Frequent Health Care Utilization Research Articles

Risk factors for long-term cardiovascular post-acute sequelae of COVID-19 infection: A nested case-control study in Hong Kong

People with COVID-19 can experience post-acute sequelae of SARS-CoV-2 (PASC). Studies on risk factors of PASC outcomes are ongoing, especially for endocrine system-related diseases that may impact the cardiovascular system. Cardiac-related PASC is one of the burdens after COVID-19 infection. This study aimed to examine the risk factors of cardiac-related PASC. In this nested case-control study, we obtained electronic health records (EHRs) database from the Hong Kong Hospital Authority. We defined cases as patients with at least one cardiac-related PASC and controls as patients without any cardiac-related PASC. We applied the incidence density sampling and matched controls to cases on age and sex at a 1:10 ratio. Multivariable conditional logistic regression was used to determine the associations between risk factors and cardiac-related PASC. A total of 455 individuals with cardiac-related PASC and matched 3,423 controls were obtained in the underlying cohort. COVID-19-associated hospitalisation (aOR: 1.41, 95% CI: 1.03–1.93) and peripheral vascular disease (aOR: 2.98, 95% CI: 1.31–6.79) were associated with an increased likelihood of cardiac-related PASC. Higher doses of the COVID-19 vaccine (2 doses: 0.68 [0.52–0.89]; ≥3 doses: 0.56 [0.40–0.78]) and more frequent healthcare utilization visits (aOR: 0.95, 95% CI: 0.92–0.97) were associated with a lower likelihood of cardiac-related PASC. This is the first study to examine risk factors of cardiac-related PASC among the Chinese population. We identified peripheral vascular disease and COVID-19-associated hospitalisation as the risk factors for cardiac-related PASC. COVID-19 vaccination was protective against cardiac-related PASC, which should be prioritized for high-risk patients.

Medication use and contextual factors associated with meeting guideline-based glycemic levels in diabetes among a nationally representative sample.

Based on the long-lasting diabetes management challenges in the United States, the objective was to examine glycemic levels among a nationally representative sample of people with diabetes stratified by prescribed antihyperglycemic treatment regimens and contextual factors. This serial cross-sectional study used United States population-based data from the 2015 to March 2020 National Health and Nutrition Examination Surveys (NHANES). The study included non-pregnant adults (≥20 years old) with non-missing A1C and self-reported diabetes diagnosis from NHANES. Using A1C lab values, we dichotomized the outcome of glycemic levels into <7% versus ≥7% (meeting vs. not meeting guideline-based glycemic levels, respectively). We stratified the outcome by antihyperglycemic medication use and contextual factors (e.g., race/ethnicity, gender, chronic conditions, diet, healthcare utilization, insurance, etc.) and performed multivariable logistic regression analyses. The 2042 adults with diabetes had a mean age of 60.63 (SE = 0.50), 55.26% (95% CI = 51.39-59.09) were male, and 51.82% (95% CI = 47.11-56.51) met guideline-based glycemic levels. Contextual factors associated with meeting guideline-based glycemic levels included reporting an "excellent" versus "poor" diet (aOR = 4.21, 95% CI = 1.92-9.25) and having no family history of diabetes (aOR = 1.43, 95% CI = 1.03-1.98). Contextual factors associated with lower odds of meeting guideline-based glycemic levels included taking insulin (aOR = 0.16, 95% CI = 0.10-0.26), taking metformin (aOR = 0.66, 95% CI = 0.46-0.96), less frequent healthcare utilization [e.g., none vs. ≥4 times/year (aOR = 0.51, 95% CI = 0.27-0.96)], being uninsured (aOR = 0.51, 95% CI = 0.33-0.79), etc. Meeting guideline-based glycemic levels was associated with medication use (taking vs. not taking respective antihyperglycemic medication classes) and contextual factors. The timely, population-based estimates can inform national efforts to optimize diabetes management.

