Higher Proportion Of Older Patients Research Articles

Community Care Needs of Highly Complex Chronic Patients: An Epidemiological Study in a Healthcare Area.

One of the priorities in family and community care is the epidemiological surveillance of the care needs and dysfunctionality present in populations of highly complex chronic patients (HCCPs) using standardised nursing languages. The aim of this study is to establish the prevalence of care needs and dysfunctionality among HCCPs in a specific health area by municipalities and geographical areas (metropolitan, north, and south) while verifying correlations with sociodemographic, financial, and health characteristics. This is an epidemiological, observational, descriptive, cross-sectional study carried out with a sample of 51,374 HCCPs, whose data were grouped into 31 municipalities. Data were collected on the following variables: sociodemographic, financial, health, functional status (health patterns), and care needs (nursing diagnoses). The mean age of the HCCPs was 73.41 (1.45) years, of which 56.18 (2.86)% were women. The municipalities in the northern area have a significantly higher proportion of older patients, HCCPs, lower incomes, and higher unemployment rates. The southern area had higher proportions of non-Spanish nationals and professionals in the hotel and catering industry, and the metropolitan area had a higher proportion of employed individuals and higher levels of education. Northern municipalities had a higher prevalence of illnesses and anxiolytic and anti-psychotic treatments. Dysfunctionality frequencies did not differ significantly by area. However, a higher prevalence of 13 nursing diagnoses was observed in the north. A high number of correlations were observed between population characteristics, dysfunctionality, and prevalent diagnoses. Finally, the frequencies of dysfunctionality in the population and the most common care needs were mapped by municipality. This research sought to ascertain whether there was an unequal distribution of these two aspects among HCCPs in order to gain a deeper epidemiological understanding of them from a family and community perspective using standardised nursing languages. This study was not registered.

Factors influencing the selection of spectacle frames and lenses – Knowledge, attitude, and practice study

Background: This study evaluated the knowledge, attitude, and practice (KAP) of patients toward the selection of frames and glasses and factors that influence selection options. Patients and Methods: In this questionnaire-based study comprising closed-end questions, consenting patients aged over 18 years were recruited. The association between family income and age on KAP was analyzed using Fisher’s exact test. Results: The mean (standard deviation) age of the cohort (n = 200, 97 males) was 44.6 ± 16.2 years. A majority (85%) stated that spectacles improved vision; 9% believed it would make eyes weaker. Only 39% were aware of alternate options for refractive error. The durability of the frame was a key factor in selecting frames in 47%; 44% stated they would change spectacles every year. Expensive frames, celebrity endorsement, fashion, and branding influenced choice in 35%, 13.5%, 12%, and 7.5% of the respondents, respectively. Higher annual family income (>Rs. 50,000) when compared with low income (<50,000), was associated with awareness of alternate options for refractive error (P < 0.001) and preference for celebrity-endorsed frames (P = 0.007). There was no association between income and choice of expensive frames (P = 0.16). A higher proportion of older patients (≥40 years) preferred to change glasses only on doctor’s recommendations when compared with younger patients (P = 0.006). Conclusion: Knowledge on alternate options for refractive error was poor. Celebrity endorsement, costly, fashionable, or branded frames did not appear to play an influential role in the choice of frames. High annual income families preferred celebrity-endorsed frames and were more aware of alternative options for refractive error.

Testing the external validity of the POUT III trial (adjuvant platnium-based chemotherapy in upper tract urothelial carcinoma) in a North American cohort

ObjectiveThe European POUT III randomized controlled trial provided level-one evidence that adjuvant platinum-based chemotherapy is the standard of care following nephroureterectomy (RNU) for locally invasive or node-positive upper tract urothelial carcinoma. We aim to assess this European randomized controlled trial's generalizability (external validity) to a North American cohort, using a nationwide database. Materials and MethodsTo compare trial patients with those seen in real-world practice, we simulated the trial inclusion criteria using data from the National Cancer Database (NCDB). We identified patients with histologically confirmed transitional cell carcinoma who underwent RNU. The available demographic characteristics of the NCDB cohort were compared with the POUT III trial cohort using Chi-squared test. ResultsThe NCDB cohort (n = 3,380) had a significantly higher proportion of older patients (age ≥ 80: 23.5% vs. 5%), and more males (68% vs. 56.2%) than the POUT cohort (Table 1, both p < 0.001). Additionally, the rate of advanced nodal disease was higher in the NCDB (N1 9.6%, N2 9.3%) than in the POUT (N1 6%, N2 3%) cohort (p < 0.001). A more extensive lymph node dissection was performed in NCDB vs. POUT patients (node≥10 10.9% vs. 3%, p < 0.001). Sensitivity analysis removing all subjects with a Charlson Comorbidity Index > 0 did not change the significance of any results. ConclusionsWhile the primary disease stage was similar, the rate of advanced nodal disease was significantly higher in NCDB, which might be explained partially by the more extensive lymph node dissection performed in the latter. These differences warrant caution when applying the POUT III findings to North American patients.

