Emerson, Jane A.

AbstractIntroductionEfforts to model the cost‐effectiveness of managing/modifying cognitive impairment lack reliable, objective, baseline medical, and nursing‐home (NH) costs.MethodsA stratified‐random sample of Olmsted County, MN, residents ages 70–89 years (N = 3545), well‐characterized as cognitively unimpaired, mild cognitive impairment (MCI), or dementia, were followed forward ≤1 year in provider‐linked billing data and the Centers for Medicare & Medicaid Services NH assessments. Direct medical/nursing home/medical + NH costs were estimated. Costs were stratified by vital status and NH‐use intensity (NH days/follow‐up days [0%, 1% to 24%, 25% to 99%, and 100%]). Between‐category mean‐annual cost differences were adjusted for patient characteristics and follow‐up days.ResultsCosts/follow‐up day distributions differed significantly across cognitive categories. Mean costs/follow‐up days were 2.5 to 18 times higher for decedents versus survivors. Among all persons with MCI, <9% with any NH use accounted for 18% of all total annual medical + NH costs. Adjusted‐between‐category comparisons revealed significantly higher medical and medical + NH costs for MCI versus cognitively unimpaired.DiscussionCost‐effectiveness for managing/modifying both MCI and dementia should consider end‐of‐life costs and NH‐use intensity. Results can help inform cost‐effectiveness models, predict future‐care needs, and aid decision‐making by individuals/providers/payers/policymakers.

The importance of coronary artery disease (CAD) surveillance, as recently underscored by the American Heart Association, is heightened by the obesity/diabetes epidemics. The need for surveillance is especially great for subclinical CAD, as the greatest increases in obesity/diabetes are occurring among younger age groups, where clinically-recognized CAD is infrequent. Yet few methods for such population-based surveillance exist. Using one such method, unbiased heart autopsy data, we previously showed that declines in grade of CAD observed since 1981 ended in the mid-1990s and may have reversed. In order to assess and interpret the factors underlying these observations, it is necessary to first examine trends in CAD risk factors among heart autopsied decedents and investigate the extent to which they mirror trends in the general population. Rochester Epidemiology Project (REP) medical records linkage resources were used to identify 1) all Olmsted County residents age 16-64 years who died from non-natural causes and went to autopsy 1981-2009 (96% autopsy rate) and 2) all Olmsted County residents age 16-64 years 1981-2009. We randomly selected two population subjects per decedent, stratified by calendar year. All REP inpatient/ ambulatory records were reviewed for CAD risk factors. Compared to population subjects, decedents were older and more likely to be male, smokers, alcohol abusers, and treated for hypertension; however, risk factor trends for both groups were generally of similar magnitude and direction, i.e., smoking, alcohol use, and blood pressure declined and anti-hypertensive medication use, diagnosed hyperlipidemia, and body mass index increased ( Table ). These population-based longitudinal data indicate that temporal trends in risk factors among autopsied decedents parallel those for the general population, supporting the concept that data on autopsied decedents can provide insight into trends in CAD risk and the changing burden of atherosclerosis within the source population. Characteristics of all 1) non-elderly adult Olmsted County residents who died non-natural deaths and were autopsied and 2) non-elderly adult Olmsted County residents with respect to CAD risk factors and calendar year trends CAD Risk Factor Autopsied Decedents (N=315) Population Subjects (N=672) P Value Autopsied Decedents, Temporal Trend Population Subjects, Temporal Trend N Calendar Year Estimate P value N Calendar Year Estimate P Value Age at Index, Mean (SD) 37.5 (14.0) 34.1 (13.6) <0.01 1 315 0.172 0.06 1 672 −0.059 0.33 1 Sex, % Male 236 (75%) 339 (50%) <0.01 2 315 0.008 0.60 2 672 −0.008 0.39 2 Race, % Non-White 29 (9%) 85 (13%) 0.14 3 305 0.054 0.04 3 589 0.023 0.12 3 Of Ever Smokers, Current = Yes 128/184 (70%) 118/210 (56%) 0.01 3 184 −0.040 0.048 3 210 −0.052 <0.01 3 Of Ever Alcohol Use, Current = Yes 175/238 (74%) 284/364 (78%) 0.08 3 238 −0.065 <0.01 3 364 −0.027 0.09 3 Mention of Alcoholism, Yes 80 (25%) 41 (6%) <0.01 3 315 0.014 0.35 3 672 0.042 0.04 3 Closest Systolic BP, Mean (SD) 124.1 (16.6) 120.3 (15.7) 0.34 3 285 −0.179 0.09 3 600 −0.156 0.02 3 Closest Diastolic BP, Mean (SD) 76.2 (11.6) 74.0 (10.5) 0.53 3 285 −0.194 0.01 3 600 −0.112 0.02 3 Closest BP on Medication, Yes 44 (14%) 36 (5%) <0.01 3 283 0.046 0.03 3 599 0.063 <0.01 3 Hyperlipidemia Diagnosis, Yes 32 (10%) 65 (10%) 0.32 3 315 0.114 <0.01 3 672 0.078 <0.01 3 Closest Fasting Glucose, Mean (SD) 95.8 (26.0) 95.0 (27.6) 0.63 3 177 0.270 0.23 3 335 0.505 <0.01 3 Closest BMI, Mean (SD) 26.1 (5.8) 25.9 (5.4) 0.52 3 280 0.080 0.04 3 593 0.091 <0.01 3 1 Unadjusted, Chi-square; 2 Unadjusted, Wilcoxon rank sum test; 3 Adjusted for age and sex, linear or logistic regression; BP = Blood Pressure; BMI = Body Mass Index

