Browsing by Author "Unroe, Kathleen"
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Item A comprehensive assessment of statin discontinuation among patients who concurrently initiate statins and CYP3A4-inhibitor drugs; a multistate transition model(Wiley, 2023) Donneyong, Macarius M.; Zhu, Yuxi; Zhang, Pengyue; Li, Yiting; Hunold, Katherine M.; Chiang, ChienWei; Unroe, Kathleen; Caterino, Jeffrey M.; Li, Lang; Medicine, School of MedicineAims: The aim of this study was to describe the 1-year direct and indirect transition probabilities to premature discontinuation of statin therapy after concurrently initiating statins and CYP3A4-inhibitor drugs. Methods: A retrospective new-user cohort study design was used to identify (N = 160 828) patients who concurrently initiated CYP3A4 inhibitors (diltiazem, ketoconazole, clarithromycin, others) and CYP3A4-metabolized statins (statin DDI exposed, n = 104 774) vs. other statins (unexposed to statin DDI, n = 56 054) from the MarketScan commercial claims database (2012-2017). The statin DDI exposed and unexposed groups were matched (2:1) through propensity score matching techniques. We applied a multistate transition model to compare the 1-year transition probabilities involving four distinct states (start, adverse drug events [ADEs], discontinuation of CYP3A4-inhibitor drugs, and discontinuation of statin therapy) between those exposed to statin DDIs vs. those unexposed. Statistically significant differences were assessed by comparing the 95% confidence intervals (CIs) of probabilities. Results: After concurrently starting stains and CYP3A, patients exposed to statin DDIs, vs. unexposed, were significantly less likely to discontinue statin therapy (71.4% [95% CI: 71.1, 71.6] vs. 73.3% [95% CI: 72.9, 73.6]) but more likely to experience an ADE (3.4% [95% CI: 3.3, 3.5] vs. 3.2% [95% CI: 3.1, 3.3]) and discontinue with CYP3A4-inhibitor therapy (21.0% [95% CI: 20.8, 21.3] vs. 19.5% [95% CI: 19.2, 19.8]). ADEs did not change these associations because those exposed to statin DDIs, vs. unexposed, were still less likely to discontinue statin therapy but more likely to discontinue CYP3A4-inhibitor therapy after experiencing an ADE. Conclusion: We did not observe any meaningful clinical differences in the probability of premature statin discontinuation between statin users exposed to statin DDIs and those unexposed.Item Age Differences in the Association Between Body Mass Index Class and Annualized Medicare Expenditures(SAGE, 2016-02) Clark, Daniel O.; Lane, Kathleen A.; Ambuehl, Roberta; Tu, Wanzhu; Liu, Chiung-Ju; Unroe, Kathleen; Callahan, Christopher M.; Department of Medicine, IU School of MedicineOBJECTIVE: The aim of the study is to assess the relationship between body mass index (BMI) class and Medicare claims among young-old (65-69), old (70-74), and old-old (75+) adults over a 10-year period. METHOD: We assessed costs by BMI class and age group among 9,300 respondents to the 1998 Health and Retirement Study (HRS) with linked 1998-2008 Medicare claims data. BMI was classified as normal (18.5-24.9), overweight (25-29.9), mild obesity (30-34.9), or severe obesity (35 or above). RESULTS: Annualized total Medicare claims adjusted for age, gender, ethnicity, education, and smoking history were 109% greater for severely obese young-old adults in comparison with normal weight young-old adults (US$9,751 vs. US$4,663). Total annualized claim differences between the normal weight and severely obese in the old and old-old groups were not statistically significant. DISCUSSION: Excess Medicare expenditures related to obesity may be concentrated among severely obese young-old adults. Preventing severe obesity among middle and older aged adults may have large cost implications for society.Item Attitudes and Experiences of Frontline Nursing Home Staff Towards Coronavirus Testing(2020) Hofschulte-Beck, Spencer L.; Hickman, Susan E.; Blackburn, Justin L.; Mack, Laramie M.; Unroe, Kathleen; Medicine, School of MedicineItem Characterizing Avoidability of Nursing Home Residents: Comparing the Claims-Based Algorithm and Nurse Assessment(Oxford University Press, 2022-12-20) Blackburn, Justin; Carnahan, Jennifer; Hickman, Susan; Sachs, Greg; Unroe, Kathleen; Health Policy and Management, School of Public HealthThe elevated risks associated with transferring nursing home residents to the hospital are problematic, but identifying which transfers can be avoided is complex. Using billing claims to determine “avoidability” based on hospital discharge diagnostic codes ignores resource constraints, clinical comorbidities, and asymmetrical information between nursing home staff making the transfer decision at the onset of clinical changes and hospital billing departments following treatment and diagnostic