Journal of Clinical Outcomes Management

CHICAGO – The COVID pandemic left hospitalist Ngozi Nwankwo, MD, with the most difficult patient interactions she had ever experienced.

“At my hospital, it was such a big thing to make sure that families are called,” said Dr. Nwankwo, in an interview following a session on compassionate communication at the annual meeting of the American College of Physicians. “So you have 19 patients, and you have to call almost every family to update them. And then you call, and they say, ‘Call this person as well.’ You feel like you’re at your wit’s end a lot of times.”

Sometimes, she has had to dig deep to find the empathy for patients that she knows her patients deserve.

“You really want to care by thinking about where is this patient coming from? What’s going on in their lives? And not just label them a difficult patient,” she said.

Become curious

Auguste Fortin, MD, MPH, offered advice for handling patient interactions under these kinds of circumstances, while serving as a moderator during the session.

“When the going gets tough, turn to wonder.” Become curious about why a patient might be feeling the way they are, he said.

Dr. Fortin, professor of internal medicine at Yale University, New Haven, Conn., said using the ADOBE acronym, has helped him more effectively communicate with his patients. This tool cues him to keep the following in mind: acknowledge, discover, opportunity, boundary setting, and extend.

He went on to explain to the audience why thinking about these terms is useful when interacting with patients.

First, acknowledge the feelings of the patient. Noting that a patient is angry, perhaps counterintuitively, helps, he said. In fact, not acknowledging the anger “throws gasoline on the fire.”

Then, discover the cause of their emotion. Saying "tell me more" and "help me understand" can be powerful tools, he noted.

Next, take this as an opportunity for empathy – especially important to remember when you’re being verbally attacked.

Boundary setting is important, because it lets the patient know that the conversation won’t continue unless they show the same respect the physician is showing, he said.

Finally, physicians can extend the system of support by asking others – such as colleagues or security – for help.

Use the NURS guide to show empathy

Dr. Fortin said he uses the “NURS” guide or calling to mind “name, express, respect, and support” to show empathy:

This involves naming a patient’s emotion; expressing understanding, with phrases like "I can see how you could be …"; showing respect, acknowledging a patient is going through a lot; and offering support, by saying something like, "Let’s see what we can do together to get to the bottom of this," he explained.

“My lived experience in using [these] in this order is that by the end of it, the patient cannot stay mad at me,” Dr. Fortin said.

“It’s really quite remarkable,” he added.

Steps for nonviolent communication

Rebecca Andrews, MD, MS, another moderator for the session, offered these steps for “nonviolent communication”:

• Observing the situation without blame or judgment.
• Telling the person how this situation makes you feel.
• Connecting with a need of the other person.
• Making a request that is specific and based on action, rather than a request not to do something, such as "Would you be willing to … ?"

Dr. Andrews, who is professor of medicine at the University of Connecticut, Farmington, said this approach has worked well for her, both in interactions with patients and in her personal life.

“It is evidence based that compassion actually makes care better,” she noted.

Varun Jain, MD, a member of the audience, expressed gratitude to the session’s speakers for teaching him something that he had not learned in medical school or residency.

“Every week you will have one or two people who will be labeled as ‘difficult,’ ” and it was nice to have some proven advice on how to handle these tough interactions, said the hospitalist at St. Francis Hospital in Hartford, Conn.

“We never got any actual training on this, and we were expected to know this because we are just physicians, and physicians are expected to be compassionate,” Dr. Jain said. “No one taught us how to have compassion.”

Dr. Fortin and Dr. Andrews disclosed no relevant financial relationships.

CHICAGO – The COVID pandemic left hospitalist Ngozi Nwankwo, MD, with the most difficult patient interactions she had ever experienced.

“At my hospital, it was such a big thing to make sure that families are called,” said Dr. Nwankwo, in an interview following a session on compassionate communication at the annual meeting of the American College of Physicians. “So you have 19 patients, and you have to call almost every family to update them. And then you call, and they say, ‘Call this person as well.’ You feel like you’re at your wit’s end a lot of times.”

Sometimes, she has had to dig deep to find the empathy for patients that she knows her patients deserve.

“You really want to care by thinking about where is this patient coming from? What’s going on in their lives? And not just label them a difficult patient,” she said.

Become curious

Auguste Fortin, MD, MPH, offered advice for handling patient interactions under these kinds of circumstances, while serving as a moderator during the session.

“When the going gets tough, turn to wonder.” Become curious about why a patient might be feeling the way they are, he said.

Dr. Fortin, professor of internal medicine at Yale University, New Haven, Conn., said using the ADOBE acronym, has helped him more effectively communicate with his patients. This tool cues him to keep the following in mind: acknowledge, discover, opportunity, boundary setting, and extend.

He went on to explain to the audience why thinking about these terms is useful when interacting with patients.

First, acknowledge the feelings of the patient. Noting that a patient is angry, perhaps counterintuitively, helps, he said. In fact, not acknowledging the anger “throws gasoline on the fire.”

Then, discover the cause of their emotion. Saying "tell me more" and "help me understand" can be powerful tools, he noted.

Next, take this as an opportunity for empathy – especially important to remember when you’re being verbally attacked.

Boundary setting is important, because it lets the patient know that the conversation won’t continue unless they show the same respect the physician is showing, he said.

Finally, physicians can extend the system of support by asking others – such as colleagues or security – for help.

Use the NURS guide to show empathy

Dr. Fortin said he uses the “NURS” guide or calling to mind “name, express, respect, and support” to show empathy:

This involves naming a patient’s emotion; expressing understanding, with phrases like "I can see how you could be …"; showing respect, acknowledging a patient is going through a lot; and offering support, by saying something like, "Let’s see what we can do together to get to the bottom of this," he explained.

“My lived experience in using [these] in this order is that by the end of it, the patient cannot stay mad at me,” Dr. Fortin said.

“It’s really quite remarkable,” he added.

Steps for nonviolent communication

Rebecca Andrews, MD, MS, another moderator for the session, offered these steps for “nonviolent communication”:

• Observing the situation without blame or judgment.
• Telling the person how this situation makes you feel.
• Connecting with a need of the other person.
• Making a request that is specific and based on action, rather than a request not to do something, such as "Would you be willing to … ?"

Dr. Andrews, who is professor of medicine at the University of Connecticut, Farmington, said this approach has worked well for her, both in interactions with patients and in her personal life.

“It is evidence based that compassion actually makes care better,” she noted.

Varun Jain, MD, a member of the audience, expressed gratitude to the session’s speakers for teaching him something that he had not learned in medical school or residency.

“Every week you will have one or two people who will be labeled as ‘difficult,’ ” and it was nice to have some proven advice on how to handle these tough interactions, said the hospitalist at St. Francis Hospital in Hartford, Conn.

“We never got any actual training on this, and we were expected to know this because we are just physicians, and physicians are expected to be compassionate,” Dr. Jain said. “No one taught us how to have compassion.”

Dr. Fortin and Dr. Andrews disclosed no relevant financial relationships.

CHICAGO – The COVID pandemic left hospitalist Ngozi Nwankwo, MD, with the most difficult patient interactions she had ever experienced.

“At my hospital, it was such a big thing to make sure that families are called,” said Dr. Nwankwo, in an interview following a session on compassionate communication at the annual meeting of the American College of Physicians. “So you have 19 patients, and you have to call almost every family to update them. And then you call, and they say, ‘Call this person as well.’ You feel like you’re at your wit’s end a lot of times.”

Sometimes, she has had to dig deep to find the empathy for patients that she knows her patients deserve.

“You really want to care by thinking about where is this patient coming from? What’s going on in their lives? And not just label them a difficult patient,” she said.

Become curious

Auguste Fortin, MD, MPH, offered advice for handling patient interactions under these kinds of circumstances, while serving as a moderator during the session.

“When the going gets tough, turn to wonder.” Become curious about why a patient might be feeling the way they are, he said.

Dr. Fortin, professor of internal medicine at Yale University, New Haven, Conn., said using the ADOBE acronym, has helped him more effectively communicate with his patients. This tool cues him to keep the following in mind: acknowledge, discover, opportunity, boundary setting, and extend.

He went on to explain to the audience why thinking about these terms is useful when interacting with patients.

First, acknowledge the feelings of the patient. Noting that a patient is angry, perhaps counterintuitively, helps, he said. In fact, not acknowledging the anger “throws gasoline on the fire.”

Then, discover the cause of their emotion. Saying "tell me more" and "help me understand" can be powerful tools, he noted.

Next, take this as an opportunity for empathy – especially important to remember when you’re being verbally attacked.

Boundary setting is important, because it lets the patient know that the conversation won’t continue unless they show the same respect the physician is showing, he said.

Finally, physicians can extend the system of support by asking others – such as colleagues or security – for help.

Use the NURS guide to show empathy

Dr. Fortin said he uses the “NURS” guide or calling to mind “name, express, respect, and support” to show empathy:

This involves naming a patient’s emotion; expressing understanding, with phrases like "I can see how you could be …"; showing respect, acknowledging a patient is going through a lot; and offering support, by saying something like, "Let’s see what we can do together to get to the bottom of this," he explained.

“My lived experience in using [these] in this order is that by the end of it, the patient cannot stay mad at me,” Dr. Fortin said.

“It’s really quite remarkable,” he added.

Steps for nonviolent communication

Rebecca Andrews, MD, MS, another moderator for the session, offered these steps for “nonviolent communication”:

• Observing the situation without blame or judgment.
• Telling the person how this situation makes you feel.
• Connecting with a need of the other person.
• Making a request that is specific and based on action, rather than a request not to do something, such as "Would you be willing to … ?"

Dr. Andrews, who is professor of medicine at the University of Connecticut, Farmington, said this approach has worked well for her, both in interactions with patients and in her personal life.

“It is evidence based that compassion actually makes care better,” she noted.

Varun Jain, MD, a member of the audience, expressed gratitude to the session’s speakers for teaching him something that he had not learned in medical school or residency.

“Every week you will have one or two people who will be labeled as ‘difficult,’ ” and it was nice to have some proven advice on how to handle these tough interactions, said the hospitalist at St. Francis Hospital in Hartford, Conn.

“We never got any actual training on this, and we were expected to know this because we are just physicians, and physicians are expected to be compassionate,” Dr. Jain said. “No one taught us how to have compassion.”

Dr. Fortin and Dr. Andrews disclosed no relevant financial relationships.

CHICAGO – Patrick Perri, MD, said during a talk that he frequently thinks about a group of people who were homeless and lived in a park about a hundred yards from the medical center in Boston where he did his training.

On a return visit about 10 years later, Dr. Perri went to the park and inquired about the men.

“I came to the horrible realization that all of these people were dead. All of them in 10 years,” he continued, speaking to an audience at the annual meeting of the American College of Physicians.

Thomas R. Collins/MDedge News

People experiencing homelessness don’t have to have such a grim health outlook, said Dr. Perri, who is medical director of the Center for Inclusion Health at the Allegheny Health Network in Pittsburgh.

During his talk, filled with jarring statistics on the health plight of those who struggle to stay sheltered, Dr. Perri said that many of the things that sicken and kill these people are the same things that sicken and kill others – liver disease, congestive heart failure, substance abuse. But the system isn’t equipped to handle the problems.

“Their needs are actually straightforward, they’re easy to describe,” he declared. “They’re known quantities. But the way that our systems respond, or don’t respond, to that creates the complexity. It’s the systems that are complex.”

Morbidity, mortality rates ‘go off a cliff’

A 2017 study in The Lancet compared morbidity and mortality in high-income countries, grouping people by their “level of deprivation.” The morbidity and mortality ticked higher with each deprivation level, but skyrocketed – nearly 10 times higher – for the group that included those experiencing homelessness or imprisonment, sex workers, and those with substance use disorders. As Dr. Perri put it, the rates “go off a cliff.”

Studies by the Boston Healthcare for the Homeless program have tracked mortality, and from 1988 to 1993 the average age at death was 47, so, “if you died while homeless, you probably died young.” Moreover, from their first contact to receive care through the program, to their death, only 25 months had elapsed.

“If there’s going to be an effective health care intervention, an acute one at least, you’ve got to get cracking,” Dr. Perri said.

Age at death has improved somewhat over time but drug overdose has become a much more common cause, Dr. Perri noted.

“There is utilitarian value in learning from people experiencing homelessness,” he said.

The same program looked at a high-risk cohort of 199 – those who went unsheltered for more than 6 months,were age 60 or older, or had certain serious health conditions, such as cirrhosis, substance abuse, and AIDS. A third of these people died within 5 years.

“There aren’t any other common diseases that I’m aware of that have statistics like that,” he said.

These people had an average of 31 emergency department visits a year and accounted for 871 hospitalizations. The estimated cost per-person, per-year was $22,000, while the average annual rent for a one-bedroom in Boston was $10,000.

“We’re hemorrhaging utilization around this population,” Dr. Perri said. “Maybe it makes sense to invest in something else other than acute health care. It’s not really yielding very much return on investment.”

Street medicine could be the answer

Housing First, a program to provide housing without the need to meet preconditions such as sobriety or passing background checks, has had a nonsignificant effect on mortality, substance use disorders, and mental health but has improved self-reported health status and quality of life. Analyses of the program suggest that better interventions are needed, Dr. Perri said.

Street medicine could be an answer, he said. Teams of medical staff go to where the people are, and the concept is intended as a continuous, cost-effective, flexible approach to care. Lehigh Valley Street Medicine in Pennsylvania has reported a reduction in emergency department visits and hospitalizations, Dr. Perri said. The programs are still too new to gauge the effect on actual health outcomes, but they hold the promise of being able to do so, he continued.

Curiosity about those experiencing homeless is a key first step in improving care, he said. The HOUSED BEDS tool, developed in Los Angeles, can help guide clinicians through their interactions with patients who do not have homes.

Dr. Perri said it is “enlightening” when you “express interest, genuine curiosity, about other people’s experiences.”

Catherine Kiley, MD, a retired internal medicine physician who volunteers as a preceptor for medical students in Cincinnati, said there is a void when it comes to teaching students about those experiencing homelessness.

“I don’t think there’s much of this type of discussion that they’re exposed to as part of medical education,” Dr. Kiley said. “Their experiences over time, as with most of medicine, will inform them.”

But the findings shared in the session show “how great the need is to speak out, speak up, about patients as people, and what they have to teach us.”

Dr. Perri disclosed no relevant financial relationships.

CHICAGO – Patrick Perri, MD, said during a talk that he frequently thinks about a group of people who were homeless and lived in a park about a hundred yards from the medical center in Boston where he did his training.

On a return visit about 10 years later, Dr. Perri went to the park and inquired about the men.

“I came to the horrible realization that all of these people were dead. All of them in 10 years,” he continued, speaking to an audience at the annual meeting of the American College of Physicians.

Thomas R. Collins/MDedge News

People experiencing homelessness don’t have to have such a grim health outlook, said Dr. Perri, who is medical director of the Center for Inclusion Health at the Allegheny Health Network in Pittsburgh.

During his talk, filled with jarring statistics on the health plight of those who struggle to stay sheltered, Dr. Perri said that many of the things that sicken and kill these people are the same things that sicken and kill others – liver disease, congestive heart failure, substance abuse. But the system isn’t equipped to handle the problems.

“Their needs are actually straightforward, they’re easy to describe,” he declared. “They’re known quantities. But the way that our systems respond, or don’t respond, to that creates the complexity. It’s the systems that are complex.”

Morbidity, mortality rates ‘go off a cliff’

A 2017 study in The Lancet compared morbidity and mortality in high-income countries, grouping people by their “level of deprivation.” The morbidity and mortality ticked higher with each deprivation level, but skyrocketed – nearly 10 times higher – for the group that included those experiencing homelessness or imprisonment, sex workers, and those with substance use disorders. As Dr. Perri put it, the rates “go off a cliff.”

Studies by the Boston Healthcare for the Homeless program have tracked mortality, and from 1988 to 1993 the average age at death was 47, so, “if you died while homeless, you probably died young.” Moreover, from their first contact to receive care through the program, to their death, only 25 months had elapsed.

“If there’s going to be an effective health care intervention, an acute one at least, you’ve got to get cracking,” Dr. Perri said.

Age at death has improved somewhat over time but drug overdose has become a much more common cause, Dr. Perri noted.

“There is utilitarian value in learning from people experiencing homelessness,” he said.

The same program looked at a high-risk cohort of 199 – those who went unsheltered for more than 6 months,were age 60 or older, or had certain serious health conditions, such as cirrhosis, substance abuse, and AIDS. A third of these people died within 5 years.

“There aren’t any other common diseases that I’m aware of that have statistics like that,” he said.

These people had an average of 31 emergency department visits a year and accounted for 871 hospitalizations. The estimated cost per-person, per-year was $22,000, while the average annual rent for a one-bedroom in Boston was $10,000.

“We’re hemorrhaging utilization around this population,” Dr. Perri said. “Maybe it makes sense to invest in something else other than acute health care. It’s not really yielding very much return on investment.”

Street medicine could be the answer

Housing First, a program to provide housing without the need to meet preconditions such as sobriety or passing background checks, has had a nonsignificant effect on mortality, substance use disorders, and mental health but has improved self-reported health status and quality of life. Analyses of the program suggest that better interventions are needed, Dr. Perri said.

Street medicine could be an answer, he said. Teams of medical staff go to where the people are, and the concept is intended as a continuous, cost-effective, flexible approach to care. Lehigh Valley Street Medicine in Pennsylvania has reported a reduction in emergency department visits and hospitalizations, Dr. Perri said. The programs are still too new to gauge the effect on actual health outcomes, but they hold the promise of being able to do so, he continued.

Curiosity about those experiencing homeless is a key first step in improving care, he said. The HOUSED BEDS tool, developed in Los Angeles, can help guide clinicians through their interactions with patients who do not have homes.

Dr. Perri said it is “enlightening” when you “express interest, genuine curiosity, about other people’s experiences.”

Catherine Kiley, MD, a retired internal medicine physician who volunteers as a preceptor for medical students in Cincinnati, said there is a void when it comes to teaching students about those experiencing homelessness.

