast cancer is increasingly prevalent in older adults and is a substantial part of routine oncology practice. However, management of breast cancer in this population is challenging because the disease is highly heterogeneous and there is insufficient evidence specific to older adults. Decision making should not be driven by age alone but should involve geriatric assessments plus careful consideration of life expectancy, competing risks of mortality, and patient preferences. A multidisciplinary taskforce, including members of the European Society of Breast Cancer Specialists and International Society of Geriatric Oncology, gathered to expand and update the previous 2012 evidence-based recommendations for the management of breast cancer in older individuals with the endorsement of the European Cancer Organisation. These guidelines were expanded to include chemotherapy toxicity prediction calculators, cultural and social considerations, surveillance imaging, genetic screening, gene expression profiles, neoadjuvant systemic treatment options, bone-modifying drugs, targeted therapies, and supportive care. Recommendations on geriatric assessment, ductal carcinoma in situ, screening, primary endocrine therapy, surgery, radiotherapy, adjuvant systemic therapy, and secondary breast cancer were updated.

Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening

Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations. To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators). This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017. Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?" Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89). The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.

Age-Related Diseases and Clinical and Public Health Implications for the 85 Years Old and Over Population.

By 2050, the American 85 years old and over population will triple. Clinicians and the public health community need to develop a culture of sensitivity to the needs of this population and its subgroups. Sensory changes, cognitive changes, and weakness may be subtle or may be severe in the heterogeneous population of people over age 85. Falls, cardiovascular disease, and difficulty with activities of daily living are common but not universal. This paper reviews relevant changes of normal aging, diseases, and syndromes common in people over age 85, cognitive and psychological changes, social and environmental changes, and then reviews common discussions which clinicians routinely have with these patients and their families. Some hearing and vision loss are a part of normal aging as is decline in immune function. Cardiovascular disease and osteoporosis and dementia are common chronic conditions at age 85. Osteoarthritis, diabetes, and related mobility disability will increase in prevalence as the population ages and becomes more overweight. These population changes have considerable public health importance. Caregiver support, services in the home, assistive technologies, and promotion of home exercise programs as well as consideration of transportation and housing policies are recommended. For clinicians, judicious prescribing and ordering of tests includes a consideration of life expectancy, lag time to benefit, and patient goals. Furthermore, healthy behaviors starting in early childhood can optimize quality of life among the oldest-old.

Undertreatment of Elderly Men With High-Risk Prostate Cancer

Treatment of high risk prostate cancer (PCa) with androgen deprivation therapy (ADT) alone is inferior to radiation therapy (RT) plus ADT. Elderly men with high-risk PCa are often undertreated. To assess for an age-dependent bias, we examined patterns of care and compared overall survival (OS) between men treated with ADT or RT+ADT. We queried the National Cancer Database between 2004-2013 and identified men ≥75 years of age with clinically localized high-risk PCa (Gleason 8-10, prostate specific antigen [PSA] >20 to 40 ng/ml, or T3a) treated with ADT alone or ADT+RT. Univariate (UVA), multivariate (MVA) and subset OS analyses were completed using chi-squared test, logistic regression, log-rank, Kaplan-Meier methods and cox-proportional hazards models. Propensity score matching was completed using significant variables from logistic regression. Among 17,636 patients treated with ADT, 14,254 (81%) were treated with RT and 3,382 (19%) with ADT alone. Median follow up was 71 months. Between 2004-2013, the proportion of men ≥75 treated with ADT alone remained unchanged (21% in 2004 and 20% in 2013). Factors independently associated with increased use of ADT alone were older age, African American race (vs. caucasian), uninsured and Medicaid insurance type (vs. Medicare), treatment in the South, Midwest and West (vs. Northeast), academic facility type (vs. non-academic), Charlson-Deyo comorbidity score (CCS) 1 and 2 (vs. 0), Gleason score 6 (vs. 7 and 8-10), and PSA of 10-20 and >20 (vs. <10). On UVA, ADT alone was associated with increased risk of death (hazard ratio [HR]: 2.5, 95% confidence interval [CI]: 2.4-2.7, p<0.001) when compared to RT+ADT. Five year OS for ADT alone and RT+ADT were 51% vs 78%, respectively (p<0.0001). On MVA, after controlling for age, race, insurance type, treatment location, facility type, CCS, PSA and clinical T-stage, ADT alone remained independently associated with increased risk of death (HR: 1.9, 95%CI: 1.7-2.0, p<0.001). Propensity score matching identified 4,216 patients and confirmed an increased risk of death associated with ADT alone (HR: 1.8, 95%CI: 1.7-2.0, p<0.001). On subset analysis, the increased risk of death associated with ADT alone persisted when stratified by CCS and age group (75-79, 80-84 and 85 years or greater) when compared to RT+ADT, except for those 85 years and older with CCS of 2 or greater. Despite randomized evidence to support the use of RT+ADT for men with high-risk PCa, approximately 1 in 5 men who are 75 years and older are treated with ADT alone. This approach is associated with a 2-fold risk of death when compared to RT+ADT in most men. Careful consideration of life expectancy and comorbidity status should be given before omitting RT in the elderly.