PO-04-055 ATRIAL FIBRILLATION EDUCATION GONE WRONG: THE INTERSECTION OF PATIENT EDUCATION, ANXIETY, AND AMBIGUITY IN AN ATRIAL FIBRILLATION PATIENT

Atrial fibrillation (AF) patients have significant symptom burden resulting in uncertainty and distress. Patients often seek out medical information from their healthcare team, online resources, and significant others to better understand their experience and diagnosis. We report a case of an AF patient referred for an ablation complicated by influx of information across settings and iatrogenic anxiety. Patient presented to the Cardiac Psychology Service with poor understanding, high anxiety, and uncertainty that led to paralysis of the recovery process. A 60-year-old White married female with medical history of AF, hypertension, diabetes, hyperlipidemia, PVCs, and former smoker presented for distress related to her AF diagnosis. Prior visits with a cardiologist triggered questions about her condition, anti-coagulation use, possible loop recorder insertion, LAAO devices, and long-term prognosis. Interactions with her healthcare team led to increased anxiety, hypervigilance of symptoms, uncertainty of medical decisions, and fears about AF recurrence and progression. This prompted online investigation of her treatment options, frequent healthcare utilization, and internet inquires for “Dr. Google” resulting in decision to postpone the ablation. The patient was treated by cardiac psychology to help restore a sense of control, reinforce shared-decision making and understanding. Focuses included disentangling alarming medical information from medical advice and existence of multiple treatment options. Given this was her first significant health concern and the episodic nature of AF, ambiguity and associated fears were normalized to further increase confidence navigating information presented. Behavioral changes and a self-management model were emphasized to promote less vigilance adversity and more attention to both appropriate psychological and physical health concerns. Psychological treatment combined with education from her EP addressed the lack of comprehensive medical information which led to improved adherence, decreased anxiety, and pursuit of recommended ablation. The present case highlights the potential implications of uncertainty and overabundance of information on AF treatment. Early recognition of anxiety by the EP physician should prompt a referral to a cardiac psychologist for comprehensive multidisciplinary care to minimize impact of misinformation on patient experience.

Difficult-to-treat rheumatoid arthritis: Current concept and unsolved problems.

Over the past several decades, the treatment of rheumatoid arthritis (RA) has advanced significantly, and clinical, structural, and functional remission are achievable therapeutic goals. However, a substantial number of patients show resistance to multiple drugs. In particular, patients whose disease activity cannot be controlled despite the use of two or more biological disease-modifying antirheumatic drugs (DMARDs) or targeted synthetic DMARDs (tsDMARDs) with different mechanisms of action (MOA) have recently been referred to as having difficult-to-treat RA (D2T RA). D2T RA is a heterogeneous and multifactorial disease state, and the major problems are uncontrolled disease activity and decreased quality of life, as well as the economic burden due to frequent healthcare utilization and multiple admissions. Since the concept of D2T RA is relatively new and publication regarding D2T RA is limited, the mechanism underlying DMARD inefficacy and which factors form a "difficult-to-treat" state in such patients are not yet fully understood. It is also possible that factors contributing to D2T RA may differ by patient, sex, country, and race. The present Mini Review introduces the current concept and unsolved problems of D2T RA, including the definition, prevalence, and factors contributing to D2T RA. We then discuss the management and therapeutic strategies for D2T RA. Finally, we explore a clinical approach to prevent patients from developing D2T RA.

B-11 | Unplanned Readmission After Hospitalization for Cardiogenic Shock: Perspective From Nationwide Readmission Database

Cardiogenic Shock (CS) is associated with significant mortality and frequent healthcare utilization. There is a lack of nationally representative data on incidence, causes and indicators of 30-day readmission after hospitalization for cardiogenic shock from both ischemic and non-ischemic etiologies.

Higher hydroxyurea adherence among young adults with sickle cell disease compared to children and adolescents