“I don’t think there’s much of this type of discussion that they’re exposed to as part of medical education,” Dr. Kiley said. “Their experiences over time, as with most of medicine, will inform them.”

But the findings shared in the session show “how great the need is to speak out, speak up, about patients as people, and what they have to teach us.”

Dr. Perri disclosed no relevant financial relationships.

CHICAGO – Patrick Perri, MD, said during a talk that he frequently thinks about a group of people who were homeless and lived in a park about a hundred yards from the medical center in Boston where he did his training.

On a return visit about 10 years later, Dr. Perri went to the park and inquired about the men.

“I came to the horrible realization that all of these people were dead. All of them in 10 years,” he continued, speaking to an audience at the annual meeting of the American College of Physicians.

Thomas R. Collins/MDedge News

People experiencing homelessness don’t have to have such a grim health outlook, said Dr. Perri, who is medical director of the Center for Inclusion Health at the Allegheny Health Network in Pittsburgh.

During his talk, filled with jarring statistics on the health plight of those who struggle to stay sheltered, Dr. Perri said that many of the things that sicken and kill these people are the same things that sicken and kill others – liver disease, congestive heart failure, substance abuse. But the system isn’t equipped to handle the problems.

“Their needs are actually straightforward, they’re easy to describe,” he declared. “They’re known quantities. But the way that our systems respond, or don’t respond, to that creates the complexity. It’s the systems that are complex.”

Morbidity, mortality rates ‘go off a cliff’

A 2017 study in The Lancet compared morbidity and mortality in high-income countries, grouping people by their “level of deprivation.” The morbidity and mortality ticked higher with each deprivation level, but skyrocketed – nearly 10 times higher – for the group that included those experiencing homelessness or imprisonment, sex workers, and those with substance use disorders. As Dr. Perri put it, the rates “go off a cliff.”

Studies by the Boston Healthcare for the Homeless program have tracked mortality, and from 1988 to 1993 the average age at death was 47, so, “if you died while homeless, you probably died young.” Moreover, from their first contact to receive care through the program, to their death, only 25 months had elapsed.

“If there’s going to be an effective health care intervention, an acute one at least, you’ve got to get cracking,” Dr. Perri said.

Age at death has improved somewhat over time but drug overdose has become a much more common cause, Dr. Perri noted.

“There is utilitarian value in learning from people experiencing homelessness,” he said.

The same program looked at a high-risk cohort of 199 – those who went unsheltered for more than 6 months,were age 60 or older, or had certain serious health conditions, such as cirrhosis, substance abuse, and AIDS. A third of these people died within 5 years.

“There aren’t any other common diseases that I’m aware of that have statistics like that,” he said.

These people had an average of 31 emergency department visits a year and accounted for 871 hospitalizations. The estimated cost per-person, per-year was $22,000, while the average annual rent for a one-bedroom in Boston was $10,000.

“We’re hemorrhaging utilization around this population,” Dr. Perri said. “Maybe it makes sense to invest in something else other than acute health care. It’s not really yielding very much return on investment.”

Street medicine could be the answer

Housing First, a program to provide housing without the need to meet preconditions such as sobriety or passing background checks, has had a nonsignificant effect on mortality, substance use disorders, and mental health but has improved self-reported health status and quality of life. Analyses of the program suggest that better interventions are needed, Dr. Perri said.

Street medicine could be an answer, he said. Teams of medical staff go to where the people are, and the concept is intended as a continuous, cost-effective, flexible approach to care. Lehigh Valley Street Medicine in Pennsylvania has reported a reduction in emergency department visits and hospitalizations, Dr. Perri said. The programs are still too new to gauge the effect on actual health outcomes, but they hold the promise of being able to do so, he continued.

Curiosity about those experiencing homeless is a key first step in improving care, he said. The HOUSED BEDS tool, developed in Los Angeles, can help guide clinicians through their interactions with patients who do not have homes.

Dr. Perri said it is “enlightening” when you “express interest, genuine curiosity, about other people’s experiences.”

Catherine Kiley, MD, a retired internal medicine physician who volunteers as a preceptor for medical students in Cincinnati, said there is a void when it comes to teaching students about those experiencing homelessness.

“I don’t think there’s much of this type of discussion that they’re exposed to as part of medical education,” Dr. Kiley said. “Their experiences over time, as with most of medicine, will inform them.”

But the findings shared in the session show “how great the need is to speak out, speak up, about patients as people, and what they have to teach us.”

Dr. Perri disclosed no relevant financial relationships.

Suboptimal treatment of primary hypothyroidism may increase the risk of worse hospital outcomes, new research suggests.

The risks, including longer length of stay (LOS) and higher readmission rates, were no longer present in patients with adequately treated hypothyroidism, and in fact, appeared better than among those without hypothyroidism.

“Unfortunately, suboptimal treatment is common amongst the patient population with hypothyroidism,” wrote Matthew D. Ettleson, MD, of the Section of Endocrinology, Diabetes, and Metabolism at the University of Chicago, and colleagues.

“It is important for both patients and physicians to know that maintaining optimal thyroid hormone replacement is important to minimize length of hospital stays and hospital readmission. It is particularly important for planned admissions where thyroid hormone replacement can be adjusted if needed prior to admission,” said Dr. Ettleson in a press release from the Endocrine Society.
 

More evidence of adverse effects of suboptimal treatment

The findings, from a large U.S. claims database, “add to the growing body of evidence demonstrating the serious adverse short- and long-term health effects associated with suboptimal treatment of hypothyroidism,” the authors write in their article, published online  in the Journal of Clinical Endocrinology and Metabolism. Dr. Ettleson will also present the data on June 11 at the ENDO 2022 meeting.

Thyroid hormone replacement therapy – generally levothyroxine – is given for primary hypothyroidism with the aim of maintaining serum thyroid-stimulating hormone (TSH) within the normal reference range.

TSH is inversely related to the level of circulating thyroid hormone, so low levels of TSH indicate overtreatment of thyroid disease and high levels indicate undertreatment.

Worse hospital outcomes associated with high TSH

In their study, Dr. Ettleson and colleagues retrospectively examined IBM MarketScan claims for 43,478 privately insured patients younger than age 65 years and hospitalized for medical or surgical reasons in 2008-2015.

Of those, 8,873 met the criteria for primary hypothyroidism based on a pre-admission prescription claim for levothyroxine, TSH > 10.00 mIU/L, confirmed diagnosis of hypothyroidism during hospitalization, or chronic lymphocytic thyroiditis. Of those, 4,770 (53.8%) had a prescription claim for levothyroxine.  

Patients who met the clinical criteria for hypothyroidism were divided into four subgroups based on prehospitalization TSH level: low (< 0.40 mIU/L), normal (0.40-4.50 mIU/L), intermediate (4.51-10.00 mIU/L), and high (> 10.00 mIU/L).

The median length of time between TSH collection and hospital admission was 56 days in the hypothyroidism group and 63 days in the control group.

There were no differences in hospital outcomes between those with and without hypothyroidism among those who had low or intermediate TSH levels, in a multivariate analysis that used propensity-score matching.

In those with normal TSH levels, those with hypothyroidism actually had a lower risk of in-hospital death (risk ratio, 0.46; P = .004) and 90-day readmission rate (RR, 0.92; P = .02) than controls.

And those in the high TSH level subgroup had longer length of stay (+1.2 days; P = .003) and higher risk of 30-day readmission (RR, 1.49; P < .001) and 90-day readmission (RR, 1.43; P < .001), compared with balanced controls.
 

Public health effort needed to improve quality of care

There are multiple reasons why those with undertreated or undiagnosed hypothyroidism might have worse hospital outcomes, the authors say.

A bit more puzzling is why those with well-controlled hypothyroidism appeared to do better than those without hypothyroidism, given that thyroid hormone replacement isn’t likely to provide an advantage over normal, endogenous thyroid hormone production.

Dr. Ettleson and colleagues speculate that in-range TSH values may be a surrogate for regular health care and adherence to medical therapy, which likely leads to better hospital outcomes.

“The long- and short-term adverse health effects associated with off-target treatment of hypothyroidism, coupled with the high frequency of off-target treatment amongst the millions of patients in the United States on thyroid hormone, suggest that a public health effort to improve the quality of care of hypothyroidism is necessary,” Dr. Ettleson and colleagues write.

However, they note that there is currently no quality measure regarding appropriate treatment of hypothyroidism within the Merit-Based Incentive Payment System of the Centers for Medicare & Medicaid Services.

“The presence of guidelines alone may not be sufficient, as demonstrated by the inadequate application of guidelines for the use of levothyroxine in the treatment of thyroid cancer, a serious but much less common disease than clinical hypothyroidism,” the authors add.

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. Dr. Ettleson has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Suboptimal treatment of primary hypothyroidism may increase the risk of worse hospital outcomes, new research suggests.

The risks, including longer length of stay (LOS) and higher readmission rates, were no longer present in patients with adequately treated hypothyroidism, and in fact, appeared better than among those without hypothyroidism.

“Unfortunately, suboptimal treatment is common amongst the patient population with hypothyroidism,” wrote Matthew D. Ettleson, MD, of the Section of Endocrinology, Diabetes, and Metabolism at the University of Chicago, and colleagues.

“It is important for both patients and physicians to know that maintaining optimal thyroid hormone replacement is important to minimize length of hospital stays and hospital readmission. It is particularly important for planned admissions where thyroid hormone replacement can be adjusted if needed prior to admission,” said Dr. Ettleson in a press release from the Endocrine Society.
 

More evidence of adverse effects of suboptimal treatment

The findings, from a large U.S. claims database, “add to the growing body of evidence demonstrating the serious adverse short- and long-term health effects associated with suboptimal treatment of hypothyroidism,” the authors write in their article, published online  in the Journal of Clinical Endocrinology and Metabolism. Dr. Ettleson will also present the data on June 11 at the ENDO 2022 meeting.

Thyroid hormone replacement therapy – generally levothyroxine – is given for primary hypothyroidism with the aim of maintaining serum thyroid-stimulating hormone (TSH) within the normal reference range.

TSH is inversely related to the level of circulating thyroid hormone, so low levels of TSH indicate overtreatment of thyroid disease and high levels indicate undertreatment.

Worse hospital outcomes associated with high TSH

In their study, Dr. Ettleson and colleagues retrospectively examined IBM MarketScan claims for 43,478 privately insured patients younger than age 65 years and hospitalized for medical or surgical reasons in 2008-2015.

Of those, 8,873 met the criteria for primary hypothyroidism based on a pre-admission prescription claim for levothyroxine, TSH > 10.00 mIU/L, confirmed diagnosis of hypothyroidism during hospitalization, or chronic lymphocytic thyroiditis. Of those, 4,770 (53.8%) had a prescription claim for levothyroxine.  

Patients who met the clinical criteria for hypothyroidism were divided into four subgroups based on prehospitalization TSH level: low (< 0.40 mIU/L), normal (0.40-4.50 mIU/L), intermediate (4.51-10.00 mIU/L), and high (> 10.00 mIU/L).

The median length of time between TSH collection and hospital admission was 56 days in the hypothyroidism group and 63 days in the control group.

There were no differences in hospital outcomes between those with and without hypothyroidism among those who had low or intermediate TSH levels, in a multivariate analysis that used propensity-score matching.

In those with normal TSH levels, those with hypothyroidism actually had a lower risk of in-hospital death (risk ratio, 0.46; P = .004) and 90-day readmission rate (RR, 0.92; P = .02) than controls.

And those in the high TSH level subgroup had longer length of stay (+1.2 days; P = .003) and higher risk of 30-day readmission (RR, 1.49; P < .001) and 90-day readmission (RR, 1.43; P < .001), compared with balanced controls.
 

Public health effort needed to improve quality of care

There are multiple reasons why those with undertreated or undiagnosed hypothyroidism might have worse hospital outcomes, the authors say.

A bit more puzzling is why those with well-controlled hypothyroidism appeared to do better than those without hypothyroidism, given that thyroid hormone replacement isn’t likely to provide an advantage over normal, endogenous thyroid hormone production.

Dr. Ettleson and colleagues speculate that in-range TSH values may be a surrogate for regular health care and adherence to medical therapy, which likely leads to better hospital outcomes.

“The long- and short-term adverse health effects associated with off-target treatment of hypothyroidism, coupled with the high frequency of off-target treatment amongst the millions of patients in the United States on thyroid hormone, suggest that a public health effort to improve the quality of care of hypothyroidism is necessary,” Dr. Ettleson and colleagues write.

However, they note that there is currently no quality measure regarding appropriate treatment of hypothyroidism within the Merit-Based Incentive Payment System of the Centers for Medicare & Medicaid Services.

“The presence of guidelines alone may not be sufficient, as demonstrated by the inadequate application of guidelines for the use of levothyroxine in the treatment of thyroid cancer, a serious but much less common disease than clinical hypothyroidism,” the authors add.

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. Dr. Ettleson has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Suboptimal treatment of primary hypothyroidism may increase the risk of worse hospital outcomes, new research suggests.

The risks, including longer length of stay (LOS) and higher readmission rates, were no longer present in patients with adequately treated hypothyroidism, and in fact, appeared better than among those without hypothyroidism.

“Unfortunately, suboptimal treatment is common amongst the patient population with hypothyroidism,” wrote Matthew D. Ettleson, MD, of the Section of Endocrinology, Diabetes, and Metabolism at the University of Chicago, and colleagues.

“It is important for both patients and physicians to know that maintaining optimal thyroid hormone replacement is important to minimize length of hospital stays and hospital readmission. It is particularly important for planned admissions where thyroid hormone replacement can be adjusted if needed prior to admission,” said Dr. Ettleson in a press release from the Endocrine Society.
 

More evidence of adverse effects of suboptimal treatment

The findings, from a large U.S. claims database, “add to the growing body of evidence demonstrating the serious adverse short- and long-term health effects associated with suboptimal treatment of hypothyroidism,” the authors write in their article, published online  in the Journal of Clinical Endocrinology and Metabolism. Dr. Ettleson will also present the data on June 11 at the ENDO 2022 meeting.

Thyroid hormone replacement therapy – generally levothyroxine – is given for primary hypothyroidism with the aim of maintaining serum thyroid-stimulating hormone (TSH) within the normal reference range.

TSH is inversely related to the level of circulating thyroid hormone, so low levels of TSH indicate overtreatment of thyroid disease and high levels indicate undertreatment.

Worse hospital outcomes associated with high TSH

In their study, Dr. Ettleson and colleagues retrospectively examined IBM MarketScan claims for 43,478 privately insured patients younger than age 65 years and hospitalized for medical or surgical reasons in 2008-2015.

Of those, 8,873 met the criteria for primary hypothyroidism based on a pre-admission prescription claim for levothyroxine, TSH > 10.00 mIU/L, confirmed diagnosis of hypothyroidism during hospitalization, or chronic lymphocytic thyroiditis. Of those, 4,770 (53.8%) had a prescription claim for levothyroxine.  

Patients who met the clinical criteria for hypothyroidism were divided into four subgroups based on prehospitalization TSH level: low (< 0.40 mIU/L), normal (0.40-4.50 mIU/L), intermediate (4.51-10.00 mIU/L), and high (> 10.00 mIU/L).

The median length of time between TSH collection and hospital admission was 56 days in the hypothyroidism group and 63 days in the control group.

There were no differences in hospital outcomes between those with and without hypothyroidism among those who had low or intermediate TSH levels, in a multivariate analysis that used propensity-score matching.

In those with normal TSH levels, those with hypothyroidism actually had a lower risk of in-hospital death (risk ratio, 0.46; P = .004) and 90-day readmission rate (RR, 0.92; P = .02) than controls.

And those in the high TSH level subgroup had longer length of stay (+1.2 days; P = .003) and higher risk of 30-day readmission (RR, 1.49; P < .001) and 90-day readmission (RR, 1.43; P < .001), compared with balanced controls.
 

Public health effort needed to improve quality of care

There are multiple reasons why those with undertreated or undiagnosed hypothyroidism might have worse hospital outcomes, the authors say.

A bit more puzzling is why those with well-controlled hypothyroidism appeared to do better than those without hypothyroidism, given that thyroid hormone replacement isn’t likely to provide an advantage over normal, endogenous thyroid hormone production.

Dr. Ettleson and colleagues speculate that in-range TSH values may be a surrogate for regular health care and adherence to medical therapy, which likely leads to better hospital outcomes.

“The long- and short-term adverse health effects associated with off-target treatment of hypothyroidism, coupled with the high frequency of off-target treatment amongst the millions of patients in the United States on thyroid hormone, suggest that a public health effort to improve the quality of care of hypothyroidism is necessary,” Dr. Ettleson and colleagues write.

However, they note that there is currently no quality measure regarding appropriate treatment of hypothyroidism within the Merit-Based Incentive Payment System of the Centers for Medicare & Medicaid Services.

“The presence of guidelines alone may not be sufficient, as demonstrated by the inadequate application of guidelines for the use of levothyroxine in the treatment of thyroid cancer, a serious but much less common disease than clinical hypothyroidism,” the authors add.

The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. Dr. Ettleson has reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A unique ratio of metabolites measured in blood may help supplement a clinical diagnosis of early Alzheimer’s disease (AD), allowing for earlier intervention, early research suggests.

Investigators found that plasma concentrations of 2-aminoethyl dihydrogen phosphate and taurine could distinguish adults with early-stage Alzheimer’s disease from cognitively normal adults.

“Our biomarker for early-stage Alzheimer’s disease represents new thinking and is unique from the amyloid-beta and p-tau molecules that are currently being investigated to diagnose AD,” Sandra Banack, PhD, senior scientist, Brain Chemistry Labs, Jackson, Wyoming, told this news organization.

If further studies pan out, Dr. Banack said this biomarker could “easily be transformed into a test to aid clinical evaluations for Alzheimer’s disease.”

The study was published online in PLOS ONE.
 

New drug target?

The researchers measured concentrations of 2-aminoethyl dihydrogen phosphate and taurine in blood plasma samples in 25 patients (21 men; mean age, 71) with a clinical diagnosis of early-stage Alzheimer’s based on a Clinical Dementia Rating (CDR) score of 0.5, suggesting very mild cognitive impairment, and 25 healthy controls (20 men; mean age, 39).

