Bocheng Jing

All Publications

• Antihypertensive Deprescribing and Cardiovascular Events Among Long-Term Care Residents. JAMA network open Odden, M. C., Graham, L. A., Liu, X., Dave, C. V., Lee, S. J., Li, Y., Jing, B., Fung, K., Peralta, C. A., Steinman, M. A. 2024; 7 (11): e2446851

  Abstract

  The practice of deprescribing antihypertensive medications is common among long-term care residents, yet the effect on cardiovascular outcomes is unclear.To compare the incidence of hospitalization for myocardial infarction (MI) or stroke among long-term care residents who are deprescribed or continue antihypertensive therapy.This comparative effectiveness research study used target trial emulation with observational electronic health record data from long-term care residents aged 65 years or older admitted to US Department of Veterans Affairs community living centers between October 1, 2006, and September 30, 2019, and taking at least 1 antihypertensive medication. Analyses were conducted between August 2023 and August 2024.A reduction in the number of antihypertensive medications or dose (by ≥30%), assessed using barcode medication administration data.Incidence of MI and stroke hospitalization up to 2 years was assessed using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. A pooled logistic regression model with inverse probability of treatment weighting (IPTW) and inverse probability of censoring weighting (IPCW) was used to estimate per-protocol effects.Of 13 096 long-term care residents (97.4% men; median age, 77 years [IQR, 70-84 years]) taking antihypertensive medication, 17.8% were deprescribed antihypertensive medication over a period of 12 weeks. The estimated unadjusted cumulative incidence of stroke or MI hospitalization over 2 years was similar among residents who were and were not deprescribed antihypertensives in per-protocol analyses (11.2% vs 8.8%; difference, 2.4 percentage points [95% CI, -2.3 to 7.1 percentage points]). Participant characteristics were balanced after applying IPTW and IPCW; all standardized mean differences were less than 0.05. After full adjustment for confounding and informative censoring, the per-protocol analysis results showed no association of antihypertensive deprescribing with MI or stroke hospitalization (hazard ratio, 0.93; 95% CI, 0.70-1.26).In this comparative effectiveness research study, deprescribing antihypertensive medication was not associated with risk of hospitalization for MI or stroke in long-term care residents. These findings may be informative for long-term care residents and clinicians who are considering deprescribing antihypertensive medications.

  View details for DOI 10.1001/jamanetworkopen.2024.46851

  View details for PubMedID 39585693

• Impact of Hospitalizations on Problematic Medication Use Among Community-Dwelling Persons With Dementia. The journals of gerontology. Series A, Biological sciences and medical sciences Deardorff, W. J., Jing, B., Growdon, M. E., Blank, L. J., Bongiovanni, T., Yaffe, K., Boscardin, W. J., Boockvar, K. S., Steinman, M. A. 2024; 79 (11)

  Abstract

  Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization.We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008 to 2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from the 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks prehospitalization (baseline) to 4 months posthospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, prehospital chronic medications, and timepoint.Among 1 475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR = 79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to posthospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs 1.40, difference 0.12 (95% CI -0.03, 0.26), p = .12). Results were consistent across medication domains and certain subgroups. In one prespecified subgroup, individuals on <5 prehospital chronic medications showed a greater increase in posthospital problematic medications compared with those on ≥5 medications (p = .04 for interaction, mean increase from baseline to posthospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications).Hospitalizations had a small, nonstatistically significant effect on longer-term problematic medication use among PWD.

  View details for DOI 10.1093/gerona/glae207

  View details for PubMedID 39155601

  View details for PubMedCentralID PMC11419320

• Deprescribing of Antihypertensive Medications and Cognitive Function in Nursing Home Residents. JAMA internal medicine Jing, B., Liu, X., Graham, L. A., Dave, C. V., Li, Y., Fung, K., Liu, C. K., Abdel Magid, H. S., Growdon, M. E., Deardorff, W. J., Boscardin, W. J., Lee, S. J., Steinman, M. A., Odden, M. C. 2024

  Abstract

  Antihypertensive medication deprescribing is common among nursing home residents, yet its association with cognitive decline remains uncertain.To investigate the association of deprescribing antihypertensive medication with changes in cognitive function in nursing home residents.This cohort study using a target trial emulation approach included VA long-term care residents aged 65 years or older with stays of at least 12 weeks from 2006 to 2019. Residents who were not prescribed antihypertensive medication, with blood pressure greater than 160/90 mm Hg, or with heart failure were excluded. Eligible residents with stable medication use for 4 weeks were classified into deprescribing or stable user groups and followed for 2 years or until death or discharge for intention-to-treat (ITT) analysis. Participants switching treatment groups were censored in the per-protocol analysis. Cognitive function measurements during follow-up were analyzed using an ordinal generalized linear mixed model, adjusting for confounders with inverse probability of treatment weighting. Per-protocol analysis included inverse probability of censoring weighting. Data analyses were performed from May 1, 2023, and July 1, 2024.Deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%, sustained for a minimum of 2 weeks.Cognitive Function Scale (CFS) was classified as cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4).Of 45 183 long-term care residents, 12 644 residents (mean [SD] age 77.7 [8.3] years; 329 [2.6%] females and 12 315 [97.4%] males) and 12 053 residents (mean [SD] age 77.7 [8.3] years; 314 [2.6%] females and 11 739 [97.4%] males) met eligibility for ITT and per-protocol analyses, respectively. At the end of the follow-up, 12.0% of residents had a worsened CFS (higher score) and 7.7% had an improved CFS (lower score) with 10.8% of the deprescribing group and 12.1% of the stable user group showing a worsened CFS score. In the per-protocol analysis, the deprescribing group had a 12% reduction in the odds of progressing to a worse CFS category per 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared to the stable user group. Among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98). These patterns remained consistent in the ITT analysis.This cohort study indicates that deprescribing is associated with less cognitive decline in nursing home residents, particularly those with dementia. More data are needed to understand the benefits and harms of antihypertensive deprescribing to inform patient-centered medication management in nursing homes.