Background Sickle cell disease (SCD) results in severe complications, such as anaemia and pain episodes. Hydroxyurea (HU) is efficacious in SCD, yet adherence remains low. Objective To assess the relationship of HU adherence to health care utilization and patients’ characteristics. Methods This is a 5-year retrospective chart review. Patients’ demographics and medical history were collected from the electronic medical record (EMR). HU adherence was evaluated using foetal haemoglobin “HbF%”, mean corpuscular volume “MCV”, and absolute neutrophil count “ANC”. Age groups included children (<12 years), adolescents (12–17 years), and young adults (≥18 years). Results A total of 113 SCD patients on HU were included (median age 14 years, IQR 10–20; 50% female; 88% HbSS). Young adults had significantly higher HU adherence compared to adolescents and children, including higher median HbF% (24.2 vs. 12.4 vs. 8.6, p = .003), MCV (fl) (106.4 vs. 96.2 vs. 95.4, p = .01) and lower ANC (103/ml) (3.25 vs. 4.9 vs. 4.2, p = .01), respectively. Patients with chronic pain had lower HU adherence (HbF% 15.3 vs. 10.7, p = .04; ANC 3.6 vs. 6.3, p = .002; MCV 102.3 vs. 93.1, p = .1). Patients with higher HbF or MCV and lower ANC had significantly less frequent emergency room visits (rs=–0.26, p = .01; rs=–0.23, p = .01; rs=0.24, p = .01) and hospitalizations (rs=–0.27, p = .01; rs=–0.31, p = .01; rs=0.21, p = .02) as well as shorter length of stays (rs=–0.27, p = .0045; rs=–.34, p = 0.004; rs=0.23, p = .02), respectively. Similar trends in HU adherence and health care utilization were seen in subgroup analysis of only HbSS patients. There was no significant association of HU adherence to patients’ sex, socio-economic status, distance from hospital, and HU duration. Conclusions Young adults with SCD had significantly higher HU adherence compared to children and adolescents. Patients with lower HU adherence and/or chronic pain had increased health care utilization. Future studies examining barriers to adherence and evaluating interventions to optimize HU adherence in SCD are warranted. KEY MESSAGES Young adults with SCD had significantly higher HU adherence, as reflected in their laboratory markers, compared to children and adolescents. Patients with higher HU adherence and/or those without chronic pain had lower or less frequent health care utilization. No significant association of HU adherence to patients’ sex, socio-economic status and distance from hospital.

Abstract EP22: Sex And Socioeconomic Difference In 30-day Readmission After Hypertensive Crisis

Introduction: Hypertensive crisis (HC) is associated with serious health implication such as hypertensive heart disease, kidney disease and strokes and frequent healthcare utilization, especially unplanned 30-day readmission. ACC/AHA published new guideline for hypertensive crisis in 2017, but its impact on unplanned readmission has not been fully appreciated. Reporting readmission trends by sex and socioeconomic difference is crucial for public health surveillance and improved healthcare equity. Methods and Results: We conducted a retrospective analysis of the 2018 to 2019 Nationwide Readmission Database (NRD). Study populations were selected using ICD-10 diagnosis code. Discharge-level weight analysis was used to produce a national estimate. Social economic status (SES) was evaluated using median household income of patient’s ZIP code and dived into quarter. We conducted univariate and multivariable hierarchical regression analysis to calculate odds ratio (OR) with STATA 17. During the study period, there were 1,495,230 hospitalizations with hypertensive crisis of which 53.68% were female. According to SES study, 39.29% of patients were from the lowest quartile followed by 27.00%, 20.80% and 12.90% respectively. The overall incidence of unplanned readmission was 15.85 %( 237,052 of 1,495,230). Readmission rate was higher in female (15.93% v 15.77%; p = 0.006) and lower income quartiles (17.17% v 15.55% v 14.78% v 14.32%; p &lt;0.0001). The most common indication for readmission was repeated hypertensive crisis with higher proportion being female (18.39% v 17.42%) and the lowest income quartile (18.59%). After adjusting for age and comorbidities, female sex (OR 1.05; 95% CI, 1.04 - 1.07; p&lt; 0.0001) and the lowest income quartile (OR 1.12; 95% CI, 1.11 - 1.14; p&lt; 0.0001) were found to be significant predictors for 30-day readmission. Discussion: According to prior study, the 30-day readmission rate after HC has been improved with implementation of the ACC/AHA 2017 guideline (15.85% v 17.8%). However, disparities in HC burden and hospital utilization by sex and socioeconomic status persists. Public health interventions are needed to reduce HC hospitalization burden in female and low socioeconomic patients.

Abstract TMP91: Healthcare Utilization For Headache And Anxiety After Surgical Revascularization In Children With Moyamoya Vasculopathy