The concentration of 2-aminoethyl dihydrogen phosphate, normalized by the concentration of taurine, reliably distinguished blood samples of early-stage Alzheimer’s patients from controls in a blinded analysis.

This biomarker “could lead to new understanding of [AD] and lead to new drug candidates,” Dr. Banack told this news organization.

The researchers note that 2-aminoethyl dihydrogen phosphate plays an important role in the structure and function of cellular membranes.

Physiologic effects of increased 2-aminoethyl dihydrogen phosphate concentrations in the blood are not known. However, in one study, concentrations of this molecule were found to be significantly lower in the temporal cortex, frontal cortex, and hippocampus (40%) in patients with Alzheimer’s disease, compared with controls.

“New biomarkers take time before they can be implemented in the clinic. The next step will be to repeat the experiments using a large sample size of AD patient blood samples,” Dr. Banack told this news organization.

The study team is looking to source a larger sample size of AD blood samples to replicate these findings. They are also examining this biomarker relative to other neurodegenerative diseases.

“If verified with larger sample sizes, the quantification of 2-aminoethyl dihydrogen phosphate could potentially assist in the diagnosis of early-stage Alzheimer’s disease when used in conjunction with the patient’s CDR score and other potential AD biomarkers,” Dr. Banack and colleagues say.
 

Caveats, cautionary notes

Commenting on the findings, Rebecca M. Edelmayer, PhD, Alzheimer’s Association senior director of scientific engagement, said the study is “interesting, though very small-scale and very preliminary.”

Dr. Edelmayer said one “major limitation” is that participants did not have their Alzheimer’s diagnosis confirmed with “gold standard biomarkers. They have been diagnosed based only on their cognitive and behavioral symptoms.”

She also cautioned that the study population is not representative – either of the general public or people living with Alzheimer’s disease.

For example, 41 out of all 50 samples are from men, “though we know women are disproportionately impacted by Alzheimer’s.”

“There is a mismatch in the age of the study groups,” Dr. Edelmayer noted. The mean age of controls in the study was 39 and the mean age of people with dementia was 71. Race or ethnicity and other demographic information is also unclear from the article.

“There is an urgent need for simple, inexpensive, noninvasive and easily available diagnostic tools for Alzheimer’s, such as a blood test. A simple blood test for Alzheimer’s would be a great advance for individuals with – and at risk for – the disease, families, doctors, and researchers,” Dr. Edelmayer said.

“Bottom line,” Dr. Edelmayer continued, “these results need to be further tested and verified in long-term, large-scale studies with diverse populations that are representative of those living with Alzheimer’s disease.”

This research was supported by the William Stamps Farish Fund and the Josephine P. & John J. Louis Foundation. Brain Chemistry Labs has applied for a patent related to this research. Dr. Edelmayer has no relevant disclosures.

A version of this article first appeared on Medscape.com.

A unique ratio of metabolites measured in blood may help supplement a clinical diagnosis of early Alzheimer’s disease (AD), allowing for earlier intervention, early research suggests.

Investigators found that plasma concentrations of 2-aminoethyl dihydrogen phosphate and taurine could distinguish adults with early-stage Alzheimer’s disease from cognitively normal adults.

“Our biomarker for early-stage Alzheimer’s disease represents new thinking and is unique from the amyloid-beta and p-tau molecules that are currently being investigated to diagnose AD,” Sandra Banack, PhD, senior scientist, Brain Chemistry Labs, Jackson, Wyoming, told this news organization.

If further studies pan out, Dr. Banack said this biomarker could “easily be transformed into a test to aid clinical evaluations for Alzheimer’s disease.”

The study was published online in PLOS ONE.
 

New drug target?

The researchers measured concentrations of 2-aminoethyl dihydrogen phosphate and taurine in blood plasma samples in 25 patients (21 men; mean age, 71) with a clinical diagnosis of early-stage Alzheimer’s based on a Clinical Dementia Rating (CDR) score of 0.5, suggesting very mild cognitive impairment, and 25 healthy controls (20 men; mean age, 39).

The concentration of 2-aminoethyl dihydrogen phosphate, normalized by the concentration of taurine, reliably distinguished blood samples of early-stage Alzheimer’s patients from controls in a blinded analysis.

This biomarker “could lead to new understanding of [AD] and lead to new drug candidates,” Dr. Banack told this news organization.

The researchers note that 2-aminoethyl dihydrogen phosphate plays an important role in the structure and function of cellular membranes.

Physiologic effects of increased 2-aminoethyl dihydrogen phosphate concentrations in the blood are not known. However, in one study, concentrations of this molecule were found to be significantly lower in the temporal cortex, frontal cortex, and hippocampus (40%) in patients with Alzheimer’s disease, compared with controls.

“New biomarkers take time before they can be implemented in the clinic. The next step will be to repeat the experiments using a large sample size of AD patient blood samples,” Dr. Banack told this news organization.

The study team is looking to source a larger sample size of AD blood samples to replicate these findings. They are also examining this biomarker relative to other neurodegenerative diseases.

“If verified with larger sample sizes, the quantification of 2-aminoethyl dihydrogen phosphate could potentially assist in the diagnosis of early-stage Alzheimer’s disease when used in conjunction with the patient’s CDR score and other potential AD biomarkers,” Dr. Banack and colleagues say.
 

Caveats, cautionary notes

Commenting on the findings, Rebecca M. Edelmayer, PhD, Alzheimer’s Association senior director of scientific engagement, said the study is “interesting, though very small-scale and very preliminary.”

Dr. Edelmayer said one “major limitation” is that participants did not have their Alzheimer’s diagnosis confirmed with “gold standard biomarkers. They have been diagnosed based only on their cognitive and behavioral symptoms.”

She also cautioned that the study population is not representative – either of the general public or people living with Alzheimer’s disease.

For example, 41 out of all 50 samples are from men, “though we know women are disproportionately impacted by Alzheimer’s.”

“There is a mismatch in the age of the study groups,” Dr. Edelmayer noted. The mean age of controls in the study was 39 and the mean age of people with dementia was 71. Race or ethnicity and other demographic information is also unclear from the article.

“There is an urgent need for simple, inexpensive, noninvasive and easily available diagnostic tools for Alzheimer’s, such as a blood test. A simple blood test for Alzheimer’s would be a great advance for individuals with – and at risk for – the disease, families, doctors, and researchers,” Dr. Edelmayer said.

“Bottom line,” Dr. Edelmayer continued, “these results need to be further tested and verified in long-term, large-scale studies with diverse populations that are representative of those living with Alzheimer’s disease.”

This research was supported by the William Stamps Farish Fund and the Josephine P. & John J. Louis Foundation. Brain Chemistry Labs has applied for a patent related to this research. Dr. Edelmayer has no relevant disclosures.

A version of this article first appeared on Medscape.com.

A unique ratio of metabolites measured in blood may help supplement a clinical diagnosis of early Alzheimer’s disease (AD), allowing for earlier intervention, early research suggests.

Investigators found that plasma concentrations of 2-aminoethyl dihydrogen phosphate and taurine could distinguish adults with early-stage Alzheimer’s disease from cognitively normal adults.

“Our biomarker for early-stage Alzheimer’s disease represents new thinking and is unique from the amyloid-beta and p-tau molecules that are currently being investigated to diagnose AD,” Sandra Banack, PhD, senior scientist, Brain Chemistry Labs, Jackson, Wyoming, told this news organization.

If further studies pan out, Dr. Banack said this biomarker could “easily be transformed into a test to aid clinical evaluations for Alzheimer’s disease.”

The study was published online in PLOS ONE.
 

New drug target?

The researchers measured concentrations of 2-aminoethyl dihydrogen phosphate and taurine in blood plasma samples in 25 patients (21 men; mean age, 71) with a clinical diagnosis of early-stage Alzheimer’s based on a Clinical Dementia Rating (CDR) score of 0.5, suggesting very mild cognitive impairment, and 25 healthy controls (20 men; mean age, 39).

The concentration of 2-aminoethyl dihydrogen phosphate, normalized by the concentration of taurine, reliably distinguished blood samples of early-stage Alzheimer’s patients from controls in a blinded analysis.

This biomarker “could lead to new understanding of [AD] and lead to new drug candidates,” Dr. Banack told this news organization.

The researchers note that 2-aminoethyl dihydrogen phosphate plays an important role in the structure and function of cellular membranes.

Physiologic effects of increased 2-aminoethyl dihydrogen phosphate concentrations in the blood are not known. However, in one study, concentrations of this molecule were found to be significantly lower in the temporal cortex, frontal cortex, and hippocampus (40%) in patients with Alzheimer’s disease, compared with controls.

“New biomarkers take time before they can be implemented in the clinic. The next step will be to repeat the experiments using a large sample size of AD patient blood samples,” Dr. Banack told this news organization.

The study team is looking to source a larger sample size of AD blood samples to replicate these findings. They are also examining this biomarker relative to other neurodegenerative diseases.

“If verified with larger sample sizes, the quantification of 2-aminoethyl dihydrogen phosphate could potentially assist in the diagnosis of early-stage Alzheimer’s disease when used in conjunction with the patient’s CDR score and other potential AD biomarkers,” Dr. Banack and colleagues say.
 

Caveats, cautionary notes

Commenting on the findings, Rebecca M. Edelmayer, PhD, Alzheimer’s Association senior director of scientific engagement, said the study is “interesting, though very small-scale and very preliminary.”

Dr. Edelmayer said one “major limitation” is that participants did not have their Alzheimer’s diagnosis confirmed with “gold standard biomarkers. They have been diagnosed based only on their cognitive and behavioral symptoms.”

She also cautioned that the study population is not representative – either of the general public or people living with Alzheimer’s disease.

For example, 41 out of all 50 samples are from men, “though we know women are disproportionately impacted by Alzheimer’s.”

“There is a mismatch in the age of the study groups,” Dr. Edelmayer noted. The mean age of controls in the study was 39 and the mean age of people with dementia was 71. Race or ethnicity and other demographic information is also unclear from the article.

“There is an urgent need for simple, inexpensive, noninvasive and easily available diagnostic tools for Alzheimer’s, such as a blood test. A simple blood test for Alzheimer’s would be a great advance for individuals with – and at risk for – the disease, families, doctors, and researchers,” Dr. Edelmayer said.

“Bottom line,” Dr. Edelmayer continued, “these results need to be further tested and verified in long-term, large-scale studies with diverse populations that are representative of those living with Alzheimer’s disease.”

This research was supported by the William Stamps Farish Fund and the Josephine P. & John J. Louis Foundation. Brain Chemistry Labs has applied for a patent related to this research. Dr. Edelmayer has no relevant disclosures.

A version of this article first appeared on Medscape.com.

A new type of genetic test known as a polygenic risk score could change the way clinicians detect and treat chronic illnesses. But to be widely used, genomic findings in large populations first need to be translated into valid clinical tests for individual patients. Then physicians need meaningful interpretations of test data to help make clinical decisions about patient care.

In a study published in Nature Medicine, researchers report details of how they set up a genetic assay for six common diseases and developed explanatory reports to help bridge the gap between science and clinical care.

The assay and reports were created for the GenoVA study, a clinical trial that aims to determine whether polygenic risk scores (PRSs), also known as polygenic scores (PGSs), could be used effectively in a primary care setting. The randomized trial will enroll 1,000 patients at the Veterans Affairs Boston Healthcare System and will follow them for 2 years.

The authors report early data from the new laboratory test. For the 227 participants enrolled so far, 11% had a high risk for atrial fibrillation, 7% were at risk for coronary artery disease, 8% for type 2 diabetes, 6% for colorectal cancer, 15% of men had an increased prostate cancer risk, and 13% of women were at increased risk for breast cancer.

Polygenic scores are promising for informing screening and treatment decisions, with the goal of preventing chronic disease. Jason Vassy, MD, of Brigham and Women’s Hospital and VA Boston, says, “It is important to think of PRS as one risk factor for disease, not a diagnostic test or an indication that an individual will certainly develop the disease.”

He continues, “Most diseases have complex, multifactorial etiologies, and a high PRS is just one piece of the puzzle. PRSs do not replace the traditional risk factors we usually think about in clinical medicine, such as diet and exercise to prevent type 2 diabetes and smoking cessation to lower cardiovascular disease risk.”

Currently, clinical genetic testing is typically performed when a patient is suspected of having a specific disease or a family history of a condition, such as sickle cell disease or breast cancer. Tests for these types of conditions are often monogenic, detecting only select mutations.

PRS tests have the potential to inform clinical decisions years before patients become symptomatic. The PRS testing in this study combines large quantities of genetic information to assess a patient’s risk for multiple conditions. The risk for common chronic conditions can involve hundreds to millions of small genetic variations. Alone, these variations have minimal impact on a person’s risk for disease, but together they can lead to an increased risk for specific conditions.

Certain PRS tests are currently available from direct-to-consumer laboratories, in oncology, and through some clinical trials, but they’re not commonly used in general practice.

Dr. Vassy and colleagues developed and validated PRSs for atrial fibrillation, coronary artery disease, type 2 diabetes, breast cancer, colorectal cancer, and prostate cancer at the Mass General Brigham Laboratory for Molecular Medicine.

The team calculated the final PRS on the basis of individual patient genotyping combined with statistical population models.

In the GenoVA study, adults aged 50-70 years who have no previous history of disease provide saliva or blood for PRS testing at the Boston VA. Participants are stratified by risk result and are randomly assigned to receive test results either immediately or after 24 months.

Enrollees are then followed for 2 years to observe how they and their primary care providers use risk score information and whether any preventive measures or other clinical tests are employed. Guidelines are provided to patients and clinicians throughout the study, along with genetic counseling. Ultimately, the study seeks to determine whether PRS implementation improves health outcomes.

Study participants are from diverse backgrounds: 52% of the first 227 patients report non-White, non-Hispanic ethnicity. To adjust for the fact that most genomic research to date has been based on European populations, researchers used statistical methods to calculate scores across racial groups.
 

Is PRS testing the future of chronic disease prevention?

Genome wide association studies (GWASs) from more inclusive datasets are needed to improve the relevance of PRS across ancestry groups, the authors write.

Dr. Vassy points out that “the risk estimates from GWAS are the underpinnings of the polygenic scores, so a score is only as valid as its original.” Fortunately, he adds, “advances are occurring on multiple fronts, and this will be key to promoting the equitable implementation of polygenic scores. Larger, more diverse cohorts are being recruited for GWAS studies, and more sophisticated, trans-ancestry statistical GWAS methods are being developed to analyze these more diverse data.”

In England, researchers are considering the benefits of using polygenic scores in National Health Service checks for cardiovascular disease, a well-studied area of genetic risk. The new article and the English effort draw from the PGS Catalogue, an open database built by Samuel Lambert, of the University of Cambridge Department of Public Health and Primary Care, and his colleagues to provide scores and methods that can be reused and adapted for clinical use.

He says he’d recommend PRS with confidence to his family members – in particular, certain in-depth cancer assays – “provided [the results] would be interpreted in collaboration with a health care professional who understands genetics (for example, a genetic counselor) with carefully vetted information on the validity and actionability of the test result.”

Mr. Lambert feels it’s important to understand that PRS testing isn’t deterministic. “The risk information is inherently probabilistic and relative (for example, you have a four times higher risk than the average person, but if the disease prevalence is 0.5%, this is a small absolute difference),” he says.

“The PRS also explains a fraction of the variability of risk in the population and thus shouldn’t be used alone but in combination with other established risk factors and tools to predict future risk when they exist,” Mr. Lambert says.

“And thirdly, most current PRS are less accurate in those of non-European ancestry due to a lack of ancestral diversity in the cohorts and datasets that have been used to develop these PRS; special attention must be paid to make sure that the PRS results are valid for the individual,” he adds.

Funding for the study was provided by the NIH National Human Genome Research Institute and NIH, the American Heart Association, the National Heart, Lung and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, and Massachusetts General Hospital. Dr. Vassy is an employee of the U.S. Department of Veterans Affairs; the views expressed do not represent those of the VA or the U.S. government. Mr. Lambert is an employee of Cambridge-Baker Systems Genomics Initiative, Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care.

A version of this article first appeared on Medscape.com.

A new type of genetic test known as a polygenic risk score could change the way clinicians detect and treat chronic illnesses. But to be widely used, genomic findings in large populations first need to be translated into valid clinical tests for individual patients. Then physicians need meaningful interpretations of test data to help make clinical decisions about patient care.

In a study published in Nature Medicine, researchers report details of how they set up a genetic assay for six common diseases and developed explanatory reports to help bridge the gap between science and clinical care.

The assay and reports were created for the GenoVA study, a clinical trial that aims to determine whether polygenic risk scores (PRSs), also known as polygenic scores (PGSs), could be used effectively in a primary care setting. The randomized trial will enroll 1,000 patients at the Veterans Affairs Boston Healthcare System and will follow them for 2 years.

The authors report early data from the new laboratory test. For the 227 participants enrolled so far, 11% had a high risk for atrial fibrillation, 7% were at risk for coronary artery disease, 8% for type 2 diabetes, 6% for colorectal cancer, 15% of men had an increased prostate cancer risk, and 13% of women were at increased risk for breast cancer.

Polygenic scores are promising for informing screening and treatment decisions, with the goal of preventing chronic disease. Jason Vassy, MD, of Brigham and Women’s Hospital and VA Boston, says, “It is important to think of PRS as one risk factor for disease, not a diagnostic test or an indication that an individual will certainly develop the disease.”

He continues, “Most diseases have complex, multifactorial etiologies, and a high PRS is just one piece of the puzzle. PRSs do not replace the traditional risk factors we usually think about in clinical medicine, such as diet and exercise to prevent type 2 diabetes and smoking cessation to lower cardiovascular disease risk.”

Currently, clinical genetic testing is typically performed when a patient is suspected of having a specific disease or a family history of a condition, such as sickle cell disease or breast cancer. Tests for these types of conditions are often monogenic, detecting only select mutations.