  View details for DOI 10.1001/jamainternmed.2024.4851

  View details for PubMedID 39312220

  View details for PubMedCentralID PMC11420821

• Complex Patterns of Antihypertensive Treatment Changes in Long-Term Care Residents. Journal of the American Medical Directors Association Liu, X., Jing, B., Graham, L. A., Liu, C. K., Lee, S. J., Steinman, M. A., Dave, C. V., Manja, V., Li, Y., Fung, K., Odden, M. C. 2024: 105119

  Abstract

  Antihypertensive treatment changes are common in long-term care residents, yet data on the frequency and predictors of changes are lacking. We described the patterns of antihypertensive changes and examined the triggering factors.Retrospective cohort study.A total of 24,870 Department of Veterans Affairs (VA) nursing home residents ≥65 years with long-term stays (≥180 days) from 2006 to 2019.We obtained data from the VA Corporate Data Warehouse. Based on Bar Code Medication Administration medication data, we defined 2 types of change events in 180 days of admission: deprescribing (reduced number of antihypertensives or dose reduction of ≥30% compared with the previous week and maintained for at least 2 weeks) and intensification (opposite of deprescribing). Mortality was identified within 2 years after admission.More than 85% of residents were prescribed antihypertensives and 68% of them experienced ≥1 change event during the first 6 months of the nursing home stay. We categorized residents into 10 distinct patterns: no change (27%), 1 deprescribing (11%), multiple deprescribing (5%), 1 intensification (10%), multiple intensification (7%), 1 deprescribing followed by 1 intensification (3%), 1 intensification followed by 1 deprescribing (4%), 3 changes with mixed events (7%), >3 changes with mixed events (10%), and no antihypertensive use (15%). Treatment changes were more frequent in residents with better physical function and/or cognitive function. Potentially triggering factors differed by the type of antihypertensive change: incident high blood pressure and cardiovascular events were associated with intensification, and low blood pressure, weight loss, and falls were associated with deprescribing. Death occurred in 7881 (32%) residents over 2 years. The highest mortality was for those without antihypertensive medication (incidence = 344/1000 person-years).Patterns of medication changes existing in long-term care residents are complex. Future studies should explore the benefits and harms of these antihypertensive treatment changes.

  View details for DOI 10.1016/j.jamda.2024.105119

  View details for PubMedID 38950584

• Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid-loop diuretic cascade. Journal of the American Geriatrics Society Growdon, M. E., Jing, B., Morris, E. J., Deardorff, W. J., Boscardin, W. J., Byers, A. L., Boockvar, K. S., Steinman, M. A. 2024; 72 (6): 1728-1740

  Abstract

  Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years.Using Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another.Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82).Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.

  View details for DOI 10.1111/jgs.18892

  View details for PubMedID 38547357

  View details for PubMedCentralID PMC11187679

• Effects of residential socioeconomic polarization on high blood pressure among nursing home residents. Health & place Abdel Magid, H. S., Jaros, S., Li, Y., Steinman, M. A., Lee, S., Peralta, C., Jing, B., Fung, K., Liu, C. K., Liu, X., Graham, L. A., Odden, M. C. 2024; 87: 103243

  Abstract

  Neighborhood concentration of racial, income, education, and housing deprivation is known to be associated with higher rates of hypertension. The objective of this study is to examine the association between tract-level spatial social polarization and hypertension in a cohort with relatively equal access to health care, a Veterans Affairs nursing home.41,973 long-term care residents aged ≥65 years were matched with tract-level Indices of Concentration at the Extremes across four socioeconomic domains. We modeled high blood pressure against these indices controlling for individual-level cardiovascular confounders.We found participants who had resided in the most disadvantaged quintile had a 1.10 (95% 1.01, 1.19) relative risk of high blood pressure compared to those in the other quintiles for the joint measuring race/ethnicity and income domain.We achieved our objective by demonstrating that concentrated deprivation is associated with worse cardiovascular outcomes even in a population with equal access to care. Measures that jointly consider economic and racial/ethnic polarization elucidate larger disparities than single domain measures.

  View details for DOI 10.1016/j.healthplace.2024.103243

  View details for PubMedID 38663339

• Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA internal medicine Dave, C. V., Li, Y., Steinman, M. A., Lee, S. J., Liu, X., Jing, B., Graham, L. A., Marcum, Z. A., Fung, K. Z., Odden, M. C. 2024

  Abstract

  Limited evidence exists on the association between initiation of antihypertensive medication and risk of fractures in older long-term nursing home residents.To assess the association between antihypertensive medication initiation and risk of fracture.This was a retrospective cohort study using target trial emulation for data derived from 29 648 older long-term care nursing home residents in the Veterans Health Administration (VA) from January 1, 2006, to October 31, 2019. Data were analyzed from December 1, 2021, to November 11, 2023.Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy.The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, across systolic and diastolic blood pressure thresholds of 140 and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching.Data from 29 648 individuals were included in this study (mean [SD] age, 78.0 [8.4] years; 28 952 [97.7%] male). In the propensity score-matched cohort of 64 710 residents (mean [SD] age, 77.9 [8.5] years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. This finding corresponded to an adjusted hazard ratio (HR) of 2.42 (95% CI, 1.43-4.08) and an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95-6.78). Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalizations or emergency department visits (HR, 1.80 [95% CI, 1.53-2.13]) and syncope (HR, 1.69 [95% CI, 1.30-2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76-6.10]), systolic blood pressure of 140 mm Hg or higher (HR, 3.12 [95% CI, 1.71-5.69]), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41 [95% CI, 1.67-11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49-15.32]).Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressures values, and no recent antihypertensive medication use. Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.

  View details for DOI 10.1001/jamainternmed.2024.0507

  View details for PubMedID 38648065

  View details for PubMedCentralID PMC11036308

• ANTIHYPERTENSIVE DEPRESCRIBING AND COGNITIVE FUNCTION IN VA NURSING HOME RESIDENTS: A TARGET TRIAL EMULATION Jing, B., Liu, X., Odden, M., Dave, C., Graham, L., Li, Y., Fung, K., Steinman, M. OXFORD UNIV PRESS. 2023: 646

  View details for Web of Science ID 001178258403150

• ANTIHYPERTENSIVE DEPRESCRIBING AND DISABILITY IN VA NURSING HOME RESIDENTS WITH AND WITHOUT DEMENTIA Liu, X., Graham, L., Jing, B., Dave, C., Li, Y., Fung, K., Odden, M. OXFORD UNIV PRESS. 2023: 703-704

  View details for Web of Science ID 001178258403333

• Tutorial: Assessing the impact of nonignorable missingness on regression analysis using Index of Local Sensitivity to Nonignorability. Psychological methods Jing, B., Qian, Y., Heitjan, D. F., Xie, H. 2023