AbstractNursing home (NH) residency is an independent risk factor for venous thromboembolism (VTE), but the VTE burden within the NH population is uncertain. This study estimates VTE incidence and VTE-associated mortality among NH residents. We identified all NH residents in any NH in Olmsted County, Minnesota, United States, 1 October 1998 to 31 December 2005 and all first lifetime VTE among county residents to estimate VTE incidence while resident of local NHs (NHVTE), using Centers for Medicare and Medicaid Services Minimum Data Set and Rochester Epidemiology Project resources. We tested associations between NHVTE and age, sex and time since each NH admission using Poisson modelling. Additionally, we tested incident NHVTE as a potential predictor of survival using Cox proportional hazards, adjusting for age, sex and NH residency. Between 1 October 1998 and 31 December 2005, 3,465 Olmsted County residents with ≥1 admission to a local NH, contributed 4,762 NH stays. Of the 3,465 NH residents, 111 experienced incident NHVTE (2.3% of all eligible stays), for an overall rate of 3,653/100,000 NH person-years (NH-PY). VTE incidence was inversely associated with time since each NH admission, and was highest in the first 7 days after each NH admission (18,764/100,000 NH-PY). The adjusted hazard of death for incident NHVTE was 1.90 (95% confidence interval [CI]: 1.38–2.62). In conclusion, VTE incidence among NH residents was nearly 30-fold higher than published incidence rates for the general Olmsted County population. VTE incidence was highest within 7 days after NH admission, and NHVTE was associated with significantly reduced survival. These data can inform future research and construction of clinical trials regarding short-term prophylaxis.