PRS tests have the potential to inform clinical decisions years before patients become symptomatic. The PRS testing in this study combines large quantities of genetic information to assess a patient’s risk for multiple conditions. The risk for common chronic conditions can involve hundreds to millions of small genetic variations. Alone, these variations have minimal impact on a person’s risk for disease, but together they can lead to an increased risk for specific conditions.

Certain PRS tests are currently available from direct-to-consumer laboratories, in oncology, and through some clinical trials, but they’re not commonly used in general practice.

Dr. Vassy and colleagues developed and validated PRSs for atrial fibrillation, coronary artery disease, type 2 diabetes, breast cancer, colorectal cancer, and prostate cancer at the Mass General Brigham Laboratory for Molecular Medicine.

The team calculated the final PRS on the basis of individual patient genotyping combined with statistical population models.

In the GenoVA study, adults aged 50-70 years who have no previous history of disease provide saliva or blood for PRS testing at the Boston VA. Participants are stratified by risk result and are randomly assigned to receive test results either immediately or after 24 months.

Enrollees are then followed for 2 years to observe how they and their primary care providers use risk score information and whether any preventive measures or other clinical tests are employed. Guidelines are provided to patients and clinicians throughout the study, along with genetic counseling. Ultimately, the study seeks to determine whether PRS implementation improves health outcomes.

Study participants are from diverse backgrounds: 52% of the first 227 patients report non-White, non-Hispanic ethnicity. To adjust for the fact that most genomic research to date has been based on European populations, researchers used statistical methods to calculate scores across racial groups.
 

Is PRS testing the future of chronic disease prevention?

Genome wide association studies (GWASs) from more inclusive datasets are needed to improve the relevance of PRS across ancestry groups, the authors write.

Dr. Vassy points out that “the risk estimates from GWAS are the underpinnings of the polygenic scores, so a score is only as valid as its original.” Fortunately, he adds, “advances are occurring on multiple fronts, and this will be key to promoting the equitable implementation of polygenic scores. Larger, more diverse cohorts are being recruited for GWAS studies, and more sophisticated, trans-ancestry statistical GWAS methods are being developed to analyze these more diverse data.”

In England, researchers are considering the benefits of using polygenic scores in National Health Service checks for cardiovascular disease, a well-studied area of genetic risk. The new article and the English effort draw from the PGS Catalogue, an open database built by Samuel Lambert, of the University of Cambridge Department of Public Health and Primary Care, and his colleagues to provide scores and methods that can be reused and adapted for clinical use.

He says he’d recommend PRS with confidence to his family members – in particular, certain in-depth cancer assays – “provided [the results] would be interpreted in collaboration with a health care professional who understands genetics (for example, a genetic counselor) with carefully vetted information on the validity and actionability of the test result.”

Mr. Lambert feels it’s important to understand that PRS testing isn’t deterministic. “The risk information is inherently probabilistic and relative (for example, you have a four times higher risk than the average person, but if the disease prevalence is 0.5%, this is a small absolute difference),” he says.

“The PRS also explains a fraction of the variability of risk in the population and thus shouldn’t be used alone but in combination with other established risk factors and tools to predict future risk when they exist,” Mr. Lambert says.

“And thirdly, most current PRS are less accurate in those of non-European ancestry due to a lack of ancestral diversity in the cohorts and datasets that have been used to develop these PRS; special attention must be paid to make sure that the PRS results are valid for the individual,” he adds.

Funding for the study was provided by the NIH National Human Genome Research Institute and NIH, the American Heart Association, the National Heart, Lung and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, and Massachusetts General Hospital. Dr. Vassy is an employee of the U.S. Department of Veterans Affairs; the views expressed do not represent those of the VA or the U.S. government. Mr. Lambert is an employee of Cambridge-Baker Systems Genomics Initiative, Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care.

A version of this article first appeared on Medscape.com.

A new type of genetic test known as a polygenic risk score could change the way clinicians detect and treat chronic illnesses. But to be widely used, genomic findings in large populations first need to be translated into valid clinical tests for individual patients. Then physicians need meaningful interpretations of test data to help make clinical decisions about patient care.

In a study published in Nature Medicine, researchers report details of how they set up a genetic assay for six common diseases and developed explanatory reports to help bridge the gap between science and clinical care.

The assay and reports were created for the GenoVA study, a clinical trial that aims to determine whether polygenic risk scores (PRSs), also known as polygenic scores (PGSs), could be used effectively in a primary care setting. The randomized trial will enroll 1,000 patients at the Veterans Affairs Boston Healthcare System and will follow them for 2 years.

The authors report early data from the new laboratory test. For the 227 participants enrolled so far, 11% had a high risk for atrial fibrillation, 7% were at risk for coronary artery disease, 8% for type 2 diabetes, 6% for colorectal cancer, 15% of men had an increased prostate cancer risk, and 13% of women were at increased risk for breast cancer.

Polygenic scores are promising for informing screening and treatment decisions, with the goal of preventing chronic disease. Jason Vassy, MD, of Brigham and Women’s Hospital and VA Boston, says, “It is important to think of PRS as one risk factor for disease, not a diagnostic test or an indication that an individual will certainly develop the disease.”

He continues, “Most diseases have complex, multifactorial etiologies, and a high PRS is just one piece of the puzzle. PRSs do not replace the traditional risk factors we usually think about in clinical medicine, such as diet and exercise to prevent type 2 diabetes and smoking cessation to lower cardiovascular disease risk.”

Currently, clinical genetic testing is typically performed when a patient is suspected of having a specific disease or a family history of a condition, such as sickle cell disease or breast cancer. Tests for these types of conditions are often monogenic, detecting only select mutations.

PRS tests have the potential to inform clinical decisions years before patients become symptomatic. The PRS testing in this study combines large quantities of genetic information to assess a patient’s risk for multiple conditions. The risk for common chronic conditions can involve hundreds to millions of small genetic variations. Alone, these variations have minimal impact on a person’s risk for disease, but together they can lead to an increased risk for specific conditions.

Certain PRS tests are currently available from direct-to-consumer laboratories, in oncology, and through some clinical trials, but they’re not commonly used in general practice.

Dr. Vassy and colleagues developed and validated PRSs for atrial fibrillation, coronary artery disease, type 2 diabetes, breast cancer, colorectal cancer, and prostate cancer at the Mass General Brigham Laboratory for Molecular Medicine.

The team calculated the final PRS on the basis of individual patient genotyping combined with statistical population models.

In the GenoVA study, adults aged 50-70 years who have no previous history of disease provide saliva or blood for PRS testing at the Boston VA. Participants are stratified by risk result and are randomly assigned to receive test results either immediately or after 24 months.

Enrollees are then followed for 2 years to observe how they and their primary care providers use risk score information and whether any preventive measures or other clinical tests are employed. Guidelines are provided to patients and clinicians throughout the study, along with genetic counseling. Ultimately, the study seeks to determine whether PRS implementation improves health outcomes.

Study participants are from diverse backgrounds: 52% of the first 227 patients report non-White, non-Hispanic ethnicity. To adjust for the fact that most genomic research to date has been based on European populations, researchers used statistical methods to calculate scores across racial groups.
 

Is PRS testing the future of chronic disease prevention?

Genome wide association studies (GWASs) from more inclusive datasets are needed to improve the relevance of PRS across ancestry groups, the authors write.

Dr. Vassy points out that “the risk estimates from GWAS are the underpinnings of the polygenic scores, so a score is only as valid as its original.” Fortunately, he adds, “advances are occurring on multiple fronts, and this will be key to promoting the equitable implementation of polygenic scores. Larger, more diverse cohorts are being recruited for GWAS studies, and more sophisticated, trans-ancestry statistical GWAS methods are being developed to analyze these more diverse data.”

In England, researchers are considering the benefits of using polygenic scores in National Health Service checks for cardiovascular disease, a well-studied area of genetic risk. The new article and the English effort draw from the PGS Catalogue, an open database built by Samuel Lambert, of the University of Cambridge Department of Public Health and Primary Care, and his colleagues to provide scores and methods that can be reused and adapted for clinical use.

He says he’d recommend PRS with confidence to his family members – in particular, certain in-depth cancer assays – “provided [the results] would be interpreted in collaboration with a health care professional who understands genetics (for example, a genetic counselor) with carefully vetted information on the validity and actionability of the test result.”

Mr. Lambert feels it’s important to understand that PRS testing isn’t deterministic. “The risk information is inherently probabilistic and relative (for example, you have a four times higher risk than the average person, but if the disease prevalence is 0.5%, this is a small absolute difference),” he says.

“The PRS also explains a fraction of the variability of risk in the population and thus shouldn’t be used alone but in combination with other established risk factors and tools to predict future risk when they exist,” Mr. Lambert says.

“And thirdly, most current PRS are less accurate in those of non-European ancestry due to a lack of ancestral diversity in the cohorts and datasets that have been used to develop these PRS; special attention must be paid to make sure that the PRS results are valid for the individual,” he adds.

Funding for the study was provided by the NIH National Human Genome Research Institute and NIH, the American Heart Association, the National Heart, Lung and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, and Massachusetts General Hospital. Dr. Vassy is an employee of the U.S. Department of Veterans Affairs; the views expressed do not represent those of the VA or the U.S. government. Mr. Lambert is an employee of Cambridge-Baker Systems Genomics Initiative, Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care.

A version of this article first appeared on Medscape.com.

Impaired vision in older adults is an underrecognized and modifiable dementia risk factor, new research suggests.

Investigators analyzed estimated population attributable fractions (PAFs) associated with dementia in more than 16,000 older adults. A PAF represents the number of dementia cases that could be prevented if a given risk factor were eliminated.

Results showed the PAF of vision impairment was 1.8%, suggesting that healthy vision had the potential to prevent more than 100,000 cases of dementia in the United States.

“Vision impairment and blindness disproportionately impact older adults, yet vision impairment is often preventable or even correctable,” study investigator Joshua Ehrlich MD, assistant professor of ophthalmology and visual sciences, University of Michigan, Ann Arbor, said in an interview.

Poor vision affects not only how individuals see the world, but also their systemic health and well-being, Dr. Ehrlich said.

“Accordingly, ensuring that older adults receive appropriate eye care is vital to promoting health, independence, and optimal aging,” he added.

The findings were published online in JAMA Neurology.
 

A surprising omission

There is an “urgent need to identify modifiable risk factors for dementia that can be targeted with interventions to slow cognitive decline and prevent dementia,” the investigators wrote.

In 2020, the Lancet Commission report on dementia prevention, intervention, and care proposed a life-course model of 12 potentially modifiable dementia risk factors. This included lower educational level, hearing loss, traumatic brain injury, hypertension, excessive alcohol consumption, obesity, smoking, depression, social isolation, physical inactivity, diabetes, and air pollution.

Together, these factors are associated with about 40% of dementia cases worldwide, the report notes.

Vision impairment was not included in this model, “despite considerable evidence that it is associated with an elevated risk of incident dementia and that it may operate through the same pathways as hearing loss,” the current researchers wrote.

“We have known for some time that vision impairment is a risk factor for dementia [and] we also know that a very large fraction of vision impairment, possibly in excess of 80%, is avoidable or has simply yet to be addressed,” Dr. Ehrlich said.

He and his colleagues found it “surprising that vision impairment had been ignored in key models of modifiable dementia risk factors that are used to shape health policy and resource allocation.” They set out to demonstrate that, “in fact, vision impairment is just as influential as a number of other long accepted modifiable dementia risk factors.”

The investigators assessed data from the Health and Retirement Study (HRS), a panel study that surveys more than 20,000 U.S. adults aged 50 years or older every 2 years.

The investigators applied the same methods used by the Lancet Commission to the HRS dataset and added vision impairment to the Lancet life-course model. Air pollution was excluded in their model “because those data were not readily available in the HRS,” the researchers wrote.

They noted the PAF is “based on the population prevalence and relative risk of dementia for each risk factor” and is “weighted, based on a principal components analysis, to account for communality (clustering of risk factors).”
 

A missed prevention opportunity

The sample included 16,690 participants (54% were women, 51.5% were at least age 65, 80.2% were White, 10.6% were Black, 9.2% were other).

In total, the 12 potentially modifiable risk factors used in the researchers’ model were associated with an estimated 62.4% of dementia cases in the United States, with hypertension as the most prevalent risk factor with the highest weighted PAF.
 

A new focus for prevention

Commenting for this article, Suzann Pershing, MD, associate professor of ophthalmology, Stanford (Calif.) University, called the study “particularly important because, despite growing recognition of its importance in relation to cognition, visual impairment is often an underrecognized risk factor.”

The current research “builds on increasingly robust medical literature linking visual impairment and dementia, applying analogous methods to those used for the life course model recently presented by the Lancet Commission to evaluate potentially modifiable dementia risk factors,” said Dr. Pershing, who was not involved with the study.

The investigators “make a compelling argument for inclusion of visual impairment as one of the potentially modifiable risk factors; practicing clinicians and health care systems may consider screening and targeted therapies to address visual impairment, with a goal of population health and contributing to a reduction in future dementia disease burden,” she added.

In an accompanying editorial), Jennifer Deal, PhD, department of epidemiology and Cochlear Center for Hearing and Public Health, Baltimore, and Julio Rojas, MD, PhD, Memory and Aging Center, department of neurology, Weill Institute for Neurosciences, University of California, San Francisco, call the findings “an important reminder that dementia is a social problem in which potentially treatable risk factors, including visual impairment, are highly prevalent in disadvantaged populations.”

The editorialists noted that 90% of cases of vision impairment are “preventable or have yet to be treated. The two “highly cost-effective interventions” of eyeglasses and/or cataract surgery “remain underused both in the U.S. and globally, especially in disadvantaged communities,” they wrote.

They added that more research is needed to “test the effectiveness of interventions to preserve cognitive health by promoting healthy vision.”

The study was supported by grants from the National Institute on Aging, the National Institutes of Health, and Research to Prevent Blindness. The investigators reported no relevant financial relationships. Dr. Deal reported having received grants from the National Institute on Aging. Dr. Rojas reported serving as site principal investigator on clinical trials for Eli Lilly and Eisai and receiving grants from the National Institute on Aging. Dr. Pershing is a consultant for Acumen, and Verana Health (as DigiSight Technologies).

A version of this article first appeared on Medscape.com.

Impaired vision in older adults is an underrecognized and modifiable dementia risk factor, new research suggests.

Investigators analyzed estimated population attributable fractions (PAFs) associated with dementia in more than 16,000 older adults. A PAF represents the number of dementia cases that could be prevented if a given risk factor were eliminated.

Results showed the PAF of vision impairment was 1.8%, suggesting that healthy vision had the potential to prevent more than 100,000 cases of dementia in the United States.

“Vision impairment and blindness disproportionately impact older adults, yet vision impairment is often preventable or even correctable,” study investigator Joshua Ehrlich MD, assistant professor of ophthalmology and visual sciences, University of Michigan, Ann Arbor, said in an interview.

Poor vision affects not only how individuals see the world, but also their systemic health and well-being, Dr. Ehrlich said.

“Accordingly, ensuring that older adults receive appropriate eye care is vital to promoting health, independence, and optimal aging,” he added.

The findings were published online in JAMA Neurology.
 

A surprising omission

There is an “urgent need to identify modifiable risk factors for dementia that can be targeted with interventions to slow cognitive decline and prevent dementia,” the investigators wrote.

In 2020, the Lancet Commission report on dementia prevention, intervention, and care proposed a life-course model of 12 potentially modifiable dementia risk factors. This included lower educational level, hearing loss, traumatic brain injury, hypertension, excessive alcohol consumption, obesity, smoking, depression, social isolation, physical inactivity, diabetes, and air pollution.

Together, these factors are associated with about 40% of dementia cases worldwide, the report notes.

Vision impairment was not included in this model, “despite considerable evidence that it is associated with an elevated risk of incident dementia and that it may operate through the same pathways as hearing loss,” the current researchers wrote.

“We have known for some time that vision impairment is a risk factor for dementia [and] we also know that a very large fraction of vision impairment, possibly in excess of 80%, is avoidable or has simply yet to be addressed,” Dr. Ehrlich said.

He and his colleagues found it “surprising that vision impairment had been ignored in key models of modifiable dementia risk factors that are used to shape health policy and resource allocation.” They set out to demonstrate that, “in fact, vision impairment is just as influential as a number of other long accepted modifiable dementia risk factors.”

The investigators assessed data from the Health and Retirement Study (HRS), a panel study that surveys more than 20,000 U.S. adults aged 50 years or older every 2 years.

The investigators applied the same methods used by the Lancet Commission to the HRS dataset and added vision impairment to the Lancet life-course model. Air pollution was excluded in their model “because those data were not readily available in the HRS,” the researchers wrote.

They noted the PAF is “based on the population prevalence and relative risk of dementia for each risk factor” and is “weighted, based on a principal components analysis, to account for communality (clustering of risk factors).”
 

A missed prevention opportunity

The sample included 16,690 participants (54% were women, 51.5% were at least age 65, 80.2% were White, 10.6% were Black, 9.2% were other).

In total, the 12 potentially modifiable risk factors used in the researchers’ model were associated with an estimated 62.4% of dementia cases in the United States, with hypertension as the most prevalent risk factor with the highest weighted PAF.
 

A new focus for prevention

Commenting for this article, Suzann Pershing, MD, associate professor of ophthalmology, Stanford (Calif.) University, called the study “particularly important because, despite growing recognition of its importance in relation to cognition, visual impairment is often an underrecognized risk factor.”

The current research “builds on increasingly robust medical literature linking visual impairment and dementia, applying analogous methods to those used for the life course model recently presented by the Lancet Commission to evaluate potentially modifiable dementia risk factors,” said Dr. Pershing, who was not involved with the study.

The investigators “make a compelling argument for inclusion of visual impairment as one of the potentially modifiable risk factors; practicing clinicians and health care systems may consider screening and targeted therapies to address visual impairment, with a goal of population health and contributing to a reduction in future dementia disease burden,” she added.