  Abstract

  Data sets with missing observations are common in psychology research. One typically analyzes such data by applying statistical methods that rely on the assumption that the missing observations are missing at random (MAR). This assumption greatly simplifies analysis but is unverifiable from the data at hand, and assuming it incorrectly may lead to bias. Thus we often wish to conduct sensitivity analyses to judge whether conclusions are robust to departures from MAR-that is, whether key findings would hold up even if MAR does not in fact hold. This article describes a class of sensitivity analyses derived from a measure of robustness called the Index of Local Sensitivity to Nonignorability (ISNI). ISNI is straightforward to compute and avoids the estimation of complicated non-MAR missing-data models. The accompanying R package isni implements the method for a range of commonly used regression models; the syntax is simple and similar to that for the regular analysis that assumes MAR. We illustrate the application of the method and software to address the credibility of MAR analyses in a series of analyses of real-world data sets from psychology research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

  View details for DOI 10.1037/met0000616

  View details for PubMedID 37971833

• Frequency of Screening for Colorectal Cancer by Predicted Life Expectancy Among Adults 76-85 Years. JAMA Deardorff, W. J., Lu, K., Jing, B., Jeon, S. Y., Boscardin, W. J., Fung, K. Z., Lee, S. J. 2023; 330 (13): 1280-1282

  View details for DOI 10.1001/jama.2023.15820

  View details for PubMedID 37676665

  View details for PubMedCentralID PMC10485741

• Medication misuse and overuse in community-dwelling persons with dementia. Journal of the American Geriatrics Society Deardorff, W. J., Jing, B., Growdon, M. E., Yaffe, K., Boscardin, W. J., Boockvar, K. S., Steinman, M. A. 2023; 71 (10): 3086-3098

  Abstract

  Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD.We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative.Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively.Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.

  View details for DOI 10.1111/jgs.18463

  View details for PubMedID 37272899

  View details for PubMedCentralID PMC10592653

• Can markers of disease severity improve the predictive power of claims-based multimorbidity indices? Journal of the American Geriatrics Society Rizzo, A., Jing, B., Boscardin, W. J., Shah, S. J., Steinman, M. A. 2023; 71 (3): 845-857

  Abstract

  Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden.We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases.Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (<0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers.Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.

  View details for DOI 10.1111/jgs.18150

  View details for PubMedID 36495264

  View details for PubMedCentralID PMC10023343

• Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents. Journal of the American Geriatrics Society Liu, X., Steinman, M. A., Lee, S. J., Peralta, C. A., Graham, L. A., Li, Y., Jing, B., Fung, K. Z., Odden, M. C. 2023

  Abstract

  Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications.Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications).More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group).The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.

  View details for DOI 10.1111/jgs.18301

  View details for PubMedID 36826917

• Development and validation of novel multimorbidity indices for older adults. Journal of the American Geriatrics Society Steinman, M. A., Jing, B., Shah, S. J., Rizzo, A., Lee, S. J., Covinsky, K. E., Ritchie, C. S., Boscardin, W. J. 2023; 71 (1): 121-135

  Abstract

  Measuring multimorbidity in claims data is used for risk adjustment and identifying populations at high risk for adverse events. Multimorbidity indices such as Charlson and Elixhauser scores have important limitations. We sought to create a better method of measuring multimorbidity using claims data by incorporating geriatric conditions, markers of disease severity, and disease-disease interactions, and by tailoring measures to different outcomes.Health conditions were assessed using Medicare inpatient and outpatient claims from subjects age 67 and older in the Health and Retirement Study. Separate indices were developed for ADL decline, IADL decline, hospitalization, and death, each over 2 years of follow-up. We validated these indices using data from Medicare claims linked to the National Health and Aging Trends Study.The development cohort included 5012 subjects with median age 76 years; 58% were female. Claims-based markers of disease severity and disease-disease interactions yielded minimal gains in predictive power and were not included in the final indices. In the validation cohort, after adjusting for age and sex, c-statistics for the new multimorbidity indices were 0.72 for ADL decline, 0.69 for IADL decline, 0.72 for hospitalization, and 0.77 for death. These c-statistics were 0.02-0.03 higher than c-statistics from Charlson and Elixhauser indices for predicting ADL decline, IADL decline, and hospitalization, and <0.01 higher for death (p < 0.05 for each outcome except death), and were similar to those from the CMS-HCC model. On decision curve analysis, the new indices provided minimal benefit compared with legacy approaches. C-statistics for both new and legacy indices varied substantially across derivation and validation cohorts.A new series of claims-based multimorbidity measures were modestly better at predicting hospitalization and functional decline than several legacy indices, and no better at predicting death. There may be limited opportunity in claims data to measure multimorbidity better than older methods.

  View details for DOI 10.1111/jgs.18052

  View details for PubMedID 36282202

  View details for PubMedCentralID PMC9870862

• Fingerstick glucose monitoring by cognitive impairment status in Veterans Affairs nursing home residents with diabetes. Journal of the American Geriatrics Society Nguyen, B., Deardorff, W. J., Shi, Y., Jing, B., Lee, A. K., Lee, S. J. 2022; 70 (11): 3176-3184

  Abstract

  Guidelines recommend nursing home (NH) residents with cognitive impairment receive less intensive glycemic treatment and less frequent fingerstick monitoring. Our objective was to determine whether current practice aligns with guideline recommendations by examining fingerstick frequency in Veterans Affairs (VA) NH residents with diabetes across cognitive impairment levels.We identified VA NH residents with diabetes aged ≥65 residing in VA NHs for >30 days between 2016 and 2019. Residents were grouped by cognitive impairment status based on the Cognitive Function Scale: cognitively intact, mild impairment, moderate impairment, and severe impairment. We also categorized residents into mutually exclusive glucose-lowering medication (GLM) categories: (1) no GLMs, (2) metformin only, (3) sulfonylureas/other GLMs (+/- metformin but no insulin), (4) long-acting insulin (+/- oral/other GLMs but no short-acting insulin), and (5) any short-acting insulin. Our outcome was mean daily fingersticks on day 31 of NH admission.Among 13,637 NH residents, mean age was 75 years and mean hemoglobin A1c was 7.0%. The percentage of NH residents on short-acting insulin varied by cognitive status from 22.7% in residents with severe cognitive impairment to 33.9% in residents who were cognitively intact. Mean daily fingersticks overall on day 31 was 1.50 (standard deviation = 1.73). There was a greater range in mean fingersticks across GLM categories compared to cognitive status. Fingersticks ranged widely across GLM categories from 0.39 per day (no GLMs) to 3.08 (short-acting insulin), while fingersticks ranged slightly across levels of cognitive impairment from 1.11 (severe cognitive impairment) to 1.59 (cognitively intact).NH residents receive frequent fingersticks regardless of level of cognitive impairment, suggesting that cognitive status is a minor consideration in monitoring decisions. Future studies should determine whether decreasing fingersticks in NH residents with moderate/severe cognitive impairment can reduce burdens without compromising safety.