Introduction: Headache and anxiety are poorly described in children with moyamoya vasculopathy following revascularization. Hypothesis: Headache and anxiety in pediatric moyamoya patients are common co-morbidities and result in frequent healthcare utilization. Methods: In this single-center retrospective cohort study, children (&lt;18 years of age) with moyamoya syndrome or disease who underwent EC-IC bypass between 2007-2020 were identified from a UCSF registry. Data regarding headache or anxiety were abstracted from medical records of inpatient, outpatient and emergency (ED) encounters using standardized forms. ED encounters were attributed to headache or anxiety when they occurred in the absence of stroke or TIA and documented as the likely cause of symptoms for that visit. Summary statistics were used to describe outcomes. Results: We identified 32 children (63% female, 53% white, 22% Hispanic) who underwent initial revascularization surgery at a median age of 8.3 years (range 0.8-17.4). Two or more EC-IC surgeries were completed in 84% of patients. During follow-up after surgery (median 6.7 years, interquartile range 3.2 - 8.2 years), 81% of patients reported headache and 53% reported anxiety (Table). Headaches led to 27 ED encounters among 10 patients (31%). Headache rescue medications were prescribed to 21 patients (66%), and headache prophylaxis was prescribed in 37.5%. Six patients (19%) were referred to a headache specialist. Symptoms attributed to anxiety led to six ED encounters among three patients, and 19% (6/32) reported panic attacks. A referral to mental health services was provided to 44% (14/32) of patients. Conclusions: Headaches and anxiety are common symptoms among children with moyamoya after revascularization and may lead to significant healthcare consumption. Symptoms and prevention measures should be explored in future studies to improve quality of life and decrease healthcare utilization.

Filled prescriptions for opioids among children and adolescents - A nationwide study from 2010 to 2018.

Prescribing opioids for children and adolescents should be reserved for advanced life-limiting diseases and moderate-to-severe acute pain. Pediatric codeine use is discouraged by several authorities, but the effects of these recommendations are not fully known. We investigated opioid utilization trends among 0-18-year-olds and characterized those who filled ≥1 opioid prescriptions, with emphasis on those who did so >3 times within a year. The prevalence of filled opioid prescriptions among 0-18-year-old Norwegians in 2010-2018 (N=77,942) was measured from nationwide healthcare registries. Characteristics, healthcare utilization, and other drug use of those who newly filled 1, 2-3, or >3 opioid prescriptions in 2011-2014 were compared to 2015-2018, excluding persons with cancer. From 2010 to 2018, the prevalence of opioid use decreased from 9.0 to 7.0 per 1000 persons. The largest decrease was among children <12years, from 4.1 to 0.4 per 1000 persons, mainly due to decreasing codeine use. The proportion of those who filled >3 opioid prescriptions was 2.1% in 2011-2014 and 3.1% in 2015-2018. Those with >3 dispensations had a median of 4 contacts/year with secondary healthcare (interquartile range 2-7); the most frequent diagnoses indicated post-surgery follow-up. Most commonly dispensed other drugs were non-steroidal anti-inflammatory drugs. Opioid dispensations for the young have declined in recent years. Multiple opioid dispensations were rare and associated with frequent healthcare utilization. Reducing codeine is in line with recommendations, but the effects of decreased opioid use on the quality of pain management remain unknown.

Clinical characteristics and disease burden in prurigo nodularis.

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intense pruritus, but information on patient experience and impact on quality of life (QoL) remains understudied. To characterize disease characteristics and QoL in a global sample of patients with PN. An anonymous survey was distributed via patient support groups for PN. In total, 231 members responded to the survey. The majority of respondents reported itch localized both to nodules and to intervening skin (67.0%). Associated symptoms included prickling, pain, stinging and burning. The extensor lower legs (69% right, 67.3% left) and flexor forearms (66.1% right, 62% left) were the most common sites of itch. Participants reported frequent healthcare utilization, with 36.3% visiting a doctor ≥10 times in the past year. Physician-diagnosed anxiety (45.4%), depression (16.4%) and the atopic triad (18.7%) were commonly reported. Patients with PN had mean scores of 16.4, 11.6 and 16.8 on the Dermatology Life Quality Index, Pittsburgh Sleep Quality Index and 5-Dimensions Itch, respectively. Severe pruritus with accompanying pain, stinging and burning is characteristic of PN, with the majority of patients experiencing itch in both nodular and interlesional skin. Patients further report decreased QoL scores and impaired sleep. Patient experiences should guide future management of PN.

Predictors of Palliative Care Knowledge: Findings from the Health Information National Trends Survey.