In an accompanying editorial), Jennifer Deal, PhD, department of epidemiology and Cochlear Center for Hearing and Public Health, Baltimore, and Julio Rojas, MD, PhD, Memory and Aging Center, department of neurology, Weill Institute for Neurosciences, University of California, San Francisco, call the findings “an important reminder that dementia is a social problem in which potentially treatable risk factors, including visual impairment, are highly prevalent in disadvantaged populations.”

The editorialists noted that 90% of cases of vision impairment are “preventable or have yet to be treated. The two “highly cost-effective interventions” of eyeglasses and/or cataract surgery “remain underused both in the U.S. and globally, especially in disadvantaged communities,” they wrote.

They added that more research is needed to “test the effectiveness of interventions to preserve cognitive health by promoting healthy vision.”

The study was supported by grants from the National Institute on Aging, the National Institutes of Health, and Research to Prevent Blindness. The investigators reported no relevant financial relationships. Dr. Deal reported having received grants from the National Institute on Aging. Dr. Rojas reported serving as site principal investigator on clinical trials for Eli Lilly and Eisai and receiving grants from the National Institute on Aging. Dr. Pershing is a consultant for Acumen, and Verana Health (as DigiSight Technologies).

A version of this article first appeared on Medscape.com.

Impaired vision in older adults is an underrecognized and modifiable dementia risk factor, new research suggests.

Investigators analyzed estimated population attributable fractions (PAFs) associated with dementia in more than 16,000 older adults. A PAF represents the number of dementia cases that could be prevented if a given risk factor were eliminated.

Results showed the PAF of vision impairment was 1.8%, suggesting that healthy vision had the potential to prevent more than 100,000 cases of dementia in the United States.

“Vision impairment and blindness disproportionately impact older adults, yet vision impairment is often preventable or even correctable,” study investigator Joshua Ehrlich MD, assistant professor of ophthalmology and visual sciences, University of Michigan, Ann Arbor, said in an interview.

Poor vision affects not only how individuals see the world, but also their systemic health and well-being, Dr. Ehrlich said.

“Accordingly, ensuring that older adults receive appropriate eye care is vital to promoting health, independence, and optimal aging,” he added.

The findings were published online in JAMA Neurology.
 

A surprising omission

There is an “urgent need to identify modifiable risk factors for dementia that can be targeted with interventions to slow cognitive decline and prevent dementia,” the investigators wrote.

In 2020, the Lancet Commission report on dementia prevention, intervention, and care proposed a life-course model of 12 potentially modifiable dementia risk factors. This included lower educational level, hearing loss, traumatic brain injury, hypertension, excessive alcohol consumption, obesity, smoking, depression, social isolation, physical inactivity, diabetes, and air pollution.

Together, these factors are associated with about 40% of dementia cases worldwide, the report notes.

Vision impairment was not included in this model, “despite considerable evidence that it is associated with an elevated risk of incident dementia and that it may operate through the same pathways as hearing loss,” the current researchers wrote.

“We have known for some time that vision impairment is a risk factor for dementia [and] we also know that a very large fraction of vision impairment, possibly in excess of 80%, is avoidable or has simply yet to be addressed,” Dr. Ehrlich said.

He and his colleagues found it “surprising that vision impairment had been ignored in key models of modifiable dementia risk factors that are used to shape health policy and resource allocation.” They set out to demonstrate that, “in fact, vision impairment is just as influential as a number of other long accepted modifiable dementia risk factors.”

The investigators assessed data from the Health and Retirement Study (HRS), a panel study that surveys more than 20,000 U.S. adults aged 50 years or older every 2 years.

The investigators applied the same methods used by the Lancet Commission to the HRS dataset and added vision impairment to the Lancet life-course model. Air pollution was excluded in their model “because those data were not readily available in the HRS,” the researchers wrote.

They noted the PAF is “based on the population prevalence and relative risk of dementia for each risk factor” and is “weighted, based on a principal components analysis, to account for communality (clustering of risk factors).”
 

A missed prevention opportunity

The sample included 16,690 participants (54% were women, 51.5% were at least age 65, 80.2% were White, 10.6% were Black, 9.2% were other).

In total, the 12 potentially modifiable risk factors used in the researchers’ model were associated with an estimated 62.4% of dementia cases in the United States, with hypertension as the most prevalent risk factor with the highest weighted PAF.
 

A new focus for prevention

Commenting for this article, Suzann Pershing, MD, associate professor of ophthalmology, Stanford (Calif.) University, called the study “particularly important because, despite growing recognition of its importance in relation to cognition, visual impairment is often an underrecognized risk factor.”

The current research “builds on increasingly robust medical literature linking visual impairment and dementia, applying analogous methods to those used for the life course model recently presented by the Lancet Commission to evaluate potentially modifiable dementia risk factors,” said Dr. Pershing, who was not involved with the study.

The investigators “make a compelling argument for inclusion of visual impairment as one of the potentially modifiable risk factors; practicing clinicians and health care systems may consider screening and targeted therapies to address visual impairment, with a goal of population health and contributing to a reduction in future dementia disease burden,” she added.

In an accompanying editorial), Jennifer Deal, PhD, department of epidemiology and Cochlear Center for Hearing and Public Health, Baltimore, and Julio Rojas, MD, PhD, Memory and Aging Center, department of neurology, Weill Institute for Neurosciences, University of California, San Francisco, call the findings “an important reminder that dementia is a social problem in which potentially treatable risk factors, including visual impairment, are highly prevalent in disadvantaged populations.”

The editorialists noted that 90% of cases of vision impairment are “preventable or have yet to be treated. The two “highly cost-effective interventions” of eyeglasses and/or cataract surgery “remain underused both in the U.S. and globally, especially in disadvantaged communities,” they wrote.

They added that more research is needed to “test the effectiveness of interventions to preserve cognitive health by promoting healthy vision.”

The study was supported by grants from the National Institute on Aging, the National Institutes of Health, and Research to Prevent Blindness. The investigators reported no relevant financial relationships. Dr. Deal reported having received grants from the National Institute on Aging. Dr. Rojas reported serving as site principal investigator on clinical trials for Eli Lilly and Eisai and receiving grants from the National Institute on Aging. Dr. Pershing is a consultant for Acumen, and Verana Health (as DigiSight Technologies).

A version of this article first appeared on Medscape.com.

CHICAGO – To give a sense of how social factors affect someone’s health, Sarah Candler, MD, MPH, described this case: A 70-year-old woman with diabetes, rheumatoid arthritis, and high blood pressure and a high hemoglobin A1C, even though she’s on insulin.

This patient is on prednisone for her RA because she can’t afford better drugs, and she has been occasionally skipping her insulin, Dr. Candler said during her presentation, at the annual meeting of the American College of Physicians

Plus, her first language is Turkish, and she’s missed many doctor appointments because she lives too far from the center-city clinics, said Dr. Candler, who is the care team medical director at Iora Primary Care in Houston.

How are this woman’s needs supposed to be met in a fee-for-service system that allows medical staff 15 to 30 minutes to help solve her problems?

Potential regulatory fixes

A panel of experts talked about potential policies and regulatory fixes that take into account the impact of “social determinants of health.” Some of these are gaining traction, but there is still a huge gap between how medicine in practiced in the United States and the health needs of people in the community, the panelists said.

The ACO REACH (Realizing Equity, Access and Community Health) model is a recent step forward, said Josh Liao, MD, MSc, associate chair for health systems at the University of Washington, Seattle. The accountable care organization model pays doctors more for caring for Medicare patients in underserved communities.

“To me, it represents that at least we’re moving in the direction where we’re acknowledging directly that social environment matters,” he said.

The American College of Physicians’ Medical Practice and Quality Committee helped improve payment for telehealth, an important step for equity to the underserved, said William Fox, MD, at Fox and Brantley Internal Medicine in Charlottesville, Va., and chair of the committee for ACP’s Virginia chapter. But many policies require much more work, he said.

One aim is getting to universal health coverage – 31 million people in the United States still don’t have health insurance, a number that is greatly improved since the Affordable Care Act but has plateaued recently.

Another is to invest more in primary care – which accounts for about 5% of spending even though 35% of patient visits are to primary care.

Dr. Fox said the U.S. system also needs to evolve beyond fee-for-service, invest in information technology to bridge the gap between the access for the rich and poor, continue to expand telehealth, and reform payment programs to recognize social factors.

“The current finance system and the quality payment program are focused on downstream impacts of poor health,” Dr. Fox said.

Primary care needs to shed the expectation that it must show that it reduces costs in order to be valued, he continued. Care sometimes is necessary but doesn’t reduce cost. Also, cost reduction is often seen in the long run, but studied only in the short term, and therefore the evidence for cost reduction can be elusive.

What can internists do to help?

Dr. Candler said internal medicine physicians can do their part by collecting data on patients and staff and measuring outcomes to identify disparities. Additionally, they could run their practices with community and cultural needs in mind, she said.

“Some of that might mean hiring differently. Think about it – if you’re in a position to start building new practices, go where they need you,” Dr. Candler explained. “It might mean a little bit more of a commute for you. But your patients are already doing that with their untreated cataracts, so who’s safer on the roads?”

George Abraham, MD, MPH – president of ACP and professor of medicine at the University of Massachusetts , Boston, who did not present in the session – suggested physicians should be looking at their own practice style, location, and the way their practice runs, and see where there are opportunities to be more in touch.

“I’m sure we all have practices where we have a diverse patient population,” he said. What doctors can do is to specifically focus on their minority population and ask: ‘What do they experience that others don’t experience as my patient coming into my office?’ he said.

Dr. Abraham, who received his medical degree in India and is ACP’s first president who is an international medical graduate, pointed to ACP’s emphasis on diversifying the internal medicine workforce to reflect the communities.

Recent measures have included the creation of an ACP international medical graduate task force and establishing an antiharassment policy and reporting process.

“The conversation has started a lot more,” he said.

Dr. Candler reports financial relationships with Abbott, AbbVie, Johnson & Johnson, Merck, Medtronic, Pfizer, and other companies. She is also a member of the editorial advisory board of Internal Medicine News. Dr. Fox reports financial relationships with Obagi Cosmeceuticals. Dr. Liao reports financial relationships with Eli Lilly, Gilead, Johnson & Johnson, Novavax, and other companies. Dr. Abraham reports no relevant financial relationships.

CHICAGO – To give a sense of how social factors affect someone’s health, Sarah Candler, MD, MPH, described this case: A 70-year-old woman with diabetes, rheumatoid arthritis, and high blood pressure and a high hemoglobin A1C, even though she’s on insulin.

This patient is on prednisone for her RA because she can’t afford better drugs, and she has been occasionally skipping her insulin, Dr. Candler said during her presentation, at the annual meeting of the American College of Physicians

Plus, her first language is Turkish, and she’s missed many doctor appointments because she lives too far from the center-city clinics, said Dr. Candler, who is the care team medical director at Iora Primary Care in Houston.

How are this woman’s needs supposed to be met in a fee-for-service system that allows medical staff 15 to 30 minutes to help solve her problems?

Potential regulatory fixes

A panel of experts talked about potential policies and regulatory fixes that take into account the impact of “social determinants of health.” Some of these are gaining traction, but there is still a huge gap between how medicine in practiced in the United States and the health needs of people in the community, the panelists said.

The ACO REACH (Realizing Equity, Access and Community Health) model is a recent step forward, said Josh Liao, MD, MSc, associate chair for health systems at the University of Washington, Seattle. The accountable care organization model pays doctors more for caring for Medicare patients in underserved communities.

“To me, it represents that at least we’re moving in the direction where we’re acknowledging directly that social environment matters,” he said.

The American College of Physicians’ Medical Practice and Quality Committee helped improve payment for telehealth, an important step for equity to the underserved, said William Fox, MD, at Fox and Brantley Internal Medicine in Charlottesville, Va., and chair of the committee for ACP’s Virginia chapter. But many policies require much more work, he said.

One aim is getting to universal health coverage – 31 million people in the United States still don’t have health insurance, a number that is greatly improved since the Affordable Care Act but has plateaued recently.

Another is to invest more in primary care – which accounts for about 5% of spending even though 35% of patient visits are to primary care.

Dr. Fox said the U.S. system also needs to evolve beyond fee-for-service, invest in information technology to bridge the gap between the access for the rich and poor, continue to expand telehealth, and reform payment programs to recognize social factors.

“The current finance system and the quality payment program are focused on downstream impacts of poor health,” Dr. Fox said.

Primary care needs to shed the expectation that it must show that it reduces costs in order to be valued, he continued. Care sometimes is necessary but doesn’t reduce cost. Also, cost reduction is often seen in the long run, but studied only in the short term, and therefore the evidence for cost reduction can be elusive.

What can internists do to help?

Dr. Candler said internal medicine physicians can do their part by collecting data on patients and staff and measuring outcomes to identify disparities. Additionally, they could run their practices with community and cultural needs in mind, she said.

“Some of that might mean hiring differently. Think about it – if you’re in a position to start building new practices, go where they need you,” Dr. Candler explained. “It might mean a little bit more of a commute for you. But your patients are already doing that with their untreated cataracts, so who’s safer on the roads?”

George Abraham, MD, MPH – president of ACP and professor of medicine at the University of Massachusetts , Boston, who did not present in the session – suggested physicians should be looking at their own practice style, location, and the way their practice runs, and see where there are opportunities to be more in touch.

“I’m sure we all have practices where we have a diverse patient population,” he said. What doctors can do is to specifically focus on their minority population and ask: ‘What do they experience that others don’t experience as my patient coming into my office?’ he said.

Dr. Abraham, who received his medical degree in India and is ACP’s first president who is an international medical graduate, pointed to ACP’s emphasis on diversifying the internal medicine workforce to reflect the communities.

Recent measures have included the creation of an ACP international medical graduate task force and establishing an antiharassment policy and reporting process.

“The conversation has started a lot more,” he said.

Dr. Candler reports financial relationships with Abbott, AbbVie, Johnson & Johnson, Merck, Medtronic, Pfizer, and other companies. She is also a member of the editorial advisory board of Internal Medicine News. Dr. Fox reports financial relationships with Obagi Cosmeceuticals. Dr. Liao reports financial relationships with Eli Lilly, Gilead, Johnson & Johnson, Novavax, and other companies. Dr. Abraham reports no relevant financial relationships.

CHICAGO – To give a sense of how social factors affect someone’s health, Sarah Candler, MD, MPH, described this case: A 70-year-old woman with diabetes, rheumatoid arthritis, and high blood pressure and a high hemoglobin A1C, even though she’s on insulin.

This patient is on prednisone for her RA because she can’t afford better drugs, and she has been occasionally skipping her insulin, Dr. Candler said during her presentation, at the annual meeting of the American College of Physicians

Plus, her first language is Turkish, and she’s missed many doctor appointments because she lives too far from the center-city clinics, said Dr. Candler, who is the care team medical director at Iora Primary Care in Houston.

How are this woman’s needs supposed to be met in a fee-for-service system that allows medical staff 15 to 30 minutes to help solve her problems?

Potential regulatory fixes

A panel of experts talked about potential policies and regulatory fixes that take into account the impact of “social determinants of health.” Some of these are gaining traction, but there is still a huge gap between how medicine in practiced in the United States and the health needs of people in the community, the panelists said.

The ACO REACH (Realizing Equity, Access and Community Health) model is a recent step forward, said Josh Liao, MD, MSc, associate chair for health systems at the University of Washington, Seattle. The accountable care organization model pays doctors more for caring for Medicare patients in underserved communities.

“To me, it represents that at least we’re moving in the direction where we’re acknowledging directly that social environment matters,” he said.

The American College of Physicians’ Medical Practice and Quality Committee helped improve payment for telehealth, an important step for equity to the underserved, said William Fox, MD, at Fox and Brantley Internal Medicine in Charlottesville, Va., and chair of the committee for ACP’s Virginia chapter. But many policies require much more work, he said.

One aim is getting to universal health coverage – 31 million people in the United States still don’t have health insurance, a number that is greatly improved since the Affordable Care Act but has plateaued recently.

Another is to invest more in primary care – which accounts for about 5% of spending even though 35% of patient visits are to primary care.

Dr. Fox said the U.S. system also needs to evolve beyond fee-for-service, invest in information technology to bridge the gap between the access for the rich and poor, continue to expand telehealth, and reform payment programs to recognize social factors.

“The current finance system and the quality payment program are focused on downstream impacts of poor health,” Dr. Fox said.

Primary care needs to shed the expectation that it must show that it reduces costs in order to be valued, he continued. Care sometimes is necessary but doesn’t reduce cost. Also, cost reduction is often seen in the long run, but studied only in the short term, and therefore the evidence for cost reduction can be elusive.

What can internists do to help?

Dr. Candler said internal medicine physicians can do their part by collecting data on patients and staff and measuring outcomes to identify disparities. Additionally, they could run their practices with community and cultural needs in mind, she said.

“Some of that might mean hiring differently. Think about it – if you’re in a position to start building new practices, go where they need you,” Dr. Candler explained. “It might mean a little bit more of a commute for you. But your patients are already doing that with their untreated cataracts, so who’s safer on the roads?”

George Abraham, MD, MPH – president of ACP and professor of medicine at the University of Massachusetts , Boston, who did not present in the session – suggested physicians should be looking at their own practice style, location, and the way their practice runs, and see where there are opportunities to be more in touch.

“I’m sure we all have practices where we have a diverse patient population,” he said. What doctors can do is to specifically focus on their minority population and ask: ‘What do they experience that others don’t experience as my patient coming into my office?’ he said.

Dr. Abraham, who received his medical degree in India and is ACP’s first president who is an international medical graduate, pointed to ACP’s emphasis on diversifying the internal medicine workforce to reflect the communities.

Recent measures have included the creation of an ACP international medical graduate task force and establishing an antiharassment policy and reporting process.

“The conversation has started a lot more,” he said.

Dr. Candler reports financial relationships with Abbott, AbbVie, Johnson & Johnson, Merck, Medtronic, Pfizer, and other companies. She is also a member of the editorial advisory board of Internal Medicine News. Dr. Fox reports financial relationships with Obagi Cosmeceuticals. Dr. Liao reports financial relationships with Eli Lilly, Gilead, Johnson & Johnson, Novavax, and other companies. Dr. Abraham reports no relevant financial relationships.