  View details for DOI 10.1111/jgs.17962

  View details for PubMedID 35924668

  View details for PubMedCentralID PMC9705158

• Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes. Journal of the American Geriatrics Society Lederle, L. I., Steinman, M. A., Jing, B., Nguyen, B., Lee, S. J. 2022; 70 (7): 2019-2028

  Abstract

  Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting.We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose-lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c.Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long-acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14-1.65 and OR 1.35, 95% CI 1.10-1.66, respectively). Severe functional impairment (MDS-ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56-0.95). Hypoglycemia was not associated with decreased odds of overtreatment.Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification.

  View details for DOI 10.1111/jgs.17735

  View details for PubMedID 35318647

  View details for PubMedCentralID PMC9283249

• Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes. Journal of the American Geriatrics Society Lam, K., Gan, S., Nguyen, B., Jing, B., Lee, S. J. 2022; 70 (7): 2008-2018

  Abstract

  Guidelines discourage sliding scale insulin (SSI) use after the first week of a nursing home (NH) admission. We sought to determine the prevalence of SSI and identify factors associated with stopping SSI or transitioning to another short-acting insulin regimen.In an observational study from October 1, 2013, to June 30, 2017 of non-hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week, we compared the weekly prevalence of SSI versus two other short-acting insulin regimens - fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) - from week 2 to week 12 of admission. Among those on SSI in week 2, we examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty-related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes-related factors (e.g., HbA1c, long-acting insulin use, hyperglycemia, and hypoglycemia).In week 2, 21% of our cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate-severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes-related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non-SSI short-acting insulin regimen than frailty-related factors.SSI is the most common method of administering short-acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.

  View details for DOI 10.1111/jgs.17771

  View details for PubMedID 35357692

  View details for PubMedCentralID PMC9283241

• Comparing Machine Learning to Regression Methods for Mortality Prediction Using Veterans Affairs Electronic Health Record Clinical Data. Medical care Jing, B., Boscardin, W. J., Deardorff, W. J., Jeon, S. Y., Lee, A. K., Donovan, A. L., Lee, S. J. 2022; 60 (6): 470-479

  Abstract

  It is unclear whether machine learning methods yield more accurate electronic health record (EHR) prediction models compared with traditional regression methods.The objective of this study was to compare machine learning and traditional regression models for 10-year mortality prediction using EHR data.This was a cohort study.Veterans Affairs (VA) EHR data.Veterans age above 50 with a primary care visit in 2005, divided into separate training and testing cohorts (n= 124,360 each).The primary outcome was 10-year all-cause mortality. We considered 924 potential predictors across a wide range of EHR data elements including demographics (3), vital signs (9), medication classes (399), disease diagnoses (293), laboratory results (71), and health care utilization (149). We compared discrimination (c-statistics), calibration metrics, and diagnostic test characteristics (sensitivity, specificity, and positive and negative predictive values) of machine learning and regression models.Our cohort mean age (SD) was 68.2 (10.5), 93.9% were male; 39.4% died within 10 years. Models yielded testing cohort c-statistics between 0.827 and 0.837. Utilizing all 924 predictors, the Gradient Boosting model yielded the highest c-statistic [0.837, 95% confidence interval (CI): 0.835-0.839]. The full (unselected) logistic regression model had the highest c-statistic of regression models (0.833, 95% CI: 0.830-0.835) but showed evidence of overfitting. The discrimination of the stepwise selection logistic model (101 predictors) was similar (0.832, 95% CI: 0.830-0.834) with minimal overfitting. All models were well-calibrated and had similar diagnostic test characteristics.Our results should be confirmed in non-VA EHRs.The differences in c-statistic between the best machine learning model (924-predictor Gradient Boosting) and 101-predictor stepwise logistic models for 10-year mortality prediction were modest, suggesting stepwise regression methods continue to be a reasonable method for VA EHR mortality prediction model development.

  View details for DOI 10.1097/MLR.0000000000001720

  View details for PubMedID 35352701

  View details for PubMedCentralID PMC9106858

• Attitudes toward deprescribing among older adults with dementia in the United States. Journal of the American Geriatrics Society Growdon, M. E., Espejo, E., Jing, B., Boscardin, W. J., Zullo, A. R., Yaffe, K., Boockvar, K. S., Steinman, M. A. 2022; 70 (6): 1764-1773

  Abstract

  People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD.This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking.The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%-38%] vs. 13% [95% CI, 8%-20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%-95%] vs. 83% [95% CI, 76%-89%]; p = 0.04).A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.

  View details for DOI 10.1111/jgs.17730

  View details for PubMedID 35266141

  View details for PubMedCentralID PMC9177826

• Do functional status and Medicare claims data improve the predictive accuracy of an electronic health record mortality index? Findings from a national Veterans Affairs cohort. BMC geriatrics Deardorff, W. J., Jing, B., Jeon, S. Y., Boscardin, W. J., Lee, A. K., Fung, K. Z., Lee, S. J. 2022; 22 (1): 434