Discrepancies Among Hospitals and Regions in the Provision of Low-Value Care.

Low-value care (LVC) is a critical issue in terms of patient safety and fiscal policy; however, little has been known in Asia. For the purpose of better understanding the extent of LVC on a national level, the utilization, costs, and associated characteristics of selected international recommendations were assessed in this study. This retrospective cohort study used the National Health Insurance (NHI) claims data during 2013-2017 to evaluate the LVC utilization. Adult beneficiaries who enrolled in the NHI program and received at least one of the low-value services in hospitals were included. We measured seven procedures derived from the international recommendations at the hospital level, and a composite measure was created by summing the total utilization of selected services to determine the overall prevalence and corresponding cost. The generalized estimating equation (GEE) model was adopted to estimate the association. A total of 1 970 496 episodes of LVC was identified among 1 218 146 beneficiary-year observations and 2054 hospital-year observations. Overall, the utilization rate of the composite measure increased from 150.70 to 186.23 episodes per 10 000 beneficiaries with the growth in cost from US$ 5.40 to US$ 6.90 million. LVC utilization was proportional to the volume of outpatient visits and length of stay. Also, hospitals with a large volume of outpatient visits (adjusted odds ratio [aOR]: 95% CI, 2.10: 1.26 to 3.49 for Q2-Q3, 2.88: 1.45 to 5.75 for ≥Q3) and a higher proportion of older patients (aOR: 95% CI, 1.06: 1.02 to 1.11) were more likely to have high costs. The utilization and corresponding cost of LVC appeared to increase annually despite the relatively lower prevalence compared to other countries. Multicomponent interventions such as recommendations, de-implementation policies and payment reforms are considered effective ways to reduce LVC. Repeated measurements would be needed to evaluate the effectiveness of interventions.

Analysis of 30-day hospital readmissions and related risk factors for COVID-19 patients with myocarditis hospitalized in the United States during 2020

Background Despite extensive research on COVID-19 and its association with myocarditis, limited data are available on readmission rates for this subset of patients. Thirty-day hospital readmission rate is an established quality metric that is associated with increased mortality and cost. Methods This retrospective analysis utilized the Nationwide Readmission Database for the year 2020 to evaluate 30-day hospital readmission rates, risk factors, and clinical outcomes among COVID-19 patients who presented with myocarditis at their index hospitalization. Results Our analysis revealed that 1) the 30-day all-cause hospital readmission rate for patients initially hospitalized with COVID-19 and myocarditis was 11.7%; 2) after multivariate adjustment, the primary predictor of readmission for COVID-19 patients with myocarditis was discharge against medical advice; 3) COVID-19 patients with myocarditis who required readmission had a higher proportion of older patients and Medicare beneficiaries; 4) the most common diagnoses at readmission were COVID-19, sepsis, congestive heart failure, acute myocardial infarction, and pneumonia; and 5) readmitted patients were more likely to require renal replacement therapy during their index hospitalization. Conclusion This study underscores the importance of optimizing discharge plans, preventing irregular discharges through shared decision-making, and ensuring robust post-hospital follow-up for patients with COVID-19 and myocarditis at index admission.

Recognition of cognitive dysfunction in hospitalised older patients: a flash mob study

BackgroundIt is important that healthcare professionals recognise cognitive dysfunction in hospitalised older patients in order to address associated care needs, such as enhanced involvement of relatives and extra cognitive and functional support. However, studies analysing medical records suggest that healthcare professionals have low awareness of cognitive dysfunction in hospitalised older patients. In this study, we investigated the prevalence of cognitive dysfunction in hospitalised older patients, the percentage of patients in which cognitive dysfunction was recognised by healthcare professionals, and which variables were associated with recognition.MethodsA multicentre, nationwide, cross-sectional observational study was conducted on a single day using a flash mob study design in thirteen university and general hospitals in the Netherlands. Cognitive function was assessed in hospitalised patients aged ≥ 65 years old, who were admitted to medical and surgical wards. A Mini-Cog score of < 3 out of 5 indicated cognitive dysfunction. The attending nurses and physicians were asked whether they suspected cognitive dysfunction in their patient. Variables associated with recognition of cognitive dysfunction were assessed using multilevel and multivariable logistic regression analyses.Results347 of 757 enrolled patients (46%) showed cognitive dysfunction. Cognitive dysfunction was recognised by attending nurses in 137 of 323 patients (42%) and by physicians in 156 patients (48%). In 135 patients (42%), cognitive dysfunction was not recognised by either the attending nurse or physician. Recognition of cognitive dysfunction was better at a lower Mini-Cog score, with the best recognition in patients with the lowest scores. Patients with a Mini-Cog score < 3 were best recognised in the geriatric department (69% by nurses and 72% by physicians).ConclusionCognitive dysfunction is common in hospitalised older patients and is poorly recognised by healthcare professionals. This study highlights the need to improve recognition of cognitive dysfunction in hospitalised older patients, particularly in individuals with less apparent cognitive dysfunction. The high proportion of older patients with cognitive dysfunction suggests that it may be beneficial to provide care tailored to cognitive dysfunction for all hospitalised older patients.