Palliative care plays an important role in improving the quality of life for patients with cancer and their caregivers and has been associated with increased patient satisfaction. However, palliative care knowledge in the general population is limited, and often physician referral occurs late in prognosis. The objective of this analysis was to examine factors associated with palliative care knowledge. Using data from the 2018 NCI's Health Information National Trends Survey (HINTS) 5 Cycle 2, descriptive statistics, bivariate analyses, and multivariable logistic regressions were used to assess factors associated with respondents' palliative care knowledge using ORs and 95% confidence intervals as measures of association. The outcome of interest was measured with the item "How would you describe your level of knowledge about palliative care?" Possible response selections were "I've never heard of it," "I know a little bit about palliative care," and "I know what palliative care is and could explain it to someone else." To reduce the risk of type 1 error, jackknife variance estimations with repeated replications were used. All analyses were conducted with the SURVEYLOGISTIC command using SAS 9.4 (SAS Institute Inc.), and the statistical significance level was set at P < 0.05. A total of 3,450 respondents (weighted sample size: 249,489,772) met the inclusion criteria. About 89% (n = 3,000) of all respondents had inadequate knowledge of palliative care. Multivariable analyses indicated that frequent health care utilization as defined as ≥ 2 times per year [OR, 3.01; 95% confidence interval (CI), 2.65-3.58], female gender (OR, 2.15; 95% CI, 1.31-3.59), being married (OR, 2.02; 95% CI, 1.14-3.59), having a college degree or higher (OR, 13.83; 95% CI, 1.71-12.04), and having a regular source of care (OR, 2.67; 95% CI, 1.37-1.90) had greater odds of adequate palliative care knowledge. Those without a cancer diagnosis were less likely to have adequate knowledge of palliative care (OR, 0.49; 95% CI, 0.41-0.89). Knowledge of palliative care in the United States is low, particularly for those not already actively using their available healthcare system. Public health education efforts are needed to target subgroups of the U.S. population identified by this analysis to increase palliative care knowledge. Healthcare providers have a major role to play in improving palliative care knowledge.

207 Sociodemographic, Behavioral, and Health-Related Factors Associated with Sleep Among Native Hawaiians and Other Pacific Islanders

Abstract Introduction Previous studies have suggested that Native Hawaiians/Pacific Islanders show different associations between sleep and health risks, compared to other groups. The present study evaluated sleep and health risk factors in a nationally-representative sample. Methods Data from the Native Hawaiian and Pacific Islander National Health Interview Survey (NHPI-NHIS), collected by the CDC in 2013, was used for analysis. A total of N=2,124 individuals provided complete data on all variables. Sleep outcomes included hours of sleep (3-12h), days/week difficulty falling asleep, difficulty maintaining sleep, and nonrestorative sleep (ordinal). Weighted regression analyses (linear or ordinal logistic) evaluated whether sleep outcomes were associated with cancer, diabetes, hypertension, stroke, obesity, poor health, depression, anxiety, smoking, alcohol, activity, functional limitations, foregoing medical care due to cost, frequent healthcare utilization, health insurance, and difficulty paying medical bills, in models that also included age, sex, immigrant status, multiracial status, education, employment, income, and relationship status. Results Shorter sleep was associated with older age, earning &amp;lt;$20,000, and being divorced/widowed/separated, and longer sleep was associated with being female and less than high school education. Shorter sleep was also associated with fair health and current drinking. Difficulty falling asleep was positively associated with older age, earning &amp;lt;=$44,999, being divorced/widowed/separated, obesity, worse health, depressed mood, anxiety, daily smoking, former and current drinking, functional limitations, foregoing care, frequent care, and difficulty with bills. Difficulty falling asleep was negatively associated with immigrant status and being retired. Difficulty maintaining sleep was associated with older age, being unmarried but partnered, obesity, worse health, depression, anxiety, daily smoking, current or heavy drinking, being inactive, functional limitations, foregoing care, frequent care, and difficulty with medical bills. Nonrestorative sleep was associated with non-immigrant status, employment, being a homemaker, disability, being unmarried, obesity, worse health, depression, anxiety, daily smoking, former, current, or heavy drinking, inactivity, functional limitations, foregoing care, frequent care, and difficulty with medical bills. Conclusion Short sleep was not significantly associated with common health risk factors seen in other groups. Sleep difficulties, though, were related to a constellation of sociodemographic, socioeconomic, behavioral, and cardiometabolic risks. Further research regarding insomnia as a health risk factor in this population is warranted. Support (if any) R01MD011600, R01DA051321

The association of co-morbid asthma and overweight/obese status with healthcare utilization and caregiver perception of health in children 4–17 years, a NHANES study