LISBON – During the pandemic, critical and acute care hospitals with medium and high rates of antimicrobial resistance (AMR) showed significant increases in antibiotic prescriptions and longer durations of antibiotic treatment among all hospital admissions, and also in those patients who were bacterial culture negative, according to a large U.S.-based study.

The analysis across 271 U.S. hospitals also showed that AMR rates were significantly higher for pathogens during the pandemic period, compared with the prepandemic period in patients who were tested for SARS-CoV-2, and highest in SARS-CoV-2–positive patients.

More than a third of SARS-CoV-2–positive patients who were prescribed antibiotics were bacterial culture negative.

Findings of the study were presented by Vikas Gupta, PharmD, director of medical affairs at medical technology firm Becton Dickinson, at this year’s European Congress of Clinical Microbiology & Infectious Diseases. He conducted the study jointly with Karri Bauer, PharmD, from Merck Sharp & Dohme, Kenilworth, N.J., and colleagues.

“There are differences in AMR that go beyond COVID-positive admissions,” Dr. Gupta told this news organization. “There is opportunity for improvement especially with those hospitalized patients who had a negative culture result, or no culture collected.”

“We found a higher percentage of COVID-positive admissions that were prescribed antibacterial therapy even in those having [tested negative for bacteria] or no culture result,” said Dr. Gupta. “Our data also shows that the percentage of admissions with duration of antibacterial therapy over 3 days was significantly higher in COVID-positive but culture-negative/no culture patients, compared to other groups evaluated.”

Of all admissions prescribed antibiotics during the pandemic, 57.8% of SARS-CoV-2–positive patients were prescribed antibiotics whereas 88.1% of SARS-CoV-2–positive admissions were bacterial culture negative/no culture. Overall, prepandemic, 35% of admissions were prescribed antibiotics.

Duration of antibiotic therapy in the prepandemic era was an average of 3.5 days, compared with an average of 3.8 days overall in the pandemic and 5.7 days in patients who tested positive for SARS-CoV-2. Similarly, the percentage of patients who were bacterial culture negative or had no culture and received antibiotic therapy for more than 72 hours was 17.6% in the prepandemic era, compared with 19.2% overall in the pandemic era, and 41.1% in patients who tested positive for COVID-19.  

Dr. Gupta and Dr. Bauer wanted to look at all patients admitted to hospitals segmented by SARS-CoV-2 positive, negative, and not tested, to get a sense of how much antibiotic use there was and how long patients were on antibiotics. “We ultimately want to optimize and not overuse antibiotics and prescribe them for right period of time,” said Dr. Gupta.

“To date, there has been no conclusive evidence about the suggestion that the pandemic has led to increased AMR rates, so we aimed to evaluate the pandemic’s impact on AMR and antibiotic use across U.S. hospitals,” he explained.

The multicenter, retrospective cohort analysis made use of BD’s infection surveillance platform (BD HealthSight Infection Advisor with MedMined Insights) and was conducted across 271 U.S. critical access/acute care facilities, representing approximately 10%-13% of U.S. hospital admissions. It included all hospitalized patients with more than 1 day of in-patient admission. Patients were considered SARS-CoV-2 positive by polymerase chain reaction test or antigen test either 7 days or less prior to or within 14 days of admission.

Patients were categorized as hospitalized during the “prepandemic” period (July 1, 2019 through February 29, 2020) and the “pandemic” period (March 1, 2020 through Oct. 30, 2021) and were stratified based on their SARS-CoV-2 result. 

Investigators included all hospital admissions with an AMR event (first positive culture for select gram-negative or gram-positive pathogens that were reported as nonsusceptible across blood, urine, respiratory, intra-abdominal, skin/wound, and other sources).

The investigators calculated AMR rates at the patient-admission level and defined per 100 admissions. Also, they further evaluated AMR rates based on community onset (defined as culture collected ≤2 days from admission) or hospital onset (>2 days from admission). Finally, AMR rates were determined according to whether they related to prepandemic or pandemic periods. 

Hospitals were also categorized according to their AMR rates as low (<25%), medium (25%-75%), and high (>75%). 

Overall AMR rates were lower in the pandemic period, compared with the prepandemic period. However, reported Dr.Gupta, for hospital-onset pathogens specifically, AMR rates were significantly higher overall in the pandemic period and mostly driven by admissions tested for SARS-CoV-2 (whether positive or negative).

Hospitals with high AMR rates also tended to have more SARS-CoV-2 positive admissions (6.1% in high-AMR hospitals vs. 3% in low-AMR hospitals). The highest antibiotic-prescribing rates and highest duration of antibiotic use was also seen in those hospitals with highest AMR rates. 

Of the SARS-CoV-2 patients who were bacterial culture negative/no culture and were prescribed antibiotics, 36.5% were in hospitals with a high AMR rate. “Roughly one-third of patients without culture evidence of a bacterial infection were prescribed antibiotics in hospitals with a high AMR rate,” said Dr. Gupta.

The researchers wanted to tease out whether hospitals with high, moderate, or low AMR rates look different with respect to antibiotic-prescribing patterns. During the pandemic period, they found that hospitals with high and medium AMR rates experienced significant increases in antibiotic prescriptions and longer durations. Prepandemic, the overall hospital-onset AMR rate was 0.8 per 100 admissions, whereas during the pandemic this rose to 1.4 per 100 admissions in high-AMR hospitals and dropped to 0.4 in low-AMR hospitals.

SARS-CoV-2–positive admission rates were higher in facilities with medium (5.6%) and high AMR (6.1%) rates than those with low (3%) AMR rates. “We found that those with medium and high AMR rates were more likely to have COVID-positive admissions than facilities with low AMR rates,” Dr. Gupta said. “It appears as if COVID is contributing to AMR in the facilities.”

Asked for independent comment, Jason C. Gallagher, PharmD, BCPS, clinical professor at Temple University School of Pharmacy in Philadelphia, said in an interview, “It is not surprising that there was more antimicrobial resistance in patients with COVID than those without. Even though antibiotics do not work for COVID, they are often prescribed, and antibiotic use is a major risk factor for antimicrobial resistance. This is likely because clinicians are sometimes concerned about coinfections with bacteria (which are rare) and because hospitalized patients with severe COVID can acquire other infections as they are treated.”
 

Antibiotic stewardship programs

Antibiotic stewardship programs have been highly stressed during the pandemic, so the researchers hope their data support the need for better antibiotic stewardship practices during pandemic surges when control is more challenging.

Dr. Gupta explained that they were seeing interesting associations that can inform antimicrobial stewardship programs and teams. “We are not trying to imply causality,” he stressed.

It is a common practice for stewardship teams to evaluate the need for continuation of antibiotic therapy at 3 days, especially in patients who are culture negative or did not have a culture collected.

“Antibiotic time-out at 3 days is a recommended practice to evaluate for continuing antibiotic therapy based on the patient’s condition and culture results,” he said. “This is what made our study unique because we wanted to look at what percentage of admissions were prescribed antibiotics beyond 3 days and compare to the prepandemic period.”

Session moderator Evangelos J. Giamarellos-Bourboulis, MD, PhD, an assistant professor of internal medicine and infectious diseases, University of Athens, Greece, thanked Dr. Gupta for his “eloquent presentation” and sought to clarify whether the data “refer to antimicrobial use that was empirical or whether use was in hospitals with high AMR rates, or whether the approach was driven through microbiology?”

Dr. Gupta replied that this was why they evaluated the negative-culture and no-culture patients. “We wanted to get a measure of antibacterial use in this population too,” he said. “Definitely, there is empirical therapy as well as definitive therapy, but I think the negative and no-culture group provide a reference point where we see similar signals and trends to that of the overall population.”

An audience member also addressed a question to Dr. Gupta: “Did you look at the patient population, because in many cases, during COVID, these patients may have been more severe than in the prepandemic period?”

Dr. Gupta replied: “In our manuscript we’ve done an analysis where we adjusted for patient-level facility and regional-level factors. There are definitely differences in the patient populations but overall, these are pretty sick patients when we look at the level of severity overall.”

Dr. Gupta is an employee of and a shareholder in Becton Dickinson. Dr. Bauer is an employee of and a shareholder in Merck. Dr. Gallagher consults for many pharmaceutical companies including Merck.

Dr. Giamarellos-Bourboulis disclosed honoraria (paid to the University of Athens) from Abbott CH, Brahms Thermo Fisher GMBH Germany, GlaxoSmithKline, and Sobi; serving as a consultant for Abbott CH, Fab’nTech, InflaRx GmbH, UCB, Sobi, and Xbiotech; research grants (paid to the Hellenic Institute for the Study of Sepsis) from Abbott CH, BioMerieux France, Johnson & Johnson, MSD, Sobi, Thermo Fisher Brahms GmbH; and EU research funding: Horizon 2020 ITN European Sepsis Academy (granted to the University of Athens); Horizon 2020 ImmunoSep and RISinCOVID (granted to the Hellenic Institute for the Study of Sepsis); Horizon Health EPIC-CROWN-2 (granted to the Hellenic Institute for the Study of Sepsis).

A version of this article first appeared on Medscape.com.

LISBON – During the pandemic, critical and acute care hospitals with medium and high rates of antimicrobial resistance (AMR) showed significant increases in antibiotic prescriptions and longer durations of antibiotic treatment among all hospital admissions, and also in those patients who were bacterial culture negative, according to a large U.S.-based study.

The analysis across 271 U.S. hospitals also showed that AMR rates were significantly higher for pathogens during the pandemic period, compared with the prepandemic period in patients who were tested for SARS-CoV-2, and highest in SARS-CoV-2–positive patients.

More than a third of SARS-CoV-2–positive patients who were prescribed antibiotics were bacterial culture negative.

Findings of the study were presented by Vikas Gupta, PharmD, director of medical affairs at medical technology firm Becton Dickinson, at this year’s European Congress of Clinical Microbiology & Infectious Diseases. He conducted the study jointly with Karri Bauer, PharmD, from Merck Sharp & Dohme, Kenilworth, N.J., and colleagues.

“There are differences in AMR that go beyond COVID-positive admissions,” Dr. Gupta told this news organization. “There is opportunity for improvement especially with those hospitalized patients who had a negative culture result, or no culture collected.”

“We found a higher percentage of COVID-positive admissions that were prescribed antibacterial therapy even in those having [tested negative for bacteria] or no culture result,” said Dr. Gupta. “Our data also shows that the percentage of admissions with duration of antibacterial therapy over 3 days was significantly higher in COVID-positive but culture-negative/no culture patients, compared to other groups evaluated.”

Of all admissions prescribed antibiotics during the pandemic, 57.8% of SARS-CoV-2–positive patients were prescribed antibiotics whereas 88.1% of SARS-CoV-2–positive admissions were bacterial culture negative/no culture. Overall, prepandemic, 35% of admissions were prescribed antibiotics.

Duration of antibiotic therapy in the prepandemic era was an average of 3.5 days, compared with an average of 3.8 days overall in the pandemic and 5.7 days in patients who tested positive for SARS-CoV-2. Similarly, the percentage of patients who were bacterial culture negative or had no culture and received antibiotic therapy for more than 72 hours was 17.6% in the prepandemic era, compared with 19.2% overall in the pandemic era, and 41.1% in patients who tested positive for COVID-19.  

Dr. Gupta and Dr. Bauer wanted to look at all patients admitted to hospitals segmented by SARS-CoV-2 positive, negative, and not tested, to get a sense of how much antibiotic use there was and how long patients were on antibiotics. “We ultimately want to optimize and not overuse antibiotics and prescribe them for right period of time,” said Dr. Gupta.

“To date, there has been no conclusive evidence about the suggestion that the pandemic has led to increased AMR rates, so we aimed to evaluate the pandemic’s impact on AMR and antibiotic use across U.S. hospitals,” he explained.

The multicenter, retrospective cohort analysis made use of BD’s infection surveillance platform (BD HealthSight Infection Advisor with MedMined Insights) and was conducted across 271 U.S. critical access/acute care facilities, representing approximately 10%-13% of U.S. hospital admissions. It included all hospitalized patients with more than 1 day of in-patient admission. Patients were considered SARS-CoV-2 positive by polymerase chain reaction test or antigen test either 7 days or less prior to or within 14 days of admission.

Patients were categorized as hospitalized during the “prepandemic” period (July 1, 2019 through February 29, 2020) and the “pandemic” period (March 1, 2020 through Oct. 30, 2021) and were stratified based on their SARS-CoV-2 result. 

Investigators included all hospital admissions with an AMR event (first positive culture for select gram-negative or gram-positive pathogens that were reported as nonsusceptible across blood, urine, respiratory, intra-abdominal, skin/wound, and other sources).

The investigators calculated AMR rates at the patient-admission level and defined per 100 admissions. Also, they further evaluated AMR rates based on community onset (defined as culture collected ≤2 days from admission) or hospital onset (>2 days from admission). Finally, AMR rates were determined according to whether they related to prepandemic or pandemic periods. 

Hospitals were also categorized according to their AMR rates as low (<25%), medium (25%-75%), and high (>75%). 

Overall AMR rates were lower in the pandemic period, compared with the prepandemic period. However, reported Dr.Gupta, for hospital-onset pathogens specifically, AMR rates were significantly higher overall in the pandemic period and mostly driven by admissions tested for SARS-CoV-2 (whether positive or negative).

Hospitals with high AMR rates also tended to have more SARS-CoV-2 positive admissions (6.1% in high-AMR hospitals vs. 3% in low-AMR hospitals). The highest antibiotic-prescribing rates and highest duration of antibiotic use was also seen in those hospitals with highest AMR rates. 

Of the SARS-CoV-2 patients who were bacterial culture negative/no culture and were prescribed antibiotics, 36.5% were in hospitals with a high AMR rate. “Roughly one-third of patients without culture evidence of a bacterial infection were prescribed antibiotics in hospitals with a high AMR rate,” said Dr. Gupta.

The researchers wanted to tease out whether hospitals with high, moderate, or low AMR rates look different with respect to antibiotic-prescribing patterns. During the pandemic period, they found that hospitals with high and medium AMR rates experienced significant increases in antibiotic prescriptions and longer durations. Prepandemic, the overall hospital-onset AMR rate was 0.8 per 100 admissions, whereas during the pandemic this rose to 1.4 per 100 admissions in high-AMR hospitals and dropped to 0.4 in low-AMR hospitals.

SARS-CoV-2–positive admission rates were higher in facilities with medium (5.6%) and high AMR (6.1%) rates than those with low (3%) AMR rates. “We found that those with medium and high AMR rates were more likely to have COVID-positive admissions than facilities with low AMR rates,” Dr. Gupta said. “It appears as if COVID is contributing to AMR in the facilities.”

Asked for independent comment, Jason C. Gallagher, PharmD, BCPS, clinical professor at Temple University School of Pharmacy in Philadelphia, said in an interview, “It is not surprising that there was more antimicrobial resistance in patients with COVID than those without. Even though antibiotics do not work for COVID, they are often prescribed, and antibiotic use is a major risk factor for antimicrobial resistance. This is likely because clinicians are sometimes concerned about coinfections with bacteria (which are rare) and because hospitalized patients with severe COVID can acquire other infections as they are treated.”
 

Antibiotic stewardship programs

Antibiotic stewardship programs have been highly stressed during the pandemic, so the researchers hope their data support the need for better antibiotic stewardship practices during pandemic surges when control is more challenging.

Dr. Gupta explained that they were seeing interesting associations that can inform antimicrobial stewardship programs and teams. “We are not trying to imply causality,” he stressed.

It is a common practice for stewardship teams to evaluate the need for continuation of antibiotic therapy at 3 days, especially in patients who are culture negative or did not have a culture collected.

“Antibiotic time-out at 3 days is a recommended practice to evaluate for continuing antibiotic therapy based on the patient’s condition and culture results,” he said. “This is what made our study unique because we wanted to look at what percentage of admissions were prescribed antibiotics beyond 3 days and compare to the prepandemic period.”

Session moderator Evangelos J. Giamarellos-Bourboulis, MD, PhD, an assistant professor of internal medicine and infectious diseases, University of Athens, Greece, thanked Dr. Gupta for his “eloquent presentation” and sought to clarify whether the data “refer to antimicrobial use that was empirical or whether use was in hospitals with high AMR rates, or whether the approach was driven through microbiology?”

Dr. Gupta replied that this was why they evaluated the negative-culture and no-culture patients. “We wanted to get a measure of antibacterial use in this population too,” he said. “Definitely, there is empirical therapy as well as definitive therapy, but I think the negative and no-culture group provide a reference point where we see similar signals and trends to that of the overall population.”

An audience member also addressed a question to Dr. Gupta: “Did you look at the patient population, because in many cases, during COVID, these patients may have been more severe than in the prepandemic period?”

Dr. Gupta replied: “In our manuscript we’ve done an analysis where we adjusted for patient-level facility and regional-level factors. There are definitely differences in the patient populations but overall, these are pretty sick patients when we look at the level of severity overall.”

Dr. Gupta is an employee of and a shareholder in Becton Dickinson. Dr. Bauer is an employee of and a shareholder in Merck. Dr. Gallagher consults for many pharmaceutical companies including Merck.

Dr. Giamarellos-Bourboulis disclosed honoraria (paid to the University of Athens) from Abbott CH, Brahms Thermo Fisher GMBH Germany, GlaxoSmithKline, and Sobi; serving as a consultant for Abbott CH, Fab’nTech, InflaRx GmbH, UCB, Sobi, and Xbiotech; research grants (paid to the Hellenic Institute for the Study of Sepsis) from Abbott CH, BioMerieux France, Johnson & Johnson, MSD, Sobi, Thermo Fisher Brahms GmbH; and EU research funding: Horizon 2020 ITN European Sepsis Academy (granted to the University of Athens); Horizon 2020 ImmunoSep and RISinCOVID (granted to the Hellenic Institute for the Study of Sepsis); Horizon Health EPIC-CROWN-2 (granted to the Hellenic Institute for the Study of Sepsis).