Background/objectives Objective, complete estimates of nursing home ( NH ) use across the spectrum of cognitive decline are needed to help predict future care needs and inform economic models constructed to assess interventions to reduce care needs. Design Retrospective longitudinal study. Setting Olmsted County, MN . Participants Mayo Clinic Study of Aging participants assessed as cognitively normal ( CN ), mild cognitive impairment ( MCI ), previously unrecognized dementia, or prevalent dementia (age = 70–89 years; N = 3,545). Measurements Participants were followed in Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) NH records and in Rochester Epidemiology Project provider‐linked medical records for 1‐year after assessment of cognition for days of observation, NH use (yes/no), NH days, NH days/days of observation, and mortality. Results In the year after cognition was assessed, for persons categorized as CN , MCI , previously unrecognized dementia, and prevalent dementia respectively, the percentages who died were 1.0%, 2.6%, 4.2%, 21%; the percentages with any NH use were 3.8%, 8.7%, 19%, 40%; for persons with any NH use, median NH days were 27, 38, 120, 305, and median percentages of NH days/days of observation were 7.8%, 12%, 33%, 100%. The year after assessment, among persons with prevalent dementia and any NH use, >50% were a NH resident all days of observation. Pairwise comparisons revealed that each increase in cognitive impairment category exhibited significantly higher proportions with any NH use. One‐year mortality was especially high for persons with prevalent dementia and any NH use (30% vs 13% for those with no NH use); 58% of all deaths among persons with prevalent dementia occurred while a NH resident. Conclusions Findings suggest reductions in NH use could result from quality alternatives to NH admission, both among persons with MCI and persons with dementia, together with suitable options for end‐of‐life care among persons with prevalent dementia.

Background Our previous study of nonelderly adult decedents with nonnatural (accident, suicide, or homicide) cause of death (96% autopsy rate) between 1981 and 2004 revealed that the decline in subclinical coronary artery disease ( CAD ) ended in the mid‐1990s. The present study investigated the contributions of trends in obesity and diabetes mellitus to patterns of subclinical CAD and explored whether the end of the decline in CAD persisted. Methods and Results We reviewed provider‐linked medical records for all residents of Olmsted County, Minnesota , who died from nonnatural causes within the age range of 16 to 64 years between 1981 and 2009 and who had CAD graded at autopsy. We estimated trends in CAD risk factors including age, sex, systolic blood pressure, diabetes (qualifying fasting glucose or medication), body mass index, smoking, and diagnosed hyperlipidemia. Using multiple regression, we tested for significant associations between trends in CAD risk factors and CAD grade and assessed the contribution of trends in diabetes and obesity to CAD trends. The 545 autopsied decedents with recorded CAD grade exhibited significant declines between 1981 and 2009 in systolic blood pressure and smoking and significant increases in blood pressure medication, diabetes, and body mass index ≥30 kg/m 2 . An overall decline in CAD grade between 1981 and 2009 was nonlinear and ended in 1994. Trends in obesity and diabetes contributed to the end of CAD decline. Conclusions Despite continued reductions in smoking and blood pressure values, the previously observed end to the decline in subclinical CAD among nonelderly adult decedents was apparent through 2009, corresponding with increasing obesity and diabetes in that population.

Abstract Background Objective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild cognitive impairment (MCI), newly discovered dementia, and prevalent dementia. Methods Subjects were a subset of the Mayo Clinic Study of Aging stratified‐random sampling of Olmsted County, MN, residents aged 70 to 89 years. A neurologist reviewed provider‐linked medical records to identify prevalent dementia (review date = index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly discovered dementia (assessment date = index). Costs for medical services/procedures 1‐year pre‐index (excluding indirect and long‐term care costs) were estimated using line‐item provider‐linked administrative data. We estimated contributions of care‐delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between‐category cost differences. Results Annual mean medical costs for CN, MCI, newly discovered dementia, and prevalent dementia were $6042, $6784, $9431, $11,678, respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age‐, sex‐, education‐adjusted differences reached significance for CN versus newly discovered and prevalent dementia and for MCI versus prevalent dementia. After considering all comorbid diagnoses, between‐category differences were reduced (e.g., prevalent dementia minus MCI (from $4842 to $3575); newly discovered dementia minus CN (from $3578 to $711)). Following the exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between‐category differences tended to revert to greater differences. Conclusions Cost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co‐occurring mental disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost‐effective.