Arteriovenous Vascular Access Selection and Evaluation.

When making decisions regarding vascular access creation, the clinician and vascular access team must evaluate each patient individually with consideration of life expectancy, timelines for dialysis start, risks and benefits of access creation, referral wait times, as well as the risk for access complications. The role of the multidisciplinary team in facilitating access choice is reviewed, as well as the clinical evaluation of the patient.

Consideration of patient age and life expectancy in implantable cardioverter-defibrillator referral

Primary prevention implantable cardioverter-defibrillator (ICD) guidelines recommend device consideration for at-risk patients with a life expectancy of greater than 1 year regardless of age. We sought to assess the influence of patient age and prognosis on ICD referral. A survey was mailed to a random, national sample of 3,000 physicians in the specialties of cardiology, family medicine, and internal medicine. Participants were asked focused questions regarding patient age, life expectancy, and ICD referral. The overall response rate was 64%. More than one quarter of physicians (n = 386 [27%], 95% CI 25%-30%) withhold primary prevention ICD referral solely because of patient age. Life expectancy is not considered by 23% (n = 324, 95% CI 20%-25%) of physicians before referral, whereas 13% (n = 144, 95% CI 11%-15%) refer patients with a prognosis of less than 1 year. Providers who refer patients for ICD implantation with a life expectancy of less than 1 year are less likely to be cardiologists (odds ratio [OR] 0.50, 95% CI 0.32-0.79, P = .003), are less often affiliated with a teaching hospital (OR 0.62, 95% CI 0.41-0.94, P = .025), and have a greater number of years in practice (OR 1.25 for each 10 years in practice, 95% CI 1.03-1.51, P = .026). Only a minority (n = 315 [22%], 95% CI 20%-24%) of physicians use a life expectancy threshold of 1 year to guide ICD referral. Physicians frequently withhold ICD referral because of patient age. The referral of patients with a prognosis of less than 1 year or without consideration of life expectancy is common.

Radical Prostatectomy Outcome in Men 65 Years Old or Older With Low Risk Prostate Cancer

A recent update of the Scandinavian Prostate Cancer Group Study-4 concluded that men older than 65 years treated with radical prostatectomy had no survival advantage compared to men treated with watchful waiting. We examined the proportion and outcomes of men 65 years old or older with low risk disease who underwent radical prostatectomy at our institution. Our institutional radical prostatectomy database with more than 19,000 patients was queried for men 65 years old or older with low risk prostate cancer. Pathological and survival outcomes were assessed. Subanalysis was done on men 70 years old or older to determine whether outcomes among older men differed by age. A total of 1,560 men (8.1%) 65 years old or older with low risk prostate cancer underwent radical prostatectomy between 1983 and 2010. After radical prostatectomy 38.3% of the men had evidence of more aggressive cancer, including Gleason score 7 or greater, or extraprostatic extension. After radical prostatectomy actuarial 5, 10 and 15-year biochemical recurrence-free survival was 93.2%, 89.2% and 82.2%, prostate cancer specific survival was 99.7%, 98.4% and 97.2%, and overall survival was 96.1%, 83.5% and 60.2%, respectively. Fewer than 10% of men treated with radical prostatectomy at our institution were 65 years old or older with low risk prostate cancer. Despite a high prevalence of aggressive disease discovered at surgery these men experienced excellent long-term survival. Treatment recommendations in older men with low risk prostate cancer should be made after careful consideration of life expectancy based on comorbidities and potential adverse outcomes of treatment.