Objective Asthma and obesity are two of the most common chronic childhood illnesses. The purpose of this study was to better understand the relationship between co-morbid asthma and obesity in children aged 4–17 and whether it impacts the caregiver’s perception of health and/or healthcare utilization. Methods This was a secondary analysis of the National Health and Nutrition Examination Surveys (NHANES) datasets from 2007 to 2018. Cumulative logistic regression models were used to analyze the caregiver’s perception of health, received healthcare, and overnight hospital stay as dependent variables. Asthma and weight status were included as covariates, with adjustment for age, income, head of the household’s education, gender, race, and insurance. Results The sample included 15,386 children. When looking at weight status in addition to asthma, compared to caregivers of children with current asthma and normal weight, caregivers of children with current asthma and with obesity are more likely to perceive their children as having worse health (OR = 1.73, 95%CI = [1.30, 2.32], p = 0.0003), and are more likely to have more frequent healthcare utilization but the results did not reach a statistical significance. Conclusions Caregiver’s perception of overall health was worse in caregivers of those with co-morbid obesity/asthma than in caregivers of children with asthma alone. This indicates that caregivers of children with co-morbid asthma and obesity have insight into their children’s condition and may be primed for discussion and counseling in the healthcare setting.

Multiple Drug Intolerance Syndrome in Fibromyalgia

Multiple drug intolerance syndrome (MDIS) describes patients with non-immunologic reactions to ≥3 drug classes. This can severely limit treatment options for affected patients. Rates of MDIS in fibromyalgia have not been previously described 1,479 patients with a diagnosis of fibromyalgia seen within our university health system in the last year were evaluated by retrospective chart review. Based on prior studies, patients with 10 or more listed allergies were considered to have MDIS. Chi-square testing and binary logistic regression were used for analysis. 128 (8.65%) patients with fibromyalgia met the definition of MDIS. The average number allergies listed for fibromyalgia patients was 3.7, while the average for age and sex matched controls was 1.4. On regression analysis, patients with fibromyalgia were found to be 6 times more likely to have MDIS (OR 6.29, CI 4.74-8.36). An active diagnosis of anxiety (X2 = 13.00, p < 0.0001) or depression (X2 = 7.14, p =0.008) was associated with MDIS. A Charlson Comorbidity Index score of ≥4 was associated with MDIS in patients with fibromyalgia (X2 = 41.44, p < 0.0001) and estimates a 10 year survival of 53%. Additionally, having >10 outpatient visits within the last year was associated with MDIS (X2 = 30.79, p < 0.0001 The association of MDIS with multiple comorbidities and frequent health care utilization in patients with fibromyalgia raises concerns that MDIS may limit therapies in these already complex patients. Additional studies are needed to explore this further.

Clinical Outcomes of Biologic Therapy on Asthma in a Medically Underserved Urban Population

Asthma is a heterogeneous disease that disproportionately affects urban populations. Uncontrolled and severe asthma necessitates frequent healthcare utilization. Biologic therapies are clinically efficacious in asthma control, but there is still an unmet need. This study evaluated the clinical outcomes of biologic therapy in moderate-to-severe persistent asthma in a population with restricted medical care access.

Significant Psychosocial Influence in Frail People Living with HIV Independent of Frailty Instrument Used.

Antiretroviral therapy (ART) usage among people living with HIV (PLWH) has led to significant mortality declines and increasing lifespan. However, high incidence and early onset of aging-related conditions such as frailty, pose as a new threat to this population. We aimed to characterize frailty by comparing health domains consisting of psychosocial, functional and physical deficits between frail PLWH and matched uninfected controls; identify associated risk factors and the impact on negative health outcomes including mortality risk score, quality of life, healthcare utilization, functional disability and history of falls among virally suppressed PLWH. Cross-sectional study. Infectious disease clinic in a tertiary institution. Individuals aged >25 years, on ART >12 months, not pregnant and without acute illness; multi-ethnic, Asian. Frailty instruments included Frailty phenotype (FP), FRAIL scale (FS) and Frailty index (FI). FI health deficits were categorized into health domains (psychosocial, functional and physical) and used as standard comparator to characterize frailty. Health domains of frail PLWH were compared with frail matched, uninfected controls. Regression analyses were applied to explore associated risk factors and health-related frailty outcomes. We recruited 336 PLWH. Majority were male (83%), Chinese (71%) with CD4+ count 561 (397-738) cells/µl. Frailty prevalence among PLWH were 7% (FP); 16% (FS) and 22% (FI). Proportions of psychosocial, functional, and physical domains were similarly distributed among frail PLWH measured by different frailty instruments. When compared with matched controls, psychosocial dominance was significant among the PLWH, but not in functional and physical domains. Identified frailty risk factors included poor nutritional status, higher CD4+ count nadir, depression, metabolic syndrome, higher highly sensitive C-reactive protein (hsCRP) and history of AIDS-defining illness (ADI). Frailty influenced the risk for negative health outcomes including increased mortality risk scores, poor quality of life (QOL), frequent healthcare utilization and increased functional disability (p<0.05). This study highlighted the importance of psychosocial influence in the development of frailty among treated PLWH in a multi-ethnic, Asian setting.