  Abstract

  Electronic health record (EHR) prediction models may be easier to use in busy clinical settings since EHR data can be auto-populated into models. This study assessed whether adding functional status and/or Medicare claims data (which are often not available in EHRs) improves the accuracy of a previously developed Veterans Affairs (VA) EHR-based mortality index.This was a retrospective cohort study of veterans aged 75 years and older enrolled in VA primary care clinics followed from January 2014 to April 2020 (n = 62,014). We randomly split participants into development (n = 49,612) and validation (n = 12,402) cohorts. The primary outcome was all-cause mortality. We performed logistic regression with backward stepwise selection to develop a 100-predictor base model using 854 EHR candidate variables, including demographics, laboratory values, medications, healthcare utilization, diagnosis codes, and vitals. We incorporated functional measures in a base + function model by adding activities of daily living (range 0-5) and instrumental activities of daily living (range 0-7) scores. Medicare data, including healthcare utilization (e.g., emergency department visits, hospitalizations) and diagnosis codes, were incorporated in a base + Medicare model. A base + function + Medicare model included all data elements. We assessed model performance with the c-statistic, reclassification metrics, fraction of new information provided, and calibration plots.In the overall cohort, mean age was 82.6 years and 98.6% were male. At the end of follow-up, 30,263 participants (48.8%) had died. The base model c-statistic was 0.809 (95% CI 0.805-0.812) in the development cohort and 0.804 (95% CI 0.796-0.812) in the validation cohort. Validation cohort c-statistics for the base + function, base + Medicare, and base + function + Medicare models were 0.809 (95% CI 0.801-0.816), 0.811 (95% CI 0.803-0.818), and 0.814 (95% CI 0.807-0.822), respectively. Adding functional status and Medicare data resulted in similarly small improvements among other model performance measures. All models showed excellent calibration.Incorporation of functional status and Medicare data into a VA EHR-based mortality index led to small but likely clinically insignificant improvements in model performance.

  View details for DOI 10.1186/s12877-022-03126-z

  View details for PubMedID 35585537

  View details for PubMedCentralID PMC9118715

• Trends in blood pressure diagnosis, treatment, and control among VA nursing home residents, 2007-2018. Journal of the American Geriatrics Society Odden, M. C., Li, Y., Graham, L. A., Steinman, M. A., Marcum, Z. A., Liu, C. K., Jing, B., Fung, K. Z., Peralta, C. A., Lee, S. J. 2022

  Abstract

  BACKGROUND: Inadequate treatment of high blood pressure (BP) can lead to preventable adverse events in nursing home residents, while excessive treatment can lead to associated harms.METHODS: Data were extracted from the VA electronic health record and Bar Code Medication Administration system on 40,079 long-term care residents aged ≥65years from October 2006 through September 2018 (FY2007-2018). Hypertension prevalence at admission was identified by ICD code(s) in the year prior, and antihypertensive medication use was defined as administration ≥50% of days. BP measures were averaged over 2-year epochs.RESULTS: The age-standardized prevalence of hypertension diagnosis at admission increased from 75.2% in FY2007-2008 to 85.1% in FY2017-2018 (p-value for trend <0.001). Rates of BP treatment and control among residents with hypertension at admission declined slightly over time (p-values for trend <0.001) but remained high (80.3% treated in FY2017-2018, 80.1% with average BP <140/90mmHg). The age-adjusted prevalence of chronic low BP (average <90/60mmHg) also declined from 11.1% in FY2007-2008 to 4.7% in FY2017-2018 (p-value for trend <0.001). Persons identified as Black race or Hispanic ethnicity and those with a history of diabetes, stroke, and renal disease were less likely to have an average BP <140/90mmHg.CONCLUSIONS: Hypertension is well controlled in VA nursing homes, and recent trends of less intensive BP control were accompanied by a lower prevalence of chronic low BP. Nonetheless, some high-risk populations have average BP levels >140/90mmHg. Future research is needed to better understand the benefits and harms of BP control in nursing home residents.

  View details for DOI 10.1111/jgs.17821

  View details for PubMedID 35524763

• Predicting Life Expectancy to Target Cancer Screening Using Electronic Health Record Clinical Data. Journal of general internal medicine Lee, A. K., Jing, B., Jeon, S. Y., Boscardin, W. J., Lee, S. J. 2022; 37 (3): 499-506

  Abstract

  Guidelines recommend breast and colorectal cancer screening for older adults with a life expectancy >10 years. Most mortality indexes require clinician data entry, presenting a barrier for routine use in care. Electronic health records (EHR) are a rich clinical data source that could be used to create individualized life expectancy predictions to identify patients for cancer screening without data entry.To develop and internally validate a life expectancy calculator from structured EHR data.Retrospective cohort study using national Veteran's Affairs (VA) EHR databases.Veterans aged 50+ with a primary care visit during 2005.We assessed demographics, diseases, medications, laboratory results, healthcare utilization, and vital signs 1 year prior to the index visit. Mortality follow-up was complete through 2017. Using the development cohort (80% sample), we used LASSO Cox regression to select ~100 predictors from 913 EHR data elements. In the validation cohort (remaining 20% sample), we calculated the integrated area under the curve (iAUC) and evaluated calibration.In 3,705,122 patients, the mean age was 68 years and the majority were male (97%) and white (85%); nearly half (49%) died. The life expectancy calculator included 93 predictors; age and gender most strongly contributed to discrimination; diseases also contributed significantly while vital signs were negligible. The iAUC was 0.816 (95% confidence interval, 0.815, 0.817) with good calibration.We developed a life expectancy calculator using VA EHR data with excellent discrimination and calibration. Automated life expectancy prediction using EHR data may improve guideline-concordant breast and colorectal cancer screening by identifying patients with a life expectancy >10 years.

  View details for DOI 10.1007/s11606-021-07018-7

  View details for PubMedID 34327653

  View details for PubMedCentralID PMC8858374

• Association of Antihypertensives and Cognitive Impairment in Long-Term Care Residents. Journal of Alzheimer's disease : JAD Marcum, Z. A., Li, Y., Lee, S. J., Steinman, M. A., Graham, L., Jing, B., Fung, K., Peralta, C. A., Odden, M. C. 2022

  Abstract

  Certain classes of antihypertensive medication may have different associations with cognitive impairment.To examine the association between prevalent use of antihypertensive medications that stimulate (thiazides, dihydropyridine calcium channel blockers, angiotensin type I receptor blockers) versus inhibit (angiotensin-converting enzyme inhibitors, beta-blockers, non-dihydropyridine calcium channel blockers) type 2 and 4 angiotensin II receptors on cognitive impairment among older adults residing in Veterans Affairs (VA) nursing homes for long-term care.Retrospective cohort study. Long-term care residents aged 65 + years admitted to a VA nursing home from 2012 to 2019 using blood pressure medication and without cognitive impairment at admission. Main exposure was prevalent use of angiotensin II receptor type 2 and 4-'stimulating' (N = 589), 'inhibiting' (N = 3,219), or 'mixed' (N = 1,715) antihypertensive medication regimens at admission. Primary outcome was any cognitive impairment (Cognitive Function Scale).Over an average of 5.4 months of follow-up, prevalent use of regimens containing exclusively 'stimulating' antihypertensives was associated with a lower risk of any incident cognitive impairment as compared to prevalent use of regimens containing exclusively 'inhibiting' antihypertensives (HR 0.83, 95% CI 0.74-0.93). Results for the comparison between 'mixed' versus 'inhibiting' regimens were in the same direction but not statistically significant (HR 0.96, 95% CI 0.88-1.06).For residents without cognitive impairment at baseline, prevalent users of regimens containing exclusively antihypertensives that stimulate type 2 and 4 angiotensin II receptors had lower rates of cognitive impairment as compared to prevalent users of regimens containing exclusively antihypertensives that inhibit these receptors. Residual confounding cannot be ruled out.