A version of this article first appeared on Medscape.com.

LISBON – During the pandemic, critical and acute care hospitals with medium and high rates of antimicrobial resistance (AMR) showed significant increases in antibiotic prescriptions and longer durations of antibiotic treatment among all hospital admissions, and also in those patients who were bacterial culture negative, according to a large U.S.-based study.

The analysis across 271 U.S. hospitals also showed that AMR rates were significantly higher for pathogens during the pandemic period, compared with the prepandemic period in patients who were tested for SARS-CoV-2, and highest in SARS-CoV-2–positive patients.

More than a third of SARS-CoV-2–positive patients who were prescribed antibiotics were bacterial culture negative.

Findings of the study were presented by Vikas Gupta, PharmD, director of medical affairs at medical technology firm Becton Dickinson, at this year’s European Congress of Clinical Microbiology & Infectious Diseases. He conducted the study jointly with Karri Bauer, PharmD, from Merck Sharp & Dohme, Kenilworth, N.J., and colleagues.

“There are differences in AMR that go beyond COVID-positive admissions,” Dr. Gupta told this news organization. “There is opportunity for improvement especially with those hospitalized patients who had a negative culture result, or no culture collected.”

“We found a higher percentage of COVID-positive admissions that were prescribed antibacterial therapy even in those having [tested negative for bacteria] or no culture result,” said Dr. Gupta. “Our data also shows that the percentage of admissions with duration of antibacterial therapy over 3 days was significantly higher in COVID-positive but culture-negative/no culture patients, compared to other groups evaluated.”

Of all admissions prescribed antibiotics during the pandemic, 57.8% of SARS-CoV-2–positive patients were prescribed antibiotics whereas 88.1% of SARS-CoV-2–positive admissions were bacterial culture negative/no culture. Overall, prepandemic, 35% of admissions were prescribed antibiotics.

Duration of antibiotic therapy in the prepandemic era was an average of 3.5 days, compared with an average of 3.8 days overall in the pandemic and 5.7 days in patients who tested positive for SARS-CoV-2. Similarly, the percentage of patients who were bacterial culture negative or had no culture and received antibiotic therapy for more than 72 hours was 17.6% in the prepandemic era, compared with 19.2% overall in the pandemic era, and 41.1% in patients who tested positive for COVID-19.  

Dr. Gupta and Dr. Bauer wanted to look at all patients admitted to hospitals segmented by SARS-CoV-2 positive, negative, and not tested, to get a sense of how much antibiotic use there was and how long patients were on antibiotics. “We ultimately want to optimize and not overuse antibiotics and prescribe them for right period of time,” said Dr. Gupta.

“To date, there has been no conclusive evidence about the suggestion that the pandemic has led to increased AMR rates, so we aimed to evaluate the pandemic’s impact on AMR and antibiotic use across U.S. hospitals,” he explained.

The multicenter, retrospective cohort analysis made use of BD’s infection surveillance platform (BD HealthSight Infection Advisor with MedMined Insights) and was conducted across 271 U.S. critical access/acute care facilities, representing approximately 10%-13% of U.S. hospital admissions. It included all hospitalized patients with more than 1 day of in-patient admission. Patients were considered SARS-CoV-2 positive by polymerase chain reaction test or antigen test either 7 days or less prior to or within 14 days of admission.

Patients were categorized as hospitalized during the “prepandemic” period (July 1, 2019 through February 29, 2020) and the “pandemic” period (March 1, 2020 through Oct. 30, 2021) and were stratified based on their SARS-CoV-2 result. 

Investigators included all hospital admissions with an AMR event (first positive culture for select gram-negative or gram-positive pathogens that were reported as nonsusceptible across blood, urine, respiratory, intra-abdominal, skin/wound, and other sources).

The investigators calculated AMR rates at the patient-admission level and defined per 100 admissions. Also, they further evaluated AMR rates based on community onset (defined as culture collected ≤2 days from admission) or hospital onset (>2 days from admission). Finally, AMR rates were determined according to whether they related to prepandemic or pandemic periods. 

Hospitals were also categorized according to their AMR rates as low (<25%), medium (25%-75%), and high (>75%). 

Overall AMR rates were lower in the pandemic period, compared with the prepandemic period. However, reported Dr.Gupta, for hospital-onset pathogens specifically, AMR rates were significantly higher overall in the pandemic period and mostly driven by admissions tested for SARS-CoV-2 (whether positive or negative).

Hospitals with high AMR rates also tended to have more SARS-CoV-2 positive admissions (6.1% in high-AMR hospitals vs. 3% in low-AMR hospitals). The highest antibiotic-prescribing rates and highest duration of antibiotic use was also seen in those hospitals with highest AMR rates. 

Of the SARS-CoV-2 patients who were bacterial culture negative/no culture and were prescribed antibiotics, 36.5% were in hospitals with a high AMR rate. “Roughly one-third of patients without culture evidence of a bacterial infection were prescribed antibiotics in hospitals with a high AMR rate,” said Dr. Gupta.

The researchers wanted to tease out whether hospitals with high, moderate, or low AMR rates look different with respect to antibiotic-prescribing patterns. During the pandemic period, they found that hospitals with high and medium AMR rates experienced significant increases in antibiotic prescriptions and longer durations. Prepandemic, the overall hospital-onset AMR rate was 0.8 per 100 admissions, whereas during the pandemic this rose to 1.4 per 100 admissions in high-AMR hospitals and dropped to 0.4 in low-AMR hospitals.

SARS-CoV-2–positive admission rates were higher in facilities with medium (5.6%) and high AMR (6.1%) rates than those with low (3%) AMR rates. “We found that those with medium and high AMR rates were more likely to have COVID-positive admissions than facilities with low AMR rates,” Dr. Gupta said. “It appears as if COVID is contributing to AMR in the facilities.”

Asked for independent comment, Jason C. Gallagher, PharmD, BCPS, clinical professor at Temple University School of Pharmacy in Philadelphia, said in an interview, “It is not surprising that there was more antimicrobial resistance in patients with COVID than those without. Even though antibiotics do not work for COVID, they are often prescribed, and antibiotic use is a major risk factor for antimicrobial resistance. This is likely because clinicians are sometimes concerned about coinfections with bacteria (which are rare) and because hospitalized patients with severe COVID can acquire other infections as they are treated.”
 

Antibiotic stewardship programs

Antibiotic stewardship programs have been highly stressed during the pandemic, so the researchers hope their data support the need for better antibiotic stewardship practices during pandemic surges when control is more challenging.

Dr. Gupta explained that they were seeing interesting associations that can inform antimicrobial stewardship programs and teams. “We are not trying to imply causality,” he stressed.

It is a common practice for stewardship teams to evaluate the need for continuation of antibiotic therapy at 3 days, especially in patients who are culture negative or did not have a culture collected.

“Antibiotic time-out at 3 days is a recommended practice to evaluate for continuing antibiotic therapy based on the patient’s condition and culture results,” he said. “This is what made our study unique because we wanted to look at what percentage of admissions were prescribed antibiotics beyond 3 days and compare to the prepandemic period.”

Session moderator Evangelos J. Giamarellos-Bourboulis, MD, PhD, an assistant professor of internal medicine and infectious diseases, University of Athens, Greece, thanked Dr. Gupta for his “eloquent presentation” and sought to clarify whether the data “refer to antimicrobial use that was empirical or whether use was in hospitals with high AMR rates, or whether the approach was driven through microbiology?”

Dr. Gupta replied that this was why they evaluated the negative-culture and no-culture patients. “We wanted to get a measure of antibacterial use in this population too,” he said. “Definitely, there is empirical therapy as well as definitive therapy, but I think the negative and no-culture group provide a reference point where we see similar signals and trends to that of the overall population.”

An audience member also addressed a question to Dr. Gupta: “Did you look at the patient population, because in many cases, during COVID, these patients may have been more severe than in the prepandemic period?”

Dr. Gupta replied: “In our manuscript we’ve done an analysis where we adjusted for patient-level facility and regional-level factors. There are definitely differences in the patient populations but overall, these are pretty sick patients when we look at the level of severity overall.”

Dr. Gupta is an employee of and a shareholder in Becton Dickinson. Dr. Bauer is an employee of and a shareholder in Merck. Dr. Gallagher consults for many pharmaceutical companies including Merck.

Dr. Giamarellos-Bourboulis disclosed honoraria (paid to the University of Athens) from Abbott CH, Brahms Thermo Fisher GMBH Germany, GlaxoSmithKline, and Sobi; serving as a consultant for Abbott CH, Fab’nTech, InflaRx GmbH, UCB, Sobi, and Xbiotech; research grants (paid to the Hellenic Institute for the Study of Sepsis) from Abbott CH, BioMerieux France, Johnson & Johnson, MSD, Sobi, Thermo Fisher Brahms GmbH; and EU research funding: Horizon 2020 ITN European Sepsis Academy (granted to the University of Athens); Horizon 2020 ImmunoSep and RISinCOVID (granted to the Hellenic Institute for the Study of Sepsis); Horizon Health EPIC-CROWN-2 (granted to the Hellenic Institute for the Study of Sepsis).

A version of this article first appeared on Medscape.com.

Even mundane tasks such as making a meal can be exhausting for Louise Salant.

“I’m totally wiped out,” said the 71-year-old former private music instructor with asthma who lives in New York City and has been coping with debilitating symptoms of fatigue, shortness of breath, and gastrointestinal symptoms since recovering from a severe bout of COVID-19 2 years ago. “I just don’t have the energy.”

Ms. Salant is not alone. Many older people who contract COVID-19 experience prolonged symptoms of the disease. An analysis of Medicare Advantage claims data published in the BMJ found that about one-third of roughly 87,000 adults aged 65 in the database with a COVID-19 diagnosis sought care for persistent or new symptoms 21 or more days later.

That figure is about twice the rate of persistent COVID-19 related symptoms seen in a cohort of adults younger than age 65 with commercial insurance analyzed by the same group of researchers in a separate BMJ study. Compared with a 2020 comparator group of patients in this age cohort, these patients had a greater likelihood of respiratory failure, fatigue, hypertension, memory problems, kidney injury, mental health conditions, hypercoagulability, and cardiac rhythm disorders. When they compared post–COVID-19 symptoms to lasting symptoms of another serious viral disease – influenza – the researchers found that only respiratory failure, dementia, and post-viral fatigue were more common in the COVID-19 group.

“It became clear early in the pandemic that there is going to be a second pandemic related to all of the complications that we’ve seen related to COVID-19 infections,” said Ken Cohen, MD, executive director of translational research and national senior medical director for Optum Labs in Minnetonka, Minn., who coauthored the BMJ studies.

The results are among a growing body of evidence suggesting that older adults are at high risk of persistent post-COVID-19 symptoms.

Researchers in Rome, for example, found that 83% of 165 patients aged 65 or older who had been hospitalized for COVID-19 reported at least one lasting symptom – problems like fatigue, shortness of breath, joint pain, and coughing – in the months after hospitalization. One-third of those had two symptoms, and 46% had three or more.

A similar study in Norway found that two-thirds of patients aged 60 or older reported reduced health-related quality of life during follow-up visits 6 months after hospitalization for COVID-19. The most-reported impairments among those patients were the inability to perform the tasks of daily life, reduced mobility, and increased pain and discomfort.
 

Cognitive concerns

Mounting evidence indicates that COVID-19 may contribute to chronic cognitive impairment in older adults. A multisite U.S. study found that 28% of 817 adults presenting to emergency departments with COVID-19 had delirium and poorer outcomes. A Chinese case-control study that enrolled 1,438 individuals hospitalized in Wuhan for COVID-19, along with 438 of their uninfected spouses, found that 12% of COVID-19 survivors experienced cognitive impairment a year after discharge. Matteo Tosato, MD, PhD, head of the outpatient clinic for patients with long COVID symptoms at Gemelli Hospital in Rome, called those findings “very concerning.”

Jin Ho Han, MD, associate professor of emergency medicine at Vanderbilt University, Nashville, Tenn., said cognitive impairment is common after an acute illness, particularly in frail or vulnerable patients.

“Hospitalization and the acute illness itself accelerate cognitive decline,” said Dr. Han, and previous evidence links delirium with worsening cognition. He and his colleagues are studying the potential role of delirium in longer-term cognitive decline in older patients after COVID-19.

Dr. Han emphasized the importance of preventing COVID-19-related delirium through vaccines and other strategies to reduce exposure of older patients to the virus. “Once you have cognitive decline, there are no interventions to reverse it,” he said.
 

Alarm bells for long-term care

Experts expressed concern that the situation might be even worse for people living in long-term care facilities. Many already need assistance with tasks of daily living and could be particularly vulnerable to lasting effects of COVID-19, said Karl Steinberg, MD, president of the Society for Post-Acute and Long-Term Care Medicine. He estimated that roughly half of his patients who have had COVID-19, regardless of the severity of their symptoms, have endured some degree of functional decline.

“It’s common for long-term care facility residents to experience functional and cognitive decline, even after seemingly minor things, like a cold or a trip to the hospital,” Dr. Steinberg, who has been a medical director of long-term care facilities in San Diego County for more than 2 decades, told this news organization. “It makes it a little harder to determine whether the declines we’ve been seeing post COVID in these residents are attributable to post COVID versus just an accelerated step in their overall expected decline.”

The pandemic may have contributed to worse outcomes for people in long-term care facilities in several ways: the disease itself, its effects on health care delivery, and necessary preventive measures to protect long-term care residents from exposure to the virus.

“During the many months where family visits were prohibited, we saw people – whether they had COVID-19 or not – suffer major clinical, functional, cognitive declines or severe psychological symptoms,” Dr. Steinberg said.

He emphasized the importance of preventive measures such as vaccines and boosters in patients in long-term care facilities. He said the benefit of preventing lasting symptoms is often a strong motivator for family caregivers of people with dementia to get them vaccinated or boosted.

“It’s clear that vaccination and booster reduce the incidence of post-COVID symptoms,” he said. Almost all studies have been in younger cohorts, but he expects the benefits would also apply to older patients.
 

Easing symptoms and offering support

As with long COVID generally, many questions remain about the causes of lasting symptoms of COVID-19 in older patients, and how best to treat them. Dr. Tosato, who led the study of long-COVID patients in Rome, is focusing on inflammation as a critical factor in the condition. He and colleagues across Europe hope to answer some of them by launching a multicenter study of lasting COVID-19 symptoms. 

In the meantime, Dr. Steinberg and Dr. Tosato said they are doing their best to evaluate and treat patients empirically.

“We pull from our armamentarium to treat system-specific symptoms,” Dr. Steinberg said. “We want to improve the quality of life and help each day be the best it can.”

Physicians in long-term care facilities might use medications such as antidepressants or nonpharmacologic approaches for patients experiencing depression symptoms. Families are also crucial in helping patients by bringing in home-cooked meals and encouraging loved ones who may be experiencing loss of taste or smell to eat, Dr. Steinberg said.

“We’ve seen with the return of families and loved ones visiting to some extent has alleviated some people’s symptoms, especially psychological ones,” he said.

Dr. Tosato said he and his colleagues start with an individualized, multidisciplinary assessment to determine what types of care may help. He noted that physicians might recommend medications or rehabilitative therapies depending on the patient’s needs.

“A personalized approach is key,” Dr. Tosato said. His study also found that the proportion of older patients experiencing symptoms declined over time – a glimmer of hope that many will recover. 

Dr. Cohen emphasized the need for a multimodal rehabilitation, an evidence-based approach used to care for patients who survived hospitalization with severe COVID-19 – a group that has substantially higher rates of persistent symptoms. This approach includes cognitive rehabilitation, physical therapy, occupational therapy, and a graded exercise program.

Dr. Han and colleagues are studying potential therapies such as cognitive rehabilitation in adults who’ve experienced delirium. But until evidence-based treatments are available, they stress the role of support for patients with cognitive decline and their families.   

“A lot of the work we do is teach patients and their families to compensate for newly acquired cognitive deficits from any illness, including COVID-19,” Dr. Han said.

Ms. Salant said she has experienced some improvement in her energy since her pulmonologist recommended a new inhaler based on her symptoms. Her sense of smell and taste, lost to the infection, returned after she received her first dose of a vaccine against COVID-19. She takes comfort in participating in Survivor Corps, a group of more than 170,000 COVID-19 survivors and their families who advocate for more scientific research on the disease.

She also expressed gratitude for the support she receives from her primary care physician, who she said has taken the time to learn more about the symptoms of long COVID, listens to her, and respects what she has to say.

“I have hope that I will keep getting better by baby steps,” Ms. Salant said. 

Dr. Tosato, Dr. Steinberg, and Dr. Han have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Even mundane tasks such as making a meal can be exhausting for Louise Salant.

“I’m totally wiped out,” said the 71-year-old former private music instructor with asthma who lives in New York City and has been coping with debilitating symptoms of fatigue, shortness of breath, and gastrointestinal symptoms since recovering from a severe bout of COVID-19 2 years ago. “I just don’t have the energy.”

Ms. Salant is not alone. Many older people who contract COVID-19 experience prolonged symptoms of the disease. An analysis of Medicare Advantage claims data published in the BMJ found that about one-third of roughly 87,000 adults aged 65 in the database with a COVID-19 diagnosis sought care for persistent or new symptoms 21 or more days later.

That figure is about twice the rate of persistent COVID-19 related symptoms seen in a cohort of adults younger than age 65 with commercial insurance analyzed by the same group of researchers in a separate BMJ study. Compared with a 2020 comparator group of patients in this age cohort, these patients had a greater likelihood of respiratory failure, fatigue, hypertension, memory problems, kidney injury, mental health conditions, hypercoagulability, and cardiac rhythm disorders. When they compared post–COVID-19 symptoms to lasting symptoms of another serious viral disease – influenza – the researchers found that only respiratory failure, dementia, and post-viral fatigue were more common in the COVID-19 group.

“It became clear early in the pandemic that there is going to be a second pandemic related to all of the complications that we’ve seen related to COVID-19 infections,” said Ken Cohen, MD, executive director of translational research and national senior medical director for Optum Labs in Minnetonka, Minn., who coauthored the BMJ studies.