Prescribing for Older Adults

Pharmacotherapy of the elderly is very complex due to age-related physiologic changes, multiple comorbidities, multiple medications (prescription, over-the counter, and herbal), and multiple providers (prescribers and pharmacies). Age-related physiologic changes and disease-related changes in organ function affect drug handling (pharmacokinetics) and response (pharmacodynamics). In addition, patients' cognitive impairment, functional difficulties, as well as caregiver issues play a large role in errors and compliance. Many older adults have several chronic conditions, and they stand to benefit the most from best practice guidelines. However, they are also at risk of toxicity given our increasingly complex pharmacopoeia and potential adverse effects that can cause morbidity and mortality. It is imperative that physicians learn how to minimize side effects and interactions. Potentially inappropriate medications (medications that pose more risk than benefit to the patient) are among the most important causes of adverse drug reactions, independent of the number of medications and other confounding factors. Many of these adverse drug reactions could be predicted from the known pharmacology of the drug and therefore could be potentially avoidable. To prescribe appropriately, we need to consider not only the pharmacological properties of the drugs, but also clinical, epidemiological, social, cultural, and economic factors. Elders' adherence to prescribed medications is also complex and depends on medical, personal, and economic factors; cognitive status; and relationship with the physician. Detection of nonadherence is a necessary prerequisite for adequate treatment, and patient education is a cornerstone in achieving medication adherence. Finally, appropriate prescribing should include a consideration of life expectancy and goals of care.

Between labour market and retirement pension - flexible transition as a new paradigm for ageing societies?

Increasing the pensionable age due to rising life expectancy meets strong political resistance. For health and labour market reasons it will always be impossible for some to achieve full pension eligibility directly from employment. Even if early retirement options are not restricted the scope for an accumulation of earnings to fund an early pension is often narrowly defined. Consequently, it is impossible for early retirees to compensate for the reductions in the pension they receive. Contrary to the general tendency to increase the pensionable age an alternative reform proposal is currently under discussion in German social policy circles. This involves free choice of retirement at age 60; unlimited accumulation of additional pension entitlements whilst earning; actuarial deductions for early retirement; and consideration of life expectancy in making adjustments to pension awards. This solution relieves the public pension system financially, raises the attractiveness of senior citizens on the labour market, offers the opportunity for a self-determined transition from work to retirement and reduces political resistance to pension reform. The effect on the labour market for senior citizens remains to be examined.

Endovascular Abdominal Aortic Aneurysm Repair in the Octogenarian

The aim of this study was to analyze patient outcomes following endovascular repair of infrarenal abdominal aortic aneurysms (EAR) among patients 80 years of age or older. In this study, reporting standards of the Ad Hoc Committee for Standardized Reporting Practices for Endovascular Aortic Aneurysm Repair of the Society of Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) were followed. Between August 8, 1996 and February 12, 2001 EAR was performed in 31 patients (29 male and 2 female) with an average age of 83 +/- 3 years and an average maximum aneurysm diameter of 59 +/- 7 mm. Overall technical success was 90% (28/31) with a single acute conversion and a 6% (2/32) incidence of major morbidity. There were no in-hospital deaths, but two patients (6%) died within 30 days of intervention. Four endoleaks, two type I and two type II, were observed within the first 30 days after endograft implantation and three new type II endoleaks were noted after implant periods that exceeded 1 month. Average follow-up was 16 months, with a single aneurysm-related death that occurred after late conversion to open repair, 2 years following initial endovascular treatment. Kaplan-Meier analysis revealed 3-, 12-, and 24-month estimated survivals of 93% (+/-5), 75% (+/-8), and 68% (+/-10), respectively. Clinical success rates were 90% (+/-5), 90% (+/-5), and 72% (+/-17) at 12, 24, and 36 months, respectively. We conclude that, in the octogenarian with mild to moderate medical comorbidities, endovascular aneurysm repair provides an alternative to open AAA repair with low operative morbidity and good clinical success rates. Elevated SVS/AAVS medical comorbidity scores were not associated with increased operative mortality rates, but they did show a trend toward decreased mid-term survival. Careful consideration of life expectancy and the probability of rupture, as with traditional AAA repair, should dictate necessity for intervention.

Practice Guidelines for Cancer Pain Management

Practice Guidelines for Cancer Pain Management