The utility of the HFA-ICOS cardiotoxicity risk assessment tool for HER2-targeted cancer therapies in patients with metastatic breast cancer: from theory to clinical practice

Abstract Background Breast cancer is the most common cancer in women. In developing countries, a considerable proportion of breast cancer diagnoses are made in advanced stages. Nevertheless, the development of targeted therapies, such as trastuzumab and other HER2 targeted agents, has revolutionized the care of these patients, leading to large improvements in disease-free and overall survival. In the other hand, these therapies are associated with cardiac dysfunction. As such, a comprehensive assessment of cardiovascular health before initiation of cancer treatment is fundamental. The HFA-ICOS´s proforma for HER2 targeted therapies is a proposed tool to evaluate the baseline risk of cardiotoxicity in these patients. Purpose To evaluate if the HFA-ICOS´s cardiotoxicity risk assessment tool for HER2-targeted cancer therapies allows to properly identify patients with HER2-positive metastatic breast cancer treated with trastuzumab at high risk for cardiotoxicity. Methods We performed an electronic chart review of patients with HER2-positive metastatic breast cancer treated with trastuzumab seen at the outpatient oncology clinic from January 2018 to December 2022. We collected the necessary data to apply the HFA-ICOS´s cardiotoxicity risk assessment tool for HER2-targeted cancer therapies, except for cardiac biomarkers. Cardiotoxicity was defined as 10% drop of left ventricular ejection fraction (LVEF) to a value of less than 50%. Results Seventy patients were included in our analysis. Mean age was 54.6+12.5 years. Cardiotoxicity was found in twenty-three patients (32%), of which, nine (39.1%) were classified at high risk for cardiotoxicity, twelve patients (52.1%) at medium risk, and two patients (8.6%) at low risk. Among the group with cardiotoxicity there was a higher proportion of older patients, obesity, borderline LVEF at baseline, prior treatment with anthracyclines, and prior exposure to radiotherapy. A high-risk score was more frequent among patients with cardiotoxicity than in those without cardiotoxicity. Most patients were classified with medium risk in both groups. The proportion of patients with low risk was not different in patients with and without cardiotoxicity. None of the variables evaluated was statistically significant. Conclusions There was a higher proportion of patients at high risk according to the HFA-ICO´s proforma for HER2 targeted therapies who developed cardiotoxicity in comparison to patients without cardiotoxicity. However, there were no significant differences in patients classified as medium or low risk. Future studies are needed to precise the most adequate method to stratify cardiotoxicity risk in patients with breast cancer exposed to anti-HER2 therapies, in order to establish effective surveillance and a suitable treatment.Table 1.

CERKL-Associated Retinal Dystrophy: Genetics, Phenotype, and Natural History

To analyze the clinical characteristics, natural history, and genetics of CERKL-associated retinal dystrophy in the largest series to date. Multicenter retrospective cohort study. Forty-seven patients (37 families) with likely disease-causing CERKL variants. Review of clinical notes, ophthalmic images, and molecular diagnosis from 2 international centers. Visual function, retinal imaging, and characteristics were evaluated and correlated. The mean age at the first visit was 29.6± 13.9 years, and the mean follow-up time was 9.1± 7.4 years. The most frequent initial symptom was central vision loss (40%), and the most common retinal feature was well-demarcated areas of macular atrophy (57%). Seventy-seven percent of the participants had double-null genotypes, and 64% had electrophysiological assessment. Among the latter, 53% showed similar severity of rod and cone dysfunction, 27% revealed a rod-cone, 10% a cone-rod, and 10% a macular dystrophy dysfunction pattern. Patients without double-null genotypes tended to have fewer pigment deposits and included a higher proportion of older patients with a relatively mild electrophysiological phenotype. Longitudinal analysis showed that over half of the cohort lost 15 ETDRS letters or more in ≥ 1 eye during the first 5 years of follow-up. The phenotype of CERKL-retinal dystrophy is broad, encompassing isolated macular disease to severe retina-wide involvement, with a range of functional phenotypes, generally not fitting in the rod-cone/cone-rod dichotomy. Disease onset is often earlier, with more severe retinal degenerative changes and photoreceptor dysfunction, in nullizygous cases. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Comparison of the survival outcomes between primary and secondary muscle-invasive bladder cancer: a propensity score-matched study.