  View details for DOI 10.3233/JAD-215393

  View details for PubMedID 35147539

• Older Adults' Persistence to Antihypertensives Prescribed at Hospital Discharge: a Retrospective Cohort Study. Journal of general internal medicine Anderson, T. S., Jing, B., Fung, K., Steinman, M. A. 2021; 36 (12): 3900-3902

  View details for DOI 10.1007/s11606-020-06401-0

  View details for PubMedID 33469765

  View details for PubMedCentralID PMC8642581

• Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System. JAMA network open Anderson, T. S., Lee, A. K., Jing, B., Lee, S., Herzig, S. J., Boscardin, W. J., Fung, K., Rizzo, A., Steinman, M. A. 2021; 4 (10): e2128998

  Abstract

  Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization.To investigate outcomes associated with intensification of outpatient diabetes medications at discharge.This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021.Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications.Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge.The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled.In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.

  View details for DOI 10.1001/jamanetworkopen.2021.28998

  View details for PubMedID 34673963

  View details for PubMedCentralID PMC8531994

• Exploring the Dynamics of Week-to-Week Blood Pressure in Nursing Home Residents Before Death. American journal of hypertension Graham, L. A., Lee, S. J., Steinman, M., Peralta, C. A., Rubinsky, A., Jing, B., Fung, K., Odden, M. C. 2021

  Abstract

  BACKGROUND: Aging is accompanied by an overall dysregulation of many dynamic physiologic processes including those related to blood pressure (BP). While year-to-year BP variability is associated with cardiovascular events and mortality, no studies have examined this trend with more frequent BP assessments. Our study objective is to take the next step to examine week-to-week BP dynamics - pattern, variability, and complexity - before death.METHODS: Using a retrospective study design, we assessed BP dynamics in the 6 months before death in long-term nursing home residents between 10/1/2006 and 9/30/2017. Variability was characterized using standard deviation and mean square error after adjusting for diurnal variations. Complexity (i.e., amount of novel information in a trend) was examined using Shannon's entropy (bits). Generalized linear models were used to examine factors associated with overall BP variability.RESULTS: We identified 17,953 nursing home residents (98.0% male, 82.5% White, mean age 80.2 years, and mean BP 125.7/68.6 mmHg). Despite a slight trend of decreasing systolic week-to-week BP over time (delta=7.2mmHg), week-to-week complexity did not change in the six months before death (delta=0.02 bits). Average weekly BP variability was stable until the last 3-4 weeks of life, at which point variability increased by 30% for both systolic and diastolic BP. Factors associated with BP variability include average weekly systolic/diastolic BP, days in the nursing home, days in the hospital, and changes to antihypertensive medications.CONCLUSIONS: Week-to-week BP variability increases substantially in the last month of life, but complexity does not change. Changes in care patterns may drive the increase in BP variability as one approaches death.

  View details for DOI 10.1093/ajh/hpab142

  View details for PubMedID 34505872

• Deprescribing Blood Pressure Treatment in Long-Term Care Residents. Journal of the American Medical Directors Association Odden, M. C., Lee, S. J., Steinman, M. A., Rubinsky, A. D., Graham, L., Jing, B., Fung, K., Marcum, Z., Peralta, C. A. 2021

  Abstract

  OBJECTIVES: To evaluate the incidence of deprescribing of antihypertensive medication among older adults residing in Veterans Affairs (VA) nursing homes for long-term care and rates of deprescribing after potentially triggering events.DESIGN: Retrospective cohort study.SETTING AND PARTICIPANTS: Long-term care residents aged 65years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure medication at admission.METHODS: Data were extracted from the VA electronic health record, and Centers for Medicare & Medicaid Services Minimum Data Set and Bar Code Medication Administration. Deprescribing was defined on a rolling basis as a reduction in the number or dose of antihypertensive medications, sustained for ≥2weeks. We examined potentially triggering events for deprescribing, including low blood pressure (<90/60mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and falls.RESULTS: Among 31,499 VA nursing home residents on antihypertensive medication, 70.4% had ≥1 deprescribing event (median length of stay= 6months), and 48.7% had a net reduction in antihypertensive medications over their stay. Deprescribing events were most common in the first 4weeks after admission and the last 4weeks of life. Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent 4weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference= 30.3%, P < .001). A fall in the past 30days was associated with the smallest magnitude increased risk of deprescribing (risk difference= 3.8%, P < .001) of the events considered.CONCLUSIONS AND IMPLICATIONS: Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.

  View details for DOI 10.1016/j.jamda.2021.07.009

  View details for PubMedID 34364847

• DEPRESCRIBING BLOOD PRESSURE TREATMENT IN VA LONG-TERM CARE RESIDENTS Odden, M., Lee, S., Steinman, M., Rubinsky, A., Jing, B., Fung, K., Graham, L., Peralta, C. OXFORD UNIV PRESS. 2021: 333

  View details for Web of Science ID 000842009901547

• BLOOD PRESSURE VARIABILITY AND COMPLEXITY IN NURSING HOME RESIDENTS BEFORE DEATH Graham, L., Lee, S., Steinman, M., Peralta, C., Rubinsky, A., Jing, B., Fung, K., Odden, M. OXFORD UNIV PRESS. 2021: 137

  View details for Web of Science ID 000842009900534

• BLOOD PRESSURE CONTROL AND CARDIOVASCULAR AND MORTALITY RISK IN VA NURSING HOME RESIDENTS Liu, X., Lee, S., Steinman, M., Graham, L., Li, Y., Jing, B., Odden, M. OXFORD UNIV PRESS. 2021: 605

