James S. Goodwin

Introduction: Operationalizing multi-site Community Engagement (CE) Studios to inform a research program is valuable for researchers. We describe the process and outcomes of hosting three CE Studios with Community Experts aged 65 years or older with chronic conditions and care partners of older adults. Experts gave feedback about processes for testing the feasibility, efficacy, effectiveness, and implementation of audio recording clinic visits and sharing recordings with patients who have multimorbidity and their care partners. Methods: The CE Cores of the Clinical and Translational Science Awards Programs at three academic health science centers created a joint CE Studio guide. Studios were conducted iteratively by site. Following receipt of the final reports, responses were compared to find themes, similarities, and differences on four topics in addition to overall commentary: Recruitment and Retention, Study Protocol, Study Reminders and Frequency, and Recording Technology. Results: Eighteen older adults and care partners in three states provided valuable feedback to inform multi-site trials. Feedback influenced multiple aspects of trials in process or subsequently funded. Experts provided critique on the wording of study invitations, information sheets, and reminders to engage in study procedures. Experts were concerned for participants being disappointed by randomization to a control arm and advised how investigators should prepare to address that. Conclusions: Multi-site CE Studios should be consecutive, so each team can learn from the previous teams. Using the CES Toolkit ensures that final reports were easily comparable and utilized to develop a research program that now includes three federally funded clinical trials.

Early in the COVID-19 pandemic, in response to hospital overcrowding, some state governments mandated that nursing homes could not refuse patients

Background: An increasing number of older adults with traumatic brain injury (TBI) require hospitalization, but it is unknown whether they return to their community following discharge. We examined community residence following acute hospital discharge for TBI in Texas and identified factors associated with 90‐day community residence and readmission. Methods: We conducted a retrospective cohort study using 100% Texas Medicare claims data of patients older than 65 years hospitalized for a TBI from January 1, 2014, through December 31, 2017, and followed for 20 weeks after discharge. Discharges to short‐term and long‐term acute hospital, inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long‐term nursing home (NH), and hospice were identified. The primary outcome was 90‐day community residence. Our secondary outcome was 90‐day, all‐cause readmission. Results: In Texas, 26,985 Medicare fee‐for‐service patients were hospitalized for TBI (Racial and ethnic minorities: 21.1%; Females 57.3%). At 90 days and 20 weeks following discharge, 80% and 84% were living in the community respectively. Female sex (OR = 1.16 [1.08–1.25]), Hispanic ethnicity (OR = 2.01 [1.80–2.25]), “other” race (OR = 2.19 [1.73–2.77]), and prior primary care provider (PCP; OR = 1.51 [1.40–1.62]) were associated with increased likelihood of 90‐day community residence. Patients aged 75+, prior NH residence, dual eligibility, prior TBI diagnosis, and moderate‐to‐severe injury severity were associated with decreased likelihood of 90‐day community residence. Being non‐Hispanic Black (HR = 1.33 [1.20–1.46]), discharge to SNF (HR = 1.56 [1.48–1.65]) or IRF (HR = 1.49 [1.40–1.59]), having prior PCP (HR = 1.23 [1.17–1.30]), dual eligibility (HR = 1.11 [1.04–1.18]), and prior TBI diagnosis (HR = 1.05 [1.01–1.10]) were associated with increased risk of 90‐day readmission. Female sex and “other” race were associated with decreased risk of 90‐day readmission. Conclusions: Most older adults with TBI return to the community following hospital discharge. Disparities exist in returning to the community and in risk of 90‐day readmission following hospital discharge. Future studies should explore how having a PCP influences post‐hospital outcomes in chronic care management of older patients with TBI.