Studies have classified muscle-invasive bladder cancer (MIBC) into primary (initially muscle-invasive, PMIBC) and secondary subtypes (initially non-muscle-invasive but progresses, SMIBC), for which controversial survival outcomes were demonstrated. This study aimed to compare the survival outcomes between PMIBC and SMIBC patients in China. Patients diagnosed with PMIBC or SMIBC at West China Hospital from January 2009 to June 2019 were retrospectively included. Kruskal-Wallis and Fisher tests were employed to compare clinicopathological characteristics. Kaplan-Meier curves and Cox competing proportional risk model were used to compare survival outcomes. Propensity score matching (PSM) was employed to reduce the bias and subgroup analysis was used to confirm the outcomes. A total of 405 MIBC patients were enrolled, including 286 PMIBC and 119 SMIBC, with a mean follow-up of 27.54 and 53.30 months, respectively. The SMIBC group had a higher proportion of older patients (17.65% [21/119] vs. 9.09% [26/286]), chronic disease (32.77% [39/119] vs . 22.38% [64/286]), and neoadjuvant chemotherapy (19.33% [23/119] vs . 8.04% [23/286]). Before matching, SMIBC had a lower risk of overall mortality (OM) (hazard ratios [HR] 0.60, 95% confidence interval [CI] 0.41-0.85, P = 0.005) and cancer-specific mortality (CSM) (HR 0.64, 95% CI 0.44-0.94, P = 0.022) after the initial diagnosis. However, higher risks of OM (HR 1.47, 95% CI 1.02-2.10, P = 0.038) and CSM (HR 1.58, 95% CI 1.09-2.29, P = 0.016) were observed for SMIBC once it became muscle-invasive. After PSM, the baseline characteristics of 146 patients (73 for each group) were well matched, and SMIBC was confirmed to have an increased CSM risk (HR 1.83, 95% CI 1.09-3.06, P = 0.021) than PMIBC after muscle invasion. Compared with PMIBC, SMIBC had worse survival outcomes once it became muscle-invasive. Specific attention should be paid to non-muscle-invasive bladder cancer with a high progression risk.

PS-BPC09-5: THE RELATIONSHIP BETWEEN CHANGES IN EXERCISE HABITS, PHYSICAL FUNCTION, AND PSYCHOLOGICAL STATUS IN OLDER PATIENTS WITH HYPERTENSION

Objective: Self-restraint from activities due to the COVID-19 pandemic has limited the range of activities and interpersonal relationships for older persons. Moreover, prolonged restraint has been reported to increase the risk of frailty and sarcopenia. Therefore, we examined the effects of changes in exercise habits on physical function and psychological status of older patients with hypertension throughout their self-restraint lifestyle from 2020 to 2022 in the 1-year follow-up study. Design and Methods: Participants were patients with hypertension aged 65 years or older attending outpatient clinics at our institution who could obtain information on exercise habits, history of falls, comprehensive geriatric assessment, and muscle strength. We conducted the same survey in the first year and one year later. The subjects were classified into four groups by combining their exercise habits in the first year with or without one year later. That is Group A: with exercise habits at both times of the survey; Group B: with exercise habits in the first year and without exercise habits one year later; Group C: without exercise habits in the first year and with exercise habits one year later; and Group D: without exercise habits at both times of the survey. Written consent forms were obtained from all participants. Our institutional review board approved the study protocol. Results: The study participants were 183 patients (Group A: 119, Group B: 26, Group C: 17, Group D: 21). The age of the participants was 76.1 ± 5.5 years, 82 (44.8%) were male, and the duration of hypertension was 18.4 ± 11.5 years. Changes in exercise habits were not associated with physical function, history of falls, and comprehensive geriatric assessment at one year. However, when the results were examined separately for men and women, the geriatric depression scale was significantly higher in women in Group B (Dunnett test, p = 0.0094) than in Group A, suggesting that the tendency toward depression had progressed. Group B women also had more falls one year later (chi-square 12.04, p = 0.0072). Conclusions: In a 1-year follow-up study during the COVID-19 pandemic, a relatively high proportion of older patients with hypertension attending our hospital maintained their exercise habits, but 14% of cases lost their exercise habits. Only women showed the development of depression and increased risk of falls when exercise habits were lost. Women were more susceptible to the effects of environmental changes than men in older patients with hypertension.

Use of the Quality of Interactions Schedule (QuIS) in assessing negative staff-patient interactions in acute care settings for older people: A content validation study.

The Quality of Interactions Schedule (QuIS) is an observational tool to assess the quality of staff-patient interactions in a healthcare context. QuIS is a promising measure for the evaluation of compassionate care, particularly where care is being delivered to patient populations, such as older people, who may be excluded from self-completion data collection methods. This study investigates the content validity of QuIS in identification of negative staff-patient interactions in acute care. Staff-patient interactions (n=1598) on adult inpatient units with a high proportion of older patients in two UK National Health Service hospitals were observed and rated using QuIS. When rating interactions as negative quality, observers recorded brief field notes to explain the rating. Content analysis was used to develop categories of negative interaction type. These categories were compared with the QuIS negative interaction definitions. Eighty-eight negative ratings were accompanied by a field note that could be used in the analysis. Five interaction categories were identified: Patient calls for help, call not acknowledged; Staff focused on task and appear to ignore/not hear patient; Patient-led interactions appear dismissed or ignored; Patient prevented from doing something without explanation; Staff interact with each other or talk to relatives, not including patient. There was clear association between the derived categories and QuIS guidance for negative ratings. These findings support the validity of QuIS data in relation to measurement of interaction quality in acute care settings. Extending the research to a wider range of settings would be useful.