  View details for Web of Science ID 000842009903012

• Glycemic Over- and Undertreatment in VA Nursing Home Residents with Type 2 Diabetes: a Retrospective Cohort Study. Journal of general internal medicine Lederle, L., Jing, B., Rodriguez, A., Hunt, L. J., Lee, S. J. 2020; 35 (6): 1900-1902

  View details for DOI 10.1007/s11606-019-05479-5

  View details for PubMedID 31705477

  View details for PubMedCentralID PMC7280465

• Association of Functional, Cognitive, and Psychological Measures With 1-Year Mortality in Patients Undergoing Major Surgery. JAMA surgery Tang, V. L., Jing, B., Boscardin, J., Ngo, S., Silvestrini, M., Finlayson, E., Covinsky, K. E. 2020; 155 (5): 412-418

  Abstract

  More older adults are undergoing major surgery despite the greater risk of postoperative mortality. Although measures, such as functional, cognitive, and psychological status, are known to be crucial components of health in older persons, they are not often used in assessing the risk of adverse postoperative outcomes in older adults.To determine the association between measures of physical, cognitive, and psychological function and 1-year mortality in older adults after major surgery.Retrospective analysis of a prospective cohort study of participants 66 years or older who were enrolled in the nationally representative Health and Retirement Study and underwent 1 of 3 types of major surgery.Major surgery, including abdominal aortic aneurysm repair, coronary artery bypass graft, and colectomy.Our outcome was mortality within 1 year of major surgery. Our primary associated factors included functional, cognitive, and psychological factors: dependence in activities of daily living (ADL), dependence in instrumental ADL, inability to walk several blocks, cognitive status, and presence of depression. We adjusted for other demographic and clinical predictors.Of 1341 participants, the mean (SD) participant age was 76 (6) years, 737 (55%) were women, 99 (7%) underwent abdominal aortic aneurysm repair, 686 (51%) coronary artery bypass graft, and 556 (42%) colectomy; 223 (17%) died within 1 year of their operation. After adjusting for age, comorbidity burden, surgical type, sex, race/ethnicity, wealth, income, and education, the following measures were significantly associated with 1-year mortality: more than 1 ADL dependence (29% vs 13%; adjusted hazard ratio [aHR], 2.76; P = .001), more than 1 instrumental ADL dependence (21% vs 14%; aHR, 1.32; P = .05), the inability to walk several blocks (17% vs 11%; aHR, 1.64; P = .01), dementia (21% vs 12%; aHR, 1.91; P = .03), and depression (19% vs 12%; aHR, 1.72; P = .01). The risk of 1-year mortality increased within the increasing risk factors present (0 factors: 10.0%; 1 factor: 16.2%; 2 factors: 27.8%).In this older adult cohort, 223 participants (17%) who underwent major surgery died within 1 year and poor function, cognition, and psychological well-being were significantly associated with mortality. Measures in function, cognition, and psychological well-being need to be incorporated into the preoperative assessment to enhance surgical decision-making and patient counseling.

  View details for DOI 10.1001/jamasurg.2020.0091

  View details for PubMedID 32159753

  View details for PubMedCentralID PMC7066523

• Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA network open Anderson, T. S., Lee, S., Jing, B., Fung, K., Ngo, S., Silvestrini, M., Steinman, M. A. 2020; 3 (3): e201511

  Abstract

  Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home.To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications.This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013.Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics.Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels.In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.

  View details for DOI 10.1001/jamanetworkopen.2020.1511

  View details for PubMedID 32207832

  View details for PubMedCentralID PMC7093767

• Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA internal medicine Anderson, T. S., Jing, B., Auerbach, A., Wray, C. M., Lee, S., Boscardin, W. J., Fung, K., Ngo, S., Silvestrini, M., Steinman, M. A. 2019; 179 (11): 1528-1536

  Abstract

  Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization.To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge.In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019.Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge.The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge.The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg).Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

  View details for DOI 10.1001/jamainternmed.2019.3007

  View details for PubMedID 31424475

  View details for PubMedCentralID PMC6705136

• Comparison of Pharmacy Database Methods for Determining Prevalent Chronic Medication Use. Medical care Anderson, T. S., Jing, B., Wray, C. M., Ngo, S., Xu, E., Fung, K., Steinman, M. A. 2019; 57 (10): 836-842

  Abstract

  Pharmacy dispensing data are frequently used to identify prevalent medication use as a predictor or covariate in observational research studies. Although several methods have been proposed for using pharmacy dispensing data to identify prevalent medication use, little is known about their comparative performance.The authors sought to compare the performance of different methods for identifying prevalent outpatient medication use.Outpatient pharmacy fill data were compared with medication reconciliation notes denoting prevalent outpatient medication use at the time of hospital admission for a random sample of 207 patients drawn from a national cohort of patients admitted to Veterans Affairs hospitals. Using reconciliation notes as the criterion standard, we determined the test characteristics of 12 pharmacy database algorithms for determining prevalent use of 11 classes of cardiovascular and diabetes medications.The best-performing algorithms included a 180-day fixed look-back period approach (sensitivity, 93%; specificity, 97%; and positive predictive value, 89%) and a medication-on-hand approach with a grace period of 60 days (sensitivity, 91%; specificity, 97%; and positive predictive value, 91%). Algorithms that have been commonly used in previous studies, such as defining prevalent medications to include any medications filled in the prior year or only medications filled in the prior 30 days, performed less well. Algorithm performance was less accurate among patients recently receiving hospital or nursing facility care.Pharmacy database algorithms that balance recentness of medication fills with grace periods performed better than more simplistic approaches and should be considered for future studies which examine prevalent chronic medication use.