procedures. Conversely, relying on clinical staff assessments at the time of transfer may be an impractical and resource-intensive strategy to drive payment reform and improve quality. Using Medicare claims data representing emergency department and hospitalization transfers from 38 nursing facilities in Indiana from 2016-2020, we compared classification of transfers using a claims-based algorithm and trained nurse assessments of avoidability. Among 960 transfers, nurses judged 48.4% were potentially avoidable while 30.8% were classified as such using claims data. Of concordant assessments, 15.3% were avoidable and 36.0% as not avoidable. Of discordant assessments, 33.1% were judged avoidable by nurses only and 15.5% via the claims-based algorithm (Kappa=0.0153). Discordance was most frequent among transfers with heart failure (64%, n=42), psychosis (74.5%, n=34), acute renal disease (50%, n=28); and lowest among urinary tract infections (31.3%, n=64). No resident demographic or clinical characteristics were associated with discordance (age, race, sex, cognitive function scale, activities of daily living, or CHESS scale). High discordance in determining avoidability may be driven by presentation of symptoms or other condition-specific factors. Policies to reduce avoidable hospitalizations must not rely on overly simplistic approaches for identification.Item Clinical Courses and Characteristics of Residents During a SARS-CoV-2 Outbreak at a Central Indiana Skilled Nursing Facility(Indiana University, 2020-12) Albert, Lauren; Lieb, Kristi; Mack, Laramie; Unroe, Kathleen; Medicine, School of MedicineBackground/Objective: Older adults such as skilled nursing facility residents have increased risk of serious SARS-CoV-2 infection and comprise a large proportion of the COVID-19 pandemic’s deceased—the US Centers for Medicare & Medicaid Services report 232,831 cases and 38,518 resident deaths to date. Recent case reports reveal, as in other diseases, older adults may experience atypical symptomology, complicating identification of ill residents and efforts to slow transmission. While a few facility outbreaks have been characterized epidemiologically, little research exists regarding clinical timelines and trajectories which residents experience during COVID-19 illness. Methods: From May 9, 2020-June 1, 2020, daily notes on each COVID-19 positive resident’s status (n = 69) were taken by the medical director of a central Indiana nursing facility. Combined with a retrospective resident chart review of this same period, these notes were examined for COVID-19 infection symptoms and illness timelines to descriptively categorize a number of common illness trajectories and symptoms seen in residents with SARS-CoV-2 infection. Results: Residents fit four descriptive clinical timelines: concurrent symptom load with quick death (Avg 5.6 days) (n = 5), accumulating symptom load with gradual decline (Avg. 13.9 days) (n = 9), prolonged active symptom load with periods of stabilization and symptom reoccurrence (n = 42), and asymptomatic or atypical symptom load (n = 12). Most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. Of the 14 residents who died (20.3% of infected), 8 died in the facility and 6 died in the hospital. Conclusion and Implications: This retrospective case study adds to literature describing the presentation and symptomology of SARS-CoV-2 infection in residents of skilled nursing facilities and aids efforts to evaluate resident presentation, prognosis, and disease course. Robust descriptions of expected clinical courses may support realistic expectations of disease progression for residents and their family members experiencing future outbreaks.Item Conditions Associated with Successful Implementation of an Advance Care Planning Intervention in Nursing Homes(Oxford University Press, 2023-12-21) Hickman, Susan; Miech, Edward; Stump, Timothy; Mack, Laramie; Tu, Wanzhu; Unroe, Kathleen; School of NursingImplementing evidence-based interventions in nursing homes is challenging in part because clinical trials requiring a controlled experimental environment are difficult to sustain. In contrast, pragmatic clinical trials develop and evaluate evidence-based interventions in the “real world” with the goal of streamlining implementation after study completion. However, there is minimal information available identifying conditions associated with successful implementation of pragmatic interventions in the nursing home setting. The “Aligning Patient Preferences - a Role Offering Alzheimer’s patients, Caregivers, and Healthcare Providers Education and Support” (APPROACHES) project is a pragmatic trial designed to test and evaluate a staff-led advance care planning (ACP) intervention for residents with ADRD in 131 nursing homes (64 intervention, 67 control) between