Perspectives on frailty screening, management and its implementation among acute care providers in Singapore: a qualitative study

BackgroundCOVID-19 pandemic has reminded how older adults with frailty are particularly exposed to adverse outcomes. In the acute care setting, consideration of evidence-based practice related to frailty screening and management is needed to improve the care provided to aging populations. It is important to assess for frailty in acute care so as to establish treatment priorities and goals for the individual. Our study explored understanding on frailty and practice of frailty screening among different acute care professionals in Singapore, and identify barriers and facilitators concerning frailty screening and its implementation.MethodsA qualitative study using focus group discussion among nurses and individual interviews among physicians from four departments (Accident & Emergency, Anesthesia, General Surgery, Orthopedics) in three acute hospitals from the three public health clusters in Singapore. Participants were recruited through purposive sampling of specific clinicians seeing a high proportion of older patients at the hospitals. Thematic analysis of the data was performed using NVIVO 12.0.ResultsFrailty was mainly but inadequately understood as a physical and age-related concept. Screening for frailty in acute care was considered important to identify high risk patients, to implement targeted treatment and care, and to support decision making and prognosis estimation. Specific issues related to screening, management and implementation were identified: cooperation from patient/caregivers, acceptance from healthcare workers/hospital managers, need for dedicated resources, guidelines for follow-up management and consensus on the scope of measurement for different specialties.ConclusionOur findings indicated the need for 1) frailty-related education program for patients/care givers and stakeholders 2) inter-professional collaboration to develop integrated approach for screening and management of hospital patients with frailty and 3) hospital-wide consensus to adopt a common frailty screening tool.

Intermediate-grade brain arteriovenous malformations and the boundary of operability using the supplemented Spetzler-Martin grading system.

Supplemented Spetzler-Martin grading (Supp-SM), which is the combination of Spetzler-Martin and Lawton-Young grades, was validated as being more accurate than stand-alone Spetzler-Martin grading, but an operability cutoff was not established. In this study, the authors surgically treated intermediate-grade AVMs to provide prognostic factors for neurological outcomes and to define AVMs at the boundary of operability. Surgically treated Supp-SM intermediate-grade (5, 6, and 7) AVMs were analyzed from 2011 to 2018 at two medical centers. Worsened neurological outcomes were defined as increased modified Rankin Scale (mRS) scores on postoperative examinations. A second analysis of 2000-2011 data for Supp-SM grade 6 and 7 AVMs was performed to determine the subtypes with improved or unchanged outcomes. Patients were separated into three groups based on nidus size (S1: < 3 cm, S2: 3-6 cm, S3: > 6 cm) and age (A1: < 20 years, A2: 20-40 years, A3: > 40 years), followed by any combination of the combined supplemented grade: low risk (S1A1, S1A2, S2A1), intermediate risk (S2A2, S1A3, S3A1, or high risk (S3A3, S3A2, S2A3). Two hundred forty-six patients had intermediate Supp-SM grade AVMs. Of these patients, 102 had Supp-SM grade 5 (41.5%), 99 had Supp-SM grade 6 (40.2%), and 45 had Supp-SM grade 7 (18.3%). Significant differences in the proportions of patients with worse mRS scores at follow-up were found between the groups, with 24.5% (25/102) of patients in Supp-SM grade 5, 29.3% (29/99) in Supp-SM grade 6, and 57.8% (26/45) in Supp-SM grade 7 (p < 0.001). Patients with Supp-SM grade 7 AVMs had significantly increased odds of worse postoperative mRS scores (p < 0.001; OR 3.7, 95% CI 1.9-7.3). In the expanded cohort of 349 Supp-SM grade 6 AVM patients, a significantly higher proportion of older patients with larger Supp-SM grade 6 AVMs (grade 6+, 38.6%) had neurological deterioration than the others with Supp-SM grade 6 AVMs (22.9%, p = 0.02). Conversely, in an expanded cohort of 197 Supp-SM grade 7 AVM patients, a significantly lower proportion of younger patients with smaller Supp-SM grade 7 AVMs (grade 7-, 19%) had neurological deterioration than the others with Supp-SM grade 7 AVMs (44.9%, p = 0.01). Patients with Supp-SM grade 7 AVMs are at increased risk of worse postoperative neurological outcomes, making Supp-SM grade 6 an appropriate operability cutoff. However, young patients with small niduses in the low-risk Supp-SM grade 7 group (grade 7-) have favorable postoperative outcomes. Outcomes in Supp-SM grade 7 patients did not improve with surgeon experience, indicating that the operability boundary is a hard limit reflecting the complexity of high-grade AVMs.