Early in the COVID-19 pandemic, rates for all cancer screening tests were severely depressed, including mammography, colonoscopy and low-dose computed tomography (LDCT).^1-9 The decrease in screening resulted in decreases in the rates of cancer diagnoses; specifically, a lower rate of diagnoses of early-stage cancer.^3,10,11 This early decrease in screening was followed by a period of recovery, with rates returning to normal or near-normal in the summer of 2020.^1,4,6,12-15

This study used data from Medicare claims to update and internally validate revised weights to the 38 comorbidities comprising the Agency for Healthcare Research and Quality (AHRQ) Elixhauser comor... Background: Older adults have many comorbidities contributing to mortality. Objective: To develop a summary Elixhauser (S-Elixhauser) comorbidity score to predict 30-day, in-hospital, and 1-year mo...

Background: Psychiatric illness may pose an additional risk of death for older adults during the COVID‐19 pandemic. Older adults in the community versus institutions might be influenced by the pandemic differently. This study examines excess deaths during the COVID‐19 pandemic among Medicare beneficiaries with and without psychiatric diagnoses (depression, anxiety, bipolar disorder, and schizophrenia) in the community versus nursing homes. Methods: This is a retrospective cohort study of a 20% random sample of 15,229,713 fee‐for‐service Medicare beneficiaries, from January 2019 through December 2021. Unadjusted monthly mortality risks, COVID‐19 infection rates, and case‐fatality rates after COVID‐19 diagnosis were calculated. Excess deaths in 2020, compared to 2019 were estimated from multivariable logistic regressions. Results: Of all included Medicare beneficiaries in 2020 ( N = 5,140,619), 28.9% had a psychiatric diagnosis; 1.7% lived in nursing homes. In 2020, there were 246,422 observed deaths, compared to 215,264 expected, representing a 14.5% increase over expected. Patients with psychiatric diagnoses had more excess deaths than those without psychiatric diagnoses (1,107 vs. 403 excess deaths per 100,000 beneficiaries, p < 0.01). The largest increases in mortality risks were observed among patients with schizophrenia (32.4% increase) and bipolar disorder (25.4% increase). The pandemic‐associated increase in deaths with psychiatric diagnoses was only found in the community, not in nursing homes. The increased mortality for patients with psychiatric diagnoses was limited to those with medical comorbidities. The increase in mortality for psychiatric diagnoses was associated with higher COVID‐19 infection rates (1‐year infection rate = 7.9% vs. 4.2% in 2020), rather than excess case fatality. Conclusions: Excess deaths during the COVID‐19 pandemic were disproportionally greater in beneficiaries with psychiatric diagnoses, at least in part due to higher infection rates. Policy interventions should focus on preventing COVID‐19 infections and deaths among community‐dwelling patients with major psychiatric disorders in addition to those living the nursing homes.

The increase in all-cause mortality in the United States during the SARS-CoV-2 pandemic is not entirely explained by deaths from SARS-CoV-2 infection.^1,2 Since the beginning of the pandemic, hospital admissions for non–SARS-CoV-2 diseases declined markedly and mortality rates increased.^3-13 In the United States and other countries, areas with higher SARS-CoV-2 prevalence or higher proportions of low-income or racial and ethnic minority residents had larger increases in deaths from non–SARS-CoV-2 causes.^2,3,14 Avoidance of emergency care by patients owing to concern for risk of SARS-CoV-2 infection, stay-at-home orders, decreases in surveillance, and other barriers to access to medical care most certainly contributed to excess deaths.^15-19 Approximately 4 of 10 US adults delayed or avoided medical care by the end of June 2020 owing to concerns about SARS-CoV-2.¹⁶

In this issue of JAMA Internal Medicine, Kato et al¹ assessed readmission and mortality rates in patients cared for by hospitalists, stratifying the hospitalists by how many days in a year they billed for services. Patients with hospitalists who worked fewer days had higher mortality, while readmission rates were not associated with how many days the hospitalist saw patients in the year. The association of number of working days with mortality was independent of hospitalists’ age and gender, and of the teaching status of the hospital, while there was a trend for a larger association among patients with more severe illness. The authors include an impressive number of secondary and sensitivity analyses to allow the reader a more complete picture of the extent of and limits to their findings. Identify all potential conflicts of interest that might be relevant to your comment. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. Err on the side of full disclosure. If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response. Not all submitted comments are published. Please see our commenting policy for details.