The results are among a growing body of evidence suggesting that older adults are at high risk of persistent post-COVID-19 symptoms.

Researchers in Rome, for example, found that 83% of 165 patients aged 65 or older who had been hospitalized for COVID-19 reported at least one lasting symptom – problems like fatigue, shortness of breath, joint pain, and coughing – in the months after hospitalization. One-third of those had two symptoms, and 46% had three or more.

A similar study in Norway found that two-thirds of patients aged 60 or older reported reduced health-related quality of life during follow-up visits 6 months after hospitalization for COVID-19. The most-reported impairments among those patients were the inability to perform the tasks of daily life, reduced mobility, and increased pain and discomfort.
 

Cognitive concerns

Mounting evidence indicates that COVID-19 may contribute to chronic cognitive impairment in older adults. A multisite U.S. study found that 28% of 817 adults presenting to emergency departments with COVID-19 had delirium and poorer outcomes. A Chinese case-control study that enrolled 1,438 individuals hospitalized in Wuhan for COVID-19, along with 438 of their uninfected spouses, found that 12% of COVID-19 survivors experienced cognitive impairment a year after discharge. Matteo Tosato, MD, PhD, head of the outpatient clinic for patients with long COVID symptoms at Gemelli Hospital in Rome, called those findings “very concerning.”

Jin Ho Han, MD, associate professor of emergency medicine at Vanderbilt University, Nashville, Tenn., said cognitive impairment is common after an acute illness, particularly in frail or vulnerable patients.

“Hospitalization and the acute illness itself accelerate cognitive decline,” said Dr. Han, and previous evidence links delirium with worsening cognition. He and his colleagues are studying the potential role of delirium in longer-term cognitive decline in older patients after COVID-19.

Dr. Han emphasized the importance of preventing COVID-19-related delirium through vaccines and other strategies to reduce exposure of older patients to the virus. “Once you have cognitive decline, there are no interventions to reverse it,” he said.
 

Alarm bells for long-term care

Experts expressed concern that the situation might be even worse for people living in long-term care facilities. Many already need assistance with tasks of daily living and could be particularly vulnerable to lasting effects of COVID-19, said Karl Steinberg, MD, president of the Society for Post-Acute and Long-Term Care Medicine. He estimated that roughly half of his patients who have had COVID-19, regardless of the severity of their symptoms, have endured some degree of functional decline.

“It’s common for long-term care facility residents to experience functional and cognitive decline, even after seemingly minor things, like a cold or a trip to the hospital,” Dr. Steinberg, who has been a medical director of long-term care facilities in San Diego County for more than 2 decades, told this news organization. “It makes it a little harder to determine whether the declines we’ve been seeing post COVID in these residents are attributable to post COVID versus just an accelerated step in their overall expected decline.”

The pandemic may have contributed to worse outcomes for people in long-term care facilities in several ways: the disease itself, its effects on health care delivery, and necessary preventive measures to protect long-term care residents from exposure to the virus.

“During the many months where family visits were prohibited, we saw people – whether they had COVID-19 or not – suffer major clinical, functional, cognitive declines or severe psychological symptoms,” Dr. Steinberg said.

He emphasized the importance of preventive measures such as vaccines and boosters in patients in long-term care facilities. He said the benefit of preventing lasting symptoms is often a strong motivator for family caregivers of people with dementia to get them vaccinated or boosted.

“It’s clear that vaccination and booster reduce the incidence of post-COVID symptoms,” he said. Almost all studies have been in younger cohorts, but he expects the benefits would also apply to older patients.
 

Easing symptoms and offering support

As with long COVID generally, many questions remain about the causes of lasting symptoms of COVID-19 in older patients, and how best to treat them. Dr. Tosato, who led the study of long-COVID patients in Rome, is focusing on inflammation as a critical factor in the condition. He and colleagues across Europe hope to answer some of them by launching a multicenter study of lasting COVID-19 symptoms. 

In the meantime, Dr. Steinberg and Dr. Tosato said they are doing their best to evaluate and treat patients empirically.

“We pull from our armamentarium to treat system-specific symptoms,” Dr. Steinberg said. “We want to improve the quality of life and help each day be the best it can.”

Physicians in long-term care facilities might use medications such as antidepressants or nonpharmacologic approaches for patients experiencing depression symptoms. Families are also crucial in helping patients by bringing in home-cooked meals and encouraging loved ones who may be experiencing loss of taste or smell to eat, Dr. Steinberg said.

“We’ve seen with the return of families and loved ones visiting to some extent has alleviated some people’s symptoms, especially psychological ones,” he said.

Dr. Tosato said he and his colleagues start with an individualized, multidisciplinary assessment to determine what types of care may help. He noted that physicians might recommend medications or rehabilitative therapies depending on the patient’s needs.

“A personalized approach is key,” Dr. Tosato said. His study also found that the proportion of older patients experiencing symptoms declined over time – a glimmer of hope that many will recover. 

Dr. Cohen emphasized the need for a multimodal rehabilitation, an evidence-based approach used to care for patients who survived hospitalization with severe COVID-19 – a group that has substantially higher rates of persistent symptoms. This approach includes cognitive rehabilitation, physical therapy, occupational therapy, and a graded exercise program.

Dr. Han and colleagues are studying potential therapies such as cognitive rehabilitation in adults who’ve experienced delirium. But until evidence-based treatments are available, they stress the role of support for patients with cognitive decline and their families.   

“A lot of the work we do is teach patients and their families to compensate for newly acquired cognitive deficits from any illness, including COVID-19,” Dr. Han said.

Ms. Salant said she has experienced some improvement in her energy since her pulmonologist recommended a new inhaler based on her symptoms. Her sense of smell and taste, lost to the infection, returned after she received her first dose of a vaccine against COVID-19. She takes comfort in participating in Survivor Corps, a group of more than 170,000 COVID-19 survivors and their families who advocate for more scientific research on the disease.

She also expressed gratitude for the support she receives from her primary care physician, who she said has taken the time to learn more about the symptoms of long COVID, listens to her, and respects what she has to say.

“I have hope that I will keep getting better by baby steps,” Ms. Salant said. 

Dr. Tosato, Dr. Steinberg, and Dr. Han have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Even mundane tasks such as making a meal can be exhausting for Louise Salant.

“I’m totally wiped out,” said the 71-year-old former private music instructor with asthma who lives in New York City and has been coping with debilitating symptoms of fatigue, shortness of breath, and gastrointestinal symptoms since recovering from a severe bout of COVID-19 2 years ago. “I just don’t have the energy.”

Ms. Salant is not alone. Many older people who contract COVID-19 experience prolonged symptoms of the disease. An analysis of Medicare Advantage claims data published in the BMJ found that about one-third of roughly 87,000 adults aged 65 in the database with a COVID-19 diagnosis sought care for persistent or new symptoms 21 or more days later.

That figure is about twice the rate of persistent COVID-19 related symptoms seen in a cohort of adults younger than age 65 with commercial insurance analyzed by the same group of researchers in a separate BMJ study. Compared with a 2020 comparator group of patients in this age cohort, these patients had a greater likelihood of respiratory failure, fatigue, hypertension, memory problems, kidney injury, mental health conditions, hypercoagulability, and cardiac rhythm disorders. When they compared post–COVID-19 symptoms to lasting symptoms of another serious viral disease – influenza – the researchers found that only respiratory failure, dementia, and post-viral fatigue were more common in the COVID-19 group.

“It became clear early in the pandemic that there is going to be a second pandemic related to all of the complications that we’ve seen related to COVID-19 infections,” said Ken Cohen, MD, executive director of translational research and national senior medical director for Optum Labs in Minnetonka, Minn., who coauthored the BMJ studies.

The results are among a growing body of evidence suggesting that older adults are at high risk of persistent post-COVID-19 symptoms.

Researchers in Rome, for example, found that 83% of 165 patients aged 65 or older who had been hospitalized for COVID-19 reported at least one lasting symptom – problems like fatigue, shortness of breath, joint pain, and coughing – in the months after hospitalization. One-third of those had two symptoms, and 46% had three or more.

A similar study in Norway found that two-thirds of patients aged 60 or older reported reduced health-related quality of life during follow-up visits 6 months after hospitalization for COVID-19. The most-reported impairments among those patients were the inability to perform the tasks of daily life, reduced mobility, and increased pain and discomfort.
 

Cognitive concerns

Mounting evidence indicates that COVID-19 may contribute to chronic cognitive impairment in older adults. A multisite U.S. study found that 28% of 817 adults presenting to emergency departments with COVID-19 had delirium and poorer outcomes. A Chinese case-control study that enrolled 1,438 individuals hospitalized in Wuhan for COVID-19, along with 438 of their uninfected spouses, found that 12% of COVID-19 survivors experienced cognitive impairment a year after discharge. Matteo Tosato, MD, PhD, head of the outpatient clinic for patients with long COVID symptoms at Gemelli Hospital in Rome, called those findings “very concerning.”

Jin Ho Han, MD, associate professor of emergency medicine at Vanderbilt University, Nashville, Tenn., said cognitive impairment is common after an acute illness, particularly in frail or vulnerable patients.

“Hospitalization and the acute illness itself accelerate cognitive decline,” said Dr. Han, and previous evidence links delirium with worsening cognition. He and his colleagues are studying the potential role of delirium in longer-term cognitive decline in older patients after COVID-19.

Dr. Han emphasized the importance of preventing COVID-19-related delirium through vaccines and other strategies to reduce exposure of older patients to the virus. “Once you have cognitive decline, there are no interventions to reverse it,” he said.
 

Alarm bells for long-term care

Experts expressed concern that the situation might be even worse for people living in long-term care facilities. Many already need assistance with tasks of daily living and could be particularly vulnerable to lasting effects of COVID-19, said Karl Steinberg, MD, president of the Society for Post-Acute and Long-Term Care Medicine. He estimated that roughly half of his patients who have had COVID-19, regardless of the severity of their symptoms, have endured some degree of functional decline.

“It’s common for long-term care facility residents to experience functional and cognitive decline, even after seemingly minor things, like a cold or a trip to the hospital,” Dr. Steinberg, who has been a medical director of long-term care facilities in San Diego County for more than 2 decades, told this news organization. “It makes it a little harder to determine whether the declines we’ve been seeing post COVID in these residents are attributable to post COVID versus just an accelerated step in their overall expected decline.”

The pandemic may have contributed to worse outcomes for people in long-term care facilities in several ways: the disease itself, its effects on health care delivery, and necessary preventive measures to protect long-term care residents from exposure to the virus.

“During the many months where family visits were prohibited, we saw people – whether they had COVID-19 or not – suffer major clinical, functional, cognitive declines or severe psychological symptoms,” Dr. Steinberg said.

He emphasized the importance of preventive measures such as vaccines and boosters in patients in long-term care facilities. He said the benefit of preventing lasting symptoms is often a strong motivator for family caregivers of people with dementia to get them vaccinated or boosted.

“It’s clear that vaccination and booster reduce the incidence of post-COVID symptoms,” he said. Almost all studies have been in younger cohorts, but he expects the benefits would also apply to older patients.
 

Easing symptoms and offering support

As with long COVID generally, many questions remain about the causes of lasting symptoms of COVID-19 in older patients, and how best to treat them. Dr. Tosato, who led the study of long-COVID patients in Rome, is focusing on inflammation as a critical factor in the condition. He and colleagues across Europe hope to answer some of them by launching a multicenter study of lasting COVID-19 symptoms. 

In the meantime, Dr. Steinberg and Dr. Tosato said they are doing their best to evaluate and treat patients empirically.

“We pull from our armamentarium to treat system-specific symptoms,” Dr. Steinberg said. “We want to improve the quality of life and help each day be the best it can.”

Physicians in long-term care facilities might use medications such as antidepressants or nonpharmacologic approaches for patients experiencing depression symptoms. Families are also crucial in helping patients by bringing in home-cooked meals and encouraging loved ones who may be experiencing loss of taste or smell to eat, Dr. Steinberg said.

“We’ve seen with the return of families and loved ones visiting to some extent has alleviated some people’s symptoms, especially psychological ones,” he said.

Dr. Tosato said he and his colleagues start with an individualized, multidisciplinary assessment to determine what types of care may help. He noted that physicians might recommend medications or rehabilitative therapies depending on the patient’s needs.

“A personalized approach is key,” Dr. Tosato said. His study also found that the proportion of older patients experiencing symptoms declined over time – a glimmer of hope that many will recover. 

Dr. Cohen emphasized the need for a multimodal rehabilitation, an evidence-based approach used to care for patients who survived hospitalization with severe COVID-19 – a group that has substantially higher rates of persistent symptoms. This approach includes cognitive rehabilitation, physical therapy, occupational therapy, and a graded exercise program.

Dr. Han and colleagues are studying potential therapies such as cognitive rehabilitation in adults who’ve experienced delirium. But until evidence-based treatments are available, they stress the role of support for patients with cognitive decline and their families.   

“A lot of the work we do is teach patients and their families to compensate for newly acquired cognitive deficits from any illness, including COVID-19,” Dr. Han said.

Ms. Salant said she has experienced some improvement in her energy since her pulmonologist recommended a new inhaler based on her symptoms. Her sense of smell and taste, lost to the infection, returned after she received her first dose of a vaccine against COVID-19. She takes comfort in participating in Survivor Corps, a group of more than 170,000 COVID-19 survivors and their families who advocate for more scientific research on the disease.

She also expressed gratitude for the support she receives from her primary care physician, who she said has taken the time to learn more about the symptoms of long COVID, listens to her, and respects what she has to say.

“I have hope that I will keep getting better by baby steps,” Ms. Salant said. 

Dr. Tosato, Dr. Steinberg, and Dr. Han have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The National Comprehensive Cancer Network (NCCN) has recommended a fifth COVID-19 mRNA shot for people who are immunocompromised, including many with cancer or a history of cancer.

A fifth shot of an mRNA vaccine represents a second booster, the group explained, because the primary mRNA immunization series for immunocompromised individuals involves three doses of either the Pfizer or Moderna vaccine.

The update, issued today, comes from the NCCN’s Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis, which released its first vaccine guidelines for patients with cancer in January 2021. The NCCN has issued numerous updates since then as information about the virus and vaccines has evolved. 

“We know a lot more about COVID-19 and the vaccines now, and we can use that knowledge to minimize the confusion and enhance the protection we can offer to our immunocompromised patients,” said advisory committee co-leader Lindsey Baden, MD, an infectious diseases specialist at the Dana-Farber Cancer Institute, Boston.

The latest iteration of the NCCN’s COVID guidelines includes an update for patients who initially received Johnson & Johnson’s single-shot vaccine, including a recommendation that patients receive an mRNA vaccine for both the first and second booster.

The group also updated dosing recommendations for pre-exposure prevention with tixagevimab plus cilgavimab (Evusheld, AstraZeneca), suggesting 300 mg of each monoclonal antibody instead of 150 mg, based on in vitro activity against Omicron variants.

The group noted that the Moderna and Pfizer shots can be used interchangeably for boosters.

“The NCCN Committee considers both homologous and heterologous boosters to be appropriate options,” the experts wrote.

A version of this article first appeared on Medscape.com.

The National Comprehensive Cancer Network (NCCN) has recommended a fifth COVID-19 mRNA shot for people who are immunocompromised, including many with cancer or a history of cancer.

A fifth shot of an mRNA vaccine represents a second booster, the group explained, because the primary mRNA immunization series for immunocompromised individuals involves three doses of either the Pfizer or Moderna vaccine.

The update, issued today, comes from the NCCN’s Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis, which released its first vaccine guidelines for patients with cancer in January 2021. The NCCN has issued numerous updates since then as information about the virus and vaccines has evolved. 

“We know a lot more about COVID-19 and the vaccines now, and we can use that knowledge to minimize the confusion and enhance the protection we can offer to our immunocompromised patients,” said advisory committee co-leader Lindsey Baden, MD, an infectious diseases specialist at the Dana-Farber Cancer Institute, Boston.

The latest iteration of the NCCN’s COVID guidelines includes an update for patients who initially received Johnson & Johnson’s single-shot vaccine, including a recommendation that patients receive an mRNA vaccine for both the first and second booster.

The group also updated dosing recommendations for pre-exposure prevention with tixagevimab plus cilgavimab (Evusheld, AstraZeneca), suggesting 300 mg of each monoclonal antibody instead of 150 mg, based on in vitro activity against Omicron variants.

The group noted that the Moderna and Pfizer shots can be used interchangeably for boosters.

“The NCCN Committee considers both homologous and heterologous boosters to be appropriate options,” the experts wrote.

A version of this article first appeared on Medscape.com.

The National Comprehensive Cancer Network (NCCN) has recommended a fifth COVID-19 mRNA shot for people who are immunocompromised, including many with cancer or a history of cancer.

A fifth shot of an mRNA vaccine represents a second booster, the group explained, because the primary mRNA immunization series for immunocompromised individuals involves three doses of either the Pfizer or Moderna vaccine.

The update, issued today, comes from the NCCN’s Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis, which released its first vaccine guidelines for patients with cancer in January 2021. The NCCN has issued numerous updates since then as information about the virus and vaccines has evolved. 

“We know a lot more about COVID-19 and the vaccines now, and we can use that knowledge to minimize the confusion and enhance the protection we can offer to our immunocompromised patients,” said advisory committee co-leader Lindsey Baden, MD, an infectious diseases specialist at the Dana-Farber Cancer Institute, Boston.

The latest iteration of the NCCN’s COVID guidelines includes an update for patients who initially received Johnson & Johnson’s single-shot vaccine, including a recommendation that patients receive an mRNA vaccine for both the first and second booster.

The group also updated dosing recommendations for pre-exposure prevention with tixagevimab plus cilgavimab (Evusheld, AstraZeneca), suggesting 300 mg of each monoclonal antibody instead of 150 mg, based on in vitro activity against Omicron variants.

The group noted that the Moderna and Pfizer shots can be used interchangeably for boosters.

“The NCCN Committee considers both homologous and heterologous boosters to be appropriate options,” the experts wrote.

A version of this article first appeared on Medscape.com.