Effect of Age on Outcomes of Allogeneic Transplantation in Patients with Acute Myeloid Leukemia and Myelodysplastic Syndrome

Background: Allogeneic stem cell transplantation (allo-SCT) has become an increasingly important consolidation treatment option for patients with acute myeloid leukemia (AML) and as upfront therapy for patients with high-risk myelodysplastic syndrome (MDS). Although the median age at diagnosis for both diseases is above 65 years, studies evaluating allo-SCT as treatment option for patients aged 65 years or older are limited. Further, as the population ages, the number of patients above 65 years considered for allo-SCT will continue to rise. Thus, the aim of our current investigation was to analyze outcomes based on age in AML/MDS patients <65 years old and ≥65 years old who received allo-SCT at the Ohio State University.Methods: A retrospective analysis was performed for all AML/MDS patients who received allo-SCT between January 1984 and December 2018 at our institution. Primary endpoints included progression free survival (PFS) and overall survival (OS). PFS was counted from the day of transplantation to relapse or death. OS was defined as survival from the day of allo-SCT until death from any cause, with censoring of patients known to be alive at the time of last follow-up. PFS and OS were calculated using Kaplan Meier Curves. Secondary endpoints included cumulative incidences of grade II-IV and III-IV acute GVHD (aGVHD), chronic GVHD (cGVHD), relapse, and non-relapse mortality (NRM). Cumulative incidence rates of aGVHD, cGVHD, relapse, NRM were estimated and compared using Gray's test accounting for competing risks.Results: The cohort consisted of 900 AML/MDS patients, with 150 patients ≥65 years and 750 patients <65 years. The median age at transplant for the <65 years group was 49 years (range: 18-64 years) and 68 years (range: 65-76 years) for the ≥65 years group. Gender, race, Karnofsky score, and comorbidity index were similar between the two groups. A higher proportion of patients received myeloablative (MA) conditioning (65.1%) in the <65 years of age compared to 20% in the ≥65 years of age (p<0.01). A higher proportion of older patients had matched unrelated donors (57.3%), and reduced intensity conditioning (RIC) regimens (80%).The median time from diagnosis to transplantation was 176 days (range: 55-4920) for age <65 years and 168 days (range: 34-6079 days) for age ≥65 years. Median follow-up from allo-SCT was 5.9 years (range 0.8-35.9 years) and 3.4 years (range: 1.0-9.6 years) from transplantation among survivors. Neutrophil and platelet engraftment were similar among the groups (p=0.35; 0.11). 3 year OS of 42.3% (95% CI: 38.7-45.8%) and PFS of 38.3% (95% CI: 34.8%-41.9%) were observed for age <65 years. The corresponding OS and PFS for age ≥65 years was 46.3% (95% CI: 37.9%-54.3%) and 43.0% (95% CI: 34.7%-51.0%), respectively (Figure 1a & 1b). Cumulative incidences of relapse at 1 year in <65 and ≥65 years were 26.4% and 25.3%, respectively (p=0.43). The cumulative incidence of NRM at 1 year in <65 and ≥65 years was 23.2% and 17.3%, respectively (p=0.12; Figures 1c and d). The incidences of acute and chronic GVHD were similar in the two age groups. The cumulative incidence of aGVHD at day 100 in <65 and ≥65 years was 40.3% (95% CI: 36.4%-44.2%) and 43.0% (95% CI: 34.9%-50.7%), respectively. The cumulative incidence of cGVHD at day 365 in <65 and ≥65 years was 40.8% (95% CI: 36.9%-44.6%) and 41.6% (95% CI: 33.6%-49.4%), respectively.Conclusion: Overall, our study suggests similar outcomes for elderly patients undergoing allo-HCT as compared to their counterparts, which is in line with prior studies. This likely is due to advancements in the transplant field, including the development of RIC and alternative donors, which have allowed greater access to transplant for older adults. Utilization of allo-HCT is feasible and should be considered for AML/MDS patients ≥65 years. Further research is underway to evaluate the important determinants of health status in older patients undergoing allo-HCT and to ultimately help predict NRM (BMT CTN 1704). [Display omitted] DisclosuresBumma: Amgen, Sanofi: Speakers Bureau; Janssen, Oncopeptides, Sanofi: Consultancy. Vasu: Seattle Genetics: Other: travel support; Boehringer Ingelheim: Other: Travel support; Kiadis, Inc.: Research Funding; Omeros, Inc.: Membership on an entity's Board of Directors or advisory committees. Jaglowski: Takeda: Consultancy; Juno: Consultancy; Kite, a Gilead Company: Consultancy, Research Funding; CRISPR Therapeutics: Consultancy; Novartis: Consultancy, Research Funding. Mims: Syndax Pharmaceuticals: Consultancy; BMS: Consultancy; Jazz Pharmaceuticals: Consultancy; Abbvie: Consultancy; Genentech: Consultancy; Kura Oncology: Consultancy; Leukemia and Lymphoma Society: Consultancy; Glycomemetics: Research Funding; Aptevo: Research Funding; Xencor: Research Funding; Daiichi-Saynko: Consultancy. Brammer: Celgene: Research Funding; Seattle Genetics: Speakers Bureau; Kymera Therapeutics: Consultancy. Saad: Incyte Pharmaceuticals: Consultancy; careDx: Consultancy; Amgen: Research Funding; Kadmon: Research Funding; OrcaBio: Research Funding; Magenta Therapeutics: Consultancy. de Lima: Miltenyi Biotec: Research Funding; Incyte: Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees.