The influence of perceived racial bias and health-related stigma on quality of life among children with sickle cell disease

ABSTRACT Objectives: Individuals with sickle cell disease (SCD) experience significant health problems that may result in unpredictable pain episodes and frequent healthcare utilization. Disparities in clinical care may contribute to health-related stigma and racial bias for this majority African-American/Black population. There is less known about the influence of health-related stigma and racial bias on the health-related quality of life (HRQOL) of children with SCD. In the present study, we assessed these relationships and identified differences across demographic factors (i.e. age, gender). Design: Data was collected from African American children with SCD aged 8–16 years (57% male, 63% HbSS). Children completed the Childhood Stigma Scale (adapted for SCD), the Child Perceptions of Racism in Children and Youth scale, and the Pediatric Quality of Life Inventory Sickle Cell Disease Module. Caregivers provided demographic information. Results: In the first regression model, health-related stigma (p = .007) predicted HRQOL, but neither age nor gender were significant predictors. In the second regression model, age (p = .03) predicted HRQOL, but neither gender nor racial bias were significant predictors. Of interest, there was a significant interaction between age, gender, and racial bias (p = .02). Specifically, older girls who reported high levels of perceived racial bias had poorer HRQOL. Conclusions: Our study highlights the need for increased awareness about the effects of health-related stigma and racial bias on HRQOL for children with SCD, particularly for older girls who endorse racial bias. Our findings will guide future stigma and bias reduction interventions that may meet the needs of older girls with SCD.

USE OF FDA-APPROVED ALZHEIMER’S DISEASE MEDICATIONS AMONG NON-INSTITUTIONALIZED U.S. ADULTS AGE 60 YEARS AND OLDER

This study examined the use of Alzheimer’s Disease medications (ADMs) among non-institutionalized U.S. adults aged 60 years and older. It described the characteristics of ADM users, compared them to adults who were not currently using ADMs, and examined how demographic characteristics, living arrangements, healthcare utilization, and self-perceived cognition are associated with use of ADMs. It also identified the duration of ADM use and the most commonly used ADMs. Data come from the National Health and Nutrition Examination Survey, a nationally representative study of the non-institutionalized U.S. population (2009-2014). Respondents were classified as ADM users if they reported using one or more of the following prescription ADMs in the past 30 days: donepezil, rivastigmine, memantine, galantamine, or a drug combination of donepezil and memantine. During the study period, 1.9% of non-institutionalized U.S. adults aged 60 years and older reported using an ADM in the past 30 days. Use of ADMs was associated with concurrent use of antidepressant medications and also frequent or worsening memory loss and confusion. Most ADM users (82.3%) reported using ADMs for more than one year and the most frequently used ADM was donepezil. In 2009-2014, about 1.1 million non-institutionalized adults aged 60 years and older used an ADM in the past 30 days. They reported relatively poor cognitive abilities, frequent healthcare utilization, and concurrent use of antidepressant medications compared to non-users. Newly released public survey data will be useful to provide updated estimates of ADM use in the community.

Trends in the Prevalence and Incidence of Attention-Deficit/Hyperactivity Disorder Among Adults and Children of Different Racial and Ethnic Groups