September 1, 2021 and August 31, 2022. ACP Specialists received training on ACP facilitation and implementation of the ACP program in the facility. Twenty of 65 (31%) sites successfully implemented the APPROACHES intervention and had > 75% of residents with documented ACP conversations. Using configurational analysis, we found two solutions directly linked with successful pragmatic implementation: (1) no executive director turnover during the observation period combined with site participation in monthly intervention support calls with ACP staff at other facilities; and (2) higher rates of hospitalization (3.96 – 7.2 per 1000 resident days) combined with a low number of certified beds. Findings suggest that leadership stability and engagement with peers were essential drivers of successful implementation. Having greater improvement opportunities as well as a more manageable caseload for the ACP Specialist may also help explain successful implementation.Item The Effects of Healthcare Service Disruptions on the Community, Healthcare Services and Access to Care(2022-08) Mills, Carol Ann; Blackburn, Justin; Holmes, Ann M.; Unroe, Kathleen; Yeager, Valerie A.Access to healthcare services is important for improving health outcomes, preventing and managing illness, and achieving health equity. The geographic maldistribution of physicians has a negative impact on rural areas compared to urban, particularly as it relates to access to healthcare. Rural hospitals have been closing or converting to another form of healthcare service at an increasing rate, adding another element to the existing complexities in rural access to care. Although a hospital closure in any location may have a considerable impact on the community, the closure of a rural hospital may have disproportionately more substantial implications for the economy and employment, health outcomes, and access to care. The contributing factors preceding rural hospital closures have been studied, but less is known about the full impact of rural hospital closures on the community. There is some evidence of shortages in healthcare providers and services, and therefore communities may employ multiple strategies to mitigate the shortages and provide services, including utilizing telehealth/virtual services. This dissertation proposes to examine the effects of rural hospital closures on the community, healthcare services, access to care, and provide a qualitative assessment of telehealth as a strategy to bridge gaps in provider access. This dissertation includes three studies: 1) a systematic review of the literature to examine the impact of rural hospital closures on the community; 2) an empirical study that utilizes a generalized difference in difference design with county and year fixed effects to estimate the relationship between rural hospital closures and nursing homes; and 3) a qualitative study exploring the perceptions and experiences of the nurses that piloted a virtual care support project, providing insights into crucial elements important to the implementation of similar models and the role of telehealth in bridging healthcare workforce gaps.Item Exploratory Factor Analysis of the Comfort Assessment in Dying With Dementia Scale(Oxford University Press, 2023-12-21) Zhang, Peiyuan; Stump, Timothy; Tu, Wanzhu; Becker, Todd; Orth, Jessica; Floyd, Alexander; Unroe, Kathleen; Cagle, John; Biostatistics and Health Data Science, Richard M. Fairbanks School of Public HealthThe 14-item Comfort Assessment in Dying with Dementia (CAD-EOLD) scale is a widely used instrument measuring end-of-life care for people with dementia (PWD). The instrument has been used to evaluate symptom burden among PWD in nursing homes, but the measurement properties are less studied for symptoms reported by family and staff caregivers. We conducted an exploratory factor analysis to evaluate the psychometric properties of the scale using staff and family (N=476) responses to CAD-EOLD at the baseline of an NIH-funded clinical trial. Subjects were long-stay nursing home residents with moderate-to-severe cognitive impairment in Indiana and Maryland. Staff (n=368) and family members (n=108) completed the CAD-EOLD, describing participating residents. We performed separate exploratory factor analyses on family and staff responses. Family and staff data showed similar clustering patterns. Restlessness, anxiety, fear, crying, and moaning had high factor loadings in the first cluster, interpreted as “Physical and Psychological Distress” (loading range = 0.47–0.91). Choking, gurgling, and difficulty swallowing had high loadings in the second cluster that depicted “Dying Symptoms” (loading range = 0.62–1.15). Serenity, calm, and peace had high loadings in the third factor on “Well-Being” (loading range = 0.72–0.93). Three “Physical Distress” items (i.e., discomfort, pain, and shortness of breath) cross-loaded with “Dying Symptoms.” Accordingly, “Physical and Psychological Distress,” “Dying Symptoms,” and “Well-Being” represented important but separate dimensions for measuring end-of-life experiences of PWD. Findings demonstrated favorable construct validity of CAD-EOLD in PWD with moderate-to-severe cognitive impairment in nursing homes, as reported by staff and family caregivers.Item Family Involvement and Symptom Burden in Nursing Home Residents with Cognitive Impairment(Oxford University Press, 2024-12-31) Tucker, Gretchen; Cagle, John; Stump, Timothy; Tu, Wanzhu; Zhang, Peiyuan; Floyd, Alex; Ersek, Mary; Unroe, Kathleen; Medicine, School of MedicineResearch suggests that family involvement improves the quality of life of nursing home residents. Using baseline data from an on-going multisite clinical trial (UPLIFT-AD), we examined the association between family involvement and staff-reported accounts of resident symptom burden. Symptom burden was measured as a composite of frequency and intensity of symptoms, using items from the End-of-Life Dementia (EOLD) scale. Higher scores indicate greater burden. Family involvement was measured by the family-reported average weekly in-person visit frequency over the past month (range 0-7 days). Data on 198 residents were collected, 61.9% of whom were in Indiana, with the remainder (38.1%) in Maryland. Of the 198 residents, 60.3% were female. The Brief Interview for Mental Status score, which indicates cognitive impairment level, was 6.5 (SD=3.9). Most family members were an adult child (58.7%), 7.9% were spouses, and 38.8% were “other.” On average, spouses visited 5 days a week, children 2 days a week, and other family members 1.5 days a week. In 53.5% of cases, the reporting staff member knew the resident for >1 year. Linear regression analysis was used to examine the associations between the frequency of in-person family visits and EOLD scores while adjusting for resident demographics, mental status, family relationship to the resident, and facility location. Visit frequency was associated with higher EOLD scores (B=0.18, p=.037). Findings suggest family involvement may sensitize nursing home staff to the presence of a resident’s burdensome symptoms, which may become more discernible to families with increased involvement.Item Front-line Nursing Home Staff Provide Insight on Advance Care Planning in a Crisis(Elsevier, 2022) Kaehr, Ellen; Gowan, Tayler; Unroe, Kathleen; Rattray, Nicholas; Hathaway, Elizabeth; Medicine, School of MedicineIntroduction/Objective: The dynamic changes stemming from the COVID-19 pandemic brought instability in advance care planning (ACP). ACP includes eliciting and documenting goals, values, and preferences for medical treatments, and requires considerable skill and resources. The goal of this study is to describe the nursing home staff experience with ACP including barriers and facilitators to goals of care discussions, which were revisited for all residents during nursing home COVID-19 outbreaks in 2020. Design/Methodology: This cross-sectional interview-based study interviewed 17 nursing home staff who facilitated ACP with residents and families during an initial COVID-19 outbreak, representing 7 Midwest nursing homes. Semi-structured telephone interviews were conducted (November 2020-April 2021), and included the Patient Health Questionaire-4 (PHQ4) and Impact of Event Scale-6 (IES-6) to explore the emotional impact of the pandemic. Qualitative thematic analysis was carried out to investigate the nursing home staff experience with goals of care discussions including the psychological impact on staff. Results: Nursing home staff described barriers to successful advance care planning in a crisis such as personal protective equipment (PPE), visitor restrictions, and lack of disease specific clinical knowledge. Self-reported stress was high, with 53% of participants screening positive for potential severe depression and anxiety (PHQ-4 total score ≥ 9) and 29% screening positive for possible post-traumatic stress disorder (PTSD) based on the IES-6 (mean score ≥ 1.75). Interview data offered evidence of the sources and nature of psychological impact of a COVID-19 outbreak. Participants experienced decreased stress when they reported increased knowledge, increased experience, decreased mortality, resolution of outbreak, and access to vaccination. Conclusion/Discussion: Nursing home staff described pandemic advance care planning as impersonal and uncomfortable compared to prior experiences. In future crises, maintaining in person conversations or equivalent interactions and supporting staff with adequate clinical knowledge and personal mental health resources is important in ACP.