Does a policy that requires adherence to a regular primary care physician improve the actual adherence of patients?

BackgroundContinuity of care by the same personal physician is a key factor in an effective and efficient health care system. Studies that support the association between high adherence and better outcomes were done in settings where allocation to the same physician was a long-term policy.ObjectivesTo evaluate the influence that changing organizational policy from the free choice of a primary care physician to a mandatory continuity of care by the same physician has on adherence to a personal physician.MethodsA cross-sectional study based on electronic databases; comparison of adherence and demographic characteristics (sex, age, and socio-economic status) of 208,286 Leumit enrollees who met the inclusion criteria, according to change in the adherence to a personal physician. To evaluate adherence, we used the Usual Provider of Care (UPC) index, which measures the number of visits made to the personal doctor out of the total primary care physician visits over the same period. The patients were divided into groups according to their UPC level.ResultsThe data shows that 54.5% of the patients were high adherers even before the organizational change; these rates are similar to those published by various organizations worldwide, years after mandating continuity of care by the same physician.In the year following the intervention, only 34.5% of the patients changed the level of their adherence group. Of these, 64% made a shift to a higher adherence group.Before the intervention, the high adherers were older (mean age 57.8 vs. 49.3 years in the low adherers group) and from a higher SES (mean SES status 9.32 vs. 8.71). After the intervention, a higher proportion of older patients and patients from a higher SES changed their adherence to a higher group.Sex distribution was similar over all the adherence level groups and did not change after the intervention.Conclusions and policy implicationsA policy change that encouraged adherence to an allocated primary care physician managed to improve adherence only in specific groups.Health organizations need to examine the potential for change and the groups they want to influence and direct their investment wisely.Trial registrationretrospectively registered.

Describing people with cognitive impairment and their complex treatment needs during routine care in the hospital \u2013 cross-sectional results of the intersec-CM study

BackgroundCognitive impairment is an important determinant in health care. In the acute hospital setting cognition has a strong impact on treatment and care. Cognitive impairment can negatively affect diagnostics and treatment success. However, little is known about the individual situation and specific risks of people with cognitive impairments during hospital stays. The aim of the present research is to describe and analyze the treatment needs of people with cognitive impairments in acute hospital care.MethodsThe analyses use baseline data of the ongoing multisite, longitudinal, randomized controlled intervention trial intersec-CM (Supporting elderly people with cognitive impairment during and after hospital stays with Intersectoral Care Management), which recruited 402 participants at baseline. We assessed sociodemographic aspects, cognitive status, functional status, frailty, comorbidities, level of impairment, formal diagnosis of dementia, geriatric diagnoses, delirium, depression, pharmacological treatment, utilization of health care services and health care related needs.ResultsThe sample under examination had been on average mildly cognitively impaired (MMSE M = 22.3) and had a mild to moderate functional impairment (Barthel Index M = 50.4; HABAM M = 19.1). The Edmonton Frail Scale showed a mean of 7.4 and half of the patients (52.3%) had been assigned a care level. About 46.9% had a geriatric diagnosis, 3.0% had a diagnosis of dementia. According to DSM-V 19.2% of the patients had at least one main symptom of depression. The mean number of regularly taken drugs per patient was 8.2. Utilization of health care services prior to the hospital stay was rather low. On average, the sample showed 4.38 care related needs in general, of which 0.60 needs were unaddressed at the time of assessment.ConclusionsDescriptive analyses highlight an in-depth insight into impairments and different care needs of people with cognitive impairments. The results emphasize the need for gender-specific analyses as well as an increased attention to the heterogeneity of needs of people with cognitive impairments related to specific wards, settings and regions where they are admitted. Our results indicate also that people with cognitive impairments represent a high proportion of older patients in acute hospital care.Trial registrationThe intersec-CM trial is registered at ClinicalTrials.gov (NCT03359408).