An increasing prevalence of adult attention-deficit/hyperactivity disorder (ADHD) diagnosis and treatment has been reported in clinical settings and administrative data in the United States. However, there are limited data on recent trends of adult ADHD diagnosis among racial/ethnic subgroups. To examine trends, including associated demographic characteristics, psychiatric diagnoses, and negative outcomes, in the prevalence and incidence of adult ADHD diagnosis among 7 racial/ethnic groups during a 10-year period. This cohort study investigated trends in the diagnosis of ADHD in adults who identified as African American or black, Native American, Pacific Islander, Latino or Hispanic, non-Hispanic white, Asian American, or other using the Kaiser Permanente Northern California health plan medical records. A total of 5 282 877 adult patients and 867 453 children aged 5 to 11 years who received care at Kaiser Permanente Northern California from January 1, 2007, to December 31, 2016, were included. Data analysis was performed from January 2017 through September 2019. Period of ADHD diagnosis. Prevalence and incidence of licensed mental health clinician-diagnosed ADHD in adults and prevalence of licensed mental health clinician-diagnosed ADHD in children aged 5 to 11 years. Of 5 282 877 adult patients (1 155 790 [21.9%] aged 25-34 years; 2 667 562 [50.5%] women; 2 204 493 [41.7%] white individuals), 59 371 (1.12%) received diagnoses of ADHD. Prevalence increased from 0.43% in 2007 to 0.96% in 2016. Among 867 453 children aged 5 to 11 years (424 449 [48.9%] girls; 260 236 [30.0%] white individuals), prevalence increased from 2.96% in 2007 to 3.74% in 2016. During the study period, annual adult ADHD prevalence increased for every race/ethnicity, but white individuals consistently had the highest prevalence rates (white individuals: 0.67%-1.42%; black individuals: 0.22%-0.69%; Native American individuals: 0.56%-1.14%; Pacific Islander individuals: 0.11%-0.39%; Hispanic or Latino individuals: 0.25%-0.65%; Asian American individuals: 0.11%-0.35%; individuals from other races/ethnicities: 0.29%-0.71%). Incidence of ADHD diagnosis per 10 000 person-years increased from 9.43 in 2007 to 13.49 in 2016. Younger age (eg, >65 years vs 18-24 years: odds ratio [OR], 0.094; 95% CI, 0.088-0.101; P < .001), male sex (women: OR, 0.943; 95% CI, 0.928-0.959; P < .001), white race (eg, Asian patients vs white patients: OR, 0.248; 95% CI, 0.240-0.257; P < .001), being divorced (OR, 1.131; 95% CI, 1.093-1.171; P < .001), being employed (eg, retired vs employed persons: OR, 0.278; 95% CI, 0.267-0.290; P < .001), and having a higher median education level (OR, 2.156; 95% CI, 2.062-2.256; P < .001) were positively associated with odds of ADHD diagnosis. Having an eating disorder (OR, 5.192; 95% CI, 4.926-5.473; P < .001), depressive disorder (OR, 4.118; 95% CI, 4.030-4.207; P < .001), bipolar disorder (OR, 4.722; 95% CI, 4.556-4.894; P < .001), or anxiety disorder (OR, 2.438; 95% CI, 2.385-2.491; P < .001) was associated with higher odds of receiving an ADHD diagnosis. Adults with ADHD had significantly higher odds of frequent health care utilization (OR, 1.303; 95% CI, 1.272-1.334; P < .001) and sexually transmitted infections (OR, 1.289; 95% CI 1.251-1.329; P < .001) compared with adults with no ADHD diagnosis. This study confirmed the reported increases in rates of ADHD diagnosis among adults, showing substantially lower rates of detection among minority racial/ethnic subgroups in the United States. Higher odds of negative outcomes reflect the economic and personal consequences that substantiate the need to improve assessment and treatment of ADHD in adults.

Impact of brain metastases on end-of-life health care utilization.

116 Background: Patients with brain metastases (BMets) represent a subset of cancer patients who may experience high costs and frequent healthcare utilization. This study aims to assess whether patients with BMets have higher likelihood of healthcare utilization at the end of life (EOL) compared to other patients with metastatic cancer. Methods: Using the Cancer Information and Population Health Resource, linking North Carolina Medicare, Medicaid, and private payer claims with state cancer registry data, we conducted an observational cohort study of decedents with metastatic melanoma, renal cell carcinoma, breast cancer, or lung cancer (diagnosed 2003-2014) with or without BMets. Multivariate logistic regression, adjusting for demographics, cancer type, systemic treatment, comorbidity, frailty, and hospice use, was used to examine the impact of BMets on use of the emergency department (ED), hospital, and intensive care unit (ICU) in the 30 days prior to death. Results: Patients with BMets are hospitalized at EOL more often than patients without BMets (44% vs 38%, p &lt; 0.001), but experience no difference in ED or ICU use. BMets patients receiving systemic treatment were particularly high risk for hospital and ICU use (odds ratios in Table). Black race and Charlson comorbidity score 3+ increased risk of hospitalization and ICU use. Utilization did not vary by cancer type. Hospice care significantly reduced all utilization. Conclusions: Patients with BMets are high risk for hospitalization at the end of life. Further study is needed to determine if targeted health system interventions can decrease hospitalizations in this patient group. [Table: see text]