  View details for DOI 10.1097/MLR.0000000000001188

  View details for PubMedID 31464843

  View details for PubMedCentralID PMC6742560

• Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study. BMJ (Clinical research ed.) Anderson, T. S., Wray, C. M., Jing, B., Fung, K., Ngo, S., Xu, E., Shi, Y., Steinman, M. A. 2018; 362: k3503

  Abstract

  To assess how often older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment, and to identify markers of appropriateness for these intensifications.Retrospective cohort study.US Veterans Administration Health System.Patients aged 65 years or over with hypertension admitted to hospital with non-cardiac conditions between 2011 and 2013.Intensification of antihypertensive treatment, defined as receiving a new or higher dose antihypertensive agent at discharge compared with drugs used before admission. Hierarchical logistic regression analyses were used to control for characteristics of patients and hospitals.Among 14 915 older adults (median age 76, interquartile range 69-84), 9636 (65%) had well controlled outpatient blood pressure before hospital admission. Overall, 2074 (14%) patients were discharged with intensified antihypertensive treatment, more than half of whom (1082) had well controlled blood pressure before admission. After adjustment for potential confounders, elevated inpatient blood pressure was strongly associated with being discharged on intensified antihypertensive regimens. Among patients with previously well controlled outpatient blood pressure, 8% (95% confidence interval 7% to 9%) of patients without elevated inpatient blood pressure, 24% (21% to 26%) of patients with moderately elevated inpatient blood pressure, and 40% (34% to 46%) of patients with severely elevated inpatient blood pressure were discharged with intensified antihypertensive regimens. No differences were seen in rates of intensification among patients least likely to benefit from tight blood pressure control (limited life expectancy, dementia, or metastatic malignancy), nor in those most likely to benefit (history of myocardial infarction, cerebrovascular disease, or renal disease).One in seven older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment. More than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. More attention is needed to reduce potentially harmful overtreatment of blood pressure as older adults transition from hospital to home.

  View details for DOI 10.1136/bmj.k3503

  View details for PubMedID 30209052

  View details for PubMedCentralID PMC6283373

• Hypoglycemia in Hospice Patients With Type 2 Diabetes in a National Sample of Nursing Homes. JAMA internal medicine Petrillo, L. A., Gan, S., Jing, B., Lang-Brown, S., Boscardin, W. J., Lee, S. J. 2018; 178 (5): 713-715

  Abstract

  This retrospective cohort study examines whether patients with type 2 diabetes on hospice are assessed for dysglycemia, receive insulin or oral hypoglycemic medications, or experience hypoglycemia and hyperglycemia in the nursing home setting.

  View details for DOI 10.1001/jamainternmed.2017.7744

  View details for PubMedID 29279891

  View details for PubMedCentralID PMC5885911

• Estimated GFR Before and After Bariatric Surgery in CKD. American journal of kidney diseases : the official journal of the National Kidney Foundation Imam, T. H., Fischer, H., Jing, B., Burchette, R., Henry, S., DeRose, S. F., Coleman, K. J. 2017; 69 (3): 380-388

  Abstract

  Several reviews have recently detailed the beneficial effects of weight loss surgery for kidney function. However, these studies have a number of limitations, including small sample size, few done in chronic kidney disease (CKD) stages 3 and 4, and many not including the main bariatric surgery procedures used in the United States today.This was an observational retrospective cohort study comparing propensity score-matched bariatric surgery patients and nonsurgery control patients who were referred for, but did not have, surgery. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy were also compared using propensity matching.Patients (714 surgery patients; 714 controls) were from a large integrated health care system, a mean of 58±8 (SD) years old, and mostly women (77%) and non-Hispanic whites (56%) and had diabetes mellitus (66%) and/or hypertension (91%).Predictors at the time of surgery or referral to surgery were age, sex, race/ethnicity, weight, and presence of diabetes and/or hypertension.The primary outcome for this study was change in estimated glomerular filtration rate (eGFR) from serum creatinine level over a median 3-year follow-up period.Serum creatinine was used to calculate eGFR using the CKD-EPI (CKD Epidemiology Collaboration) creatinine equation.Surgery patients had 9.84 (95% CI, 8.05-11.62) mL/min/1.73m2 greater eGFRs than controls at a median 3 years' follow-up and RYGB patients had 6.60 (95% CI, 3.42-9.78) mL/min/1.73m2 greater eGFRs than sleeve gastrectomy patients during the same period.This study is limited by its nonrandomized observational study design, estimation of GFR, and large changes in muscle mass, which may affect serum creatinine level independent of changes in kidney function.Bariatric surgery, especially the RYGB procedure, results in significant improvements for up to 3 years in eGFRs for patients with CKD stages 3 and 4.

  View details for DOI 10.1053/j.ajkd.2016.09.020

  View details for PubMedID 27927587

  View details for PubMedCentralID PMC6264887

• The epidemiology of chronic kidney disease in sub-Saharan Africa: a systematic review and meta-analysis. The Lancet. Global health Stanifer, J. W., Jing, B., Tolan, S., Helmke, N., Mukerjee, R., Naicker, S., Patel, U. 2014; 2 (3): e174-81

  Abstract

  Amid rapid urbanisation, the HIV epidemic, and increasing rates of non-communicable diseases, people in sub-Saharan Africa are especially vulnerable to kidney disease. Little is known about the epidemiology of chronic kidney disease (CKD) in sub-Saharan Africa, so we did a systematic review and meta-analysis examining the epidemiology of the disease.We searched Medline, Embase, and WHO Global Health Library databases for all articles published through March 29, 2012, and searched the reference lists of retrieved articles. We independently reviewed each study for quality. We used the inverse-variance random-effects method for meta-analyses of the medium-quality and high-quality data and explored heterogeneity by comparing CKD burdens across countries, settings (urban or rural), comorbid disorders (hypertension, diabetes, HIV), CKD definitions, and time.Overall, we included 90 studies from 96 sites in the review. Study quality was low, with only 18 (20%) medium-quality studies and three (3%) high-quality studies. We noted moderate heterogeneity between the medium-quality and high-quality studies (n=21; I(2)=47·11%, p<0·0009). Measurement of urine protein was the most common method of determining the presence of kidney disease (62 [69%] studies), but the Cockcroft-Gault formula (22 [24%] studies) and Modification of Diet in Renal Disease formula (17 [19%] studies) were also used. Most of the studies were done in urban settings (83 [93%] studies) and after the year 2000 (57 [63%] studies), and we detected no significant difference in the prevalence of CKD between urban (12·4%, 95% CI 11-14) and rural (16·5%, 13·8-19·6) settings (p=0·474). The overall prevalence of CKD from the 21 medium-quality and high-quality studies was 13·9% (95% CI 12·2-15·7).In sub-Saharan Africa, CKD is a substantial health burden with risk factors that include communicable and non-communicable diseases. However, poor data quality limits inferences and draws attention to the need for more information and validated measures of kidney function especially in the context of the growing burden of non-communicable diseases.Duke University.

  View details for DOI 10.1016/S2214-109X(14)70002-6

  View details for PubMedID 25102850