Efficacy and Safety of Ravulizumab in Older Patients Aged >65 Years with Paroxysmal Nocturnal Hemoglobinuria in the 301 and 302 Phase 3 Extension Studies

Efficacy and Safety of Ravulizumab in Older Patients Aged >65 Years with Paroxysmal Nocturnal Hemoglobinuria in the 301 and 302 Phase 3 Extension Studies

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

BackgroundEvidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients.MethodsPatients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence.ResultsOver the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0–19.5% < 60 years; 15.2–17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved.ConclusionsDespite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

P0474UTILITY OF NATIVE KIDNEY BIOPSY IN OLDER ADULTS: SAFETY AND DIAGNOSES

Abstract Background and Aims Population aging is an increasing phenomenon worldwide and consequently more are developing kidney diseases which may necessitate diagnostic kidney biopsy. However, older patients may be at increased risk for complications such as bleeding. We aimed to examine the utility and safety of native kidney biopsies among our older adults. Method This was a single-centre retrospective study of older adults (≥60 years) who had native kidney biopsies at the Singapore General Hospital between June 2011 and March 2015. Demographic data, co-morbid illnesses, clinical presentation at kidney biopsy, as well as laboratory results before and after kidney biopsy, were retrieved from electronic medical records. Patient outcomes were recorded until their last visit or death before 30th March 2017. End stage renal disease (ESRD) was defined as estimated glomerular filtration rate (eGFR) &amp;lt;15 ml/min/1.73 m2 or need for renal replacement therapy persisting &amp;gt;3 months. All post biopsy bleeding events were documented, with major bleeding defined as the need for transfusion and/or intervention; or if bleeding was either a direct or contributory cause of death. Results Older adults accounted for 153 of 545 (28.1%) native renal biopsies performed. The indications for biopsy in older adults included microscopic hematuria with proteinuria (51.0%), nephrotic syndrome (32.0%) and isolated proteinuria (17.0%). One hundred and ten patients (71.9%) had eGFR &amp;lt;60ml/min/1.72m2 at biopsy and a significantly higher proportion of older patients (85.5% vs 62.4%, p&amp;lt;0.001) had eGFR &amp;lt;30ml/min/1.72m2. Compared to the younger individuals &amp;lt;60 years old, older patients were more likely to be hypertensive (86.3% vs 58.4%, p&amp;lt;0.001) and diabetic (49.0% vs 28.1%, p&amp;lt;0.001). Post biopsy, major bleeding was more frequent among older adults compared with younger adults (13.3% vs 5.7% respectively; p=0.04), although overall bleeding episodes between older and younger adults were not significantly different (15.9% vs 22.9% respectively; p=0.18). Among older adults, minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS) was the most frequent diagnosis (23.5%), followed by membranous nephropathy (20.9%) and IgA nephropathy (9.8%), whereas MCD/FSGS (26.5%), lupus nephritis (24.5%) and IgA nephropathy (19.6%) were the top three diagnoses amongst younger adults. Co-existing glomerulonephritis (GN) with diabetic nephropathy and isolated diabetic nephropathy were seen in 12 (7.8%) and 20 (13.1%) elderly patients respectively. The majority (124 patients, 81.0%) of biopsies in older adults had histological diagnoses of glomerulonephritis that were potentially amendable to treatment although only 90 (58.8%) patients subsequently received immunosuppressants. Among older adults with biopsy-proven glomerulonephritis, median follow up was similar between those treated and not treated with immunosuppressants (30.4 [27.3, 53.7] months versus 38.8 [30.7, 51.9] months, p=0.12). Among older adults with GN, ESRD was less frequent among those treated with immunosuppressants, compared to those who did not receive immunosuppressants, although the difference did not reach statistical significance (10.3% versus 18.9%, p=0.24). However, the combined endpoint of ESRD or mortality were similar (24.1% vs 21.6%, p=0.76). Conclusion Our findings support the utility of renal biopsy for diagnosis and to guide clinical care. Older adults undergoing kidney biopsy should be counselled and monitored for bleeding complications.

Older asthmatic patients have increased discrepancies between symptoms and objective asthma control parameters

RATIONALE: Discrepancies between clinical, physiological and inflammatory asthma control parameters need to be documented in older patients.OBJECTIVE: To compare the prevalence of discrepancies between asthma control parameters among older and younger patients.METHODS: This retrospective, cross-sectional study compared data from older (≥60 years; n = 92) and younger (18–35 years; n = 266) subjects with asthma. Discrepancies ( > 20% difference) between any two parameters of the asthma control scoring system (ACSS): (1) clinical (respiratory symptoms), (2) physiological (forced expiratory volume in one second percent predicted) and (3) inflammatory (sputum eosinophil percentage) were determined.MEASUREMENTS AND MAIN RESULTS: Fifty-seven percent of older asthmatics had at least one discrepancy, against 40% of younger (P = 0.008). A higher proportion of older patients showed discrepancies between clinical and physiological scores (P = 0.0005) and between clinical and inflammatory scores (P = 0.007), with a better clinical than physiological or inflammatory score in most cases.CONCLUSION: The increased prevalence of discrepancies between asthma control parameters in older asthmatics strengthens the importance of considering all parameters of control in the evaluation and management of asthma in older patients.