Anthony J. Perkins

Background: Thirty‐day performance measures (e.g., unplanned readmissions), designed to evaluate inpatient care, were neither designed to reflect the experience of patients transitioning from hospital to home, nor the impact of transitional programs to improve postdischarge outcomes. Objective: To identify transitional care outcomes by examining a range of postdischarge encounters and mortality. Methods: This retrospective observational cohort (October 2022–September 2023) included community‐dwelling patients ≥65‐years‐old, discharged from 120 Department of Veterans Affairs (VA) hospitals to home after medical or neurological admissions. The outcomes, assessed 30‐ and 90‐days postdischarge were: mortality; planned and unplanned readmissions; observation stays; Emergency Department (ED) visits at VA or non‐VA hospitals; and number of days in acute care. Results: Among 99,778 patients, 71.1% had no acute care utilization within 30 days postdischarge; 49.9% in 90 days. Unplanned readmissions occurred in 14.4% ( N = 14,400) at 30 days; 27.5% ( N = 27,386) at 90 days. Mortality occurred in 1.8% ( N = 1750) within 30 days; 5.6% ( N = 5624) within 90 days. Mortality was highest among patients with unplanned readmissions: 30 days, 6.1% (882/14,400); 90 days, 13.1% (3599/27,386). Planned readmission mortality rates were 30 days, 5.8% (59/1017); 90 days, 9.6% (258/2692). Half of patients who died within 30 days postdischarge did so after an unplanned readmission (50.4% [882/1750]); 35.0% (613/1750) had no acute care utilization. Among N = 94,154 patients who survived 90‐day postdischarge, 11.2% spent ≥10 days in acute care settings. Conclusions: These findings support using the number of days in acute care within 90 days postdischarge as a transitional outcome. Thirty‐day readmissions do not capture the full scope of postdischarge healthcare utilization and mortality among community‐dwelling older adults.

The optimal induction regimen for pediatric liver transplantation (LT) in patients with Autoimmune Liver Disease (AILD) is not well-defined. This study compared outcomes between corticosteroids only, anti-thymocyte globulin (ATG), and IL-2 receptor antagonists (IL2RA; Basiliximab/Daclizumab). A retrospective review of 445 pediatric LT recipients with AILD (Autoimmune hepatitis, primary sclerosing cholangitis, or autoimmune sclerosing cholangitis) was conducted using the SPLIT database. Re-transplants were excluded. Primary outcomes included biopsy-confirmed rejection, culture-proven infection, graft loss, and mortality. Baseline demographics were comparable across groups. At 30 days post-LT, the IL2RA group demonstrated a significantly lower rate of biopsy-confirmed rejection (11.2%) compared to corticosteroids only (20.9%) and ATG (28%; p =0.05). Conversely, the ATG group experienced a significantly higher incidence of culture-proven infections between days 30–90 (42.9%) compared to corticosteroids only (10.2%) and IL2RA (17.9%; p =0.03). In multivariable-adjusted models, ATG induction was associated with a 10-fold higher risk of sub-acute culture-proven infection at 30–90 days (aOR=10.0, 95%CI: 1.4–71.8, p =0.02) compared to corticosteroids alone. However, neither ATG (aOR=0.47) nor IL-2RA (aOR=0.63) significantly altered the odds of early acute rejection at 0–30 days ( p >0.30). No significant differences were observed in graft loss, mortality, disease recurrence, or post-transplant lymphoproliferative disorder up to five years post-transplant. In pediatric AILD, induction with IL2RA significantly reduces early acute rejection without increasing infection risks or compromising long-term graft and patient survival.

Introduction: More than half of older adults living with Alzheimer’s disease and related dementias (ADRD) never receive a formal diagnosis, and when a diagnosis occurs, it is often years after symptom onset. Primary care clinicians are ideally positioned to detect ADRD early; however, current workflows lack scalable tools that support systematic identification and follow-up. The Passive Digital Marker (PDM), a machine learning model that uses structured electronic health record (EHR) data, can identify patients at elevated risk for ADRD without adding burden to clinicians. This protocol outlines a feasibility study to develop and evaluate a patient-informed secure messaging intervention paired with PDM-based risk stratification to enhance patient engagement in cognitive assessment in primary care settings. Methods and analysis: This will be a non-randomised pilot study conducted across 12 single health system primary care clinics. The PDM will be applied to EHR data to identify patients aged ≥65 years who are at high risk for ADRD. High-risk patients will receive a co-designed secure message prior to and after upcoming primary care visits encouraging follow-up evaluation with a trained nurse, the Brain Health Navigator (BHN). The primary objectives are to: (1) determine the feasibility of applying the PDM to EHR data across 12 primary care clinics; (2) assess the feasibility of engaging patients identified as positive on the PDM through secure text messaging prior to a primary care encounter and (3) evaluate engagement with the BHN following secure text messaging. Study outcomes will assess the feasibility of implementing the PDM and secure messaging workflow, including identification of high-risk patients using the PDM, message delivery and patient engagement measured through message open rates, completion of cognitive concern questions and appointments scheduled with the BHN. Quantitative data will be analysed using descriptive statistics. Ethics and dissemination: This study was deemed exempt as part of enhanced patient care. The findings will be disseminated through peer-reviewed publications, professional conferences, health system reports and public-facing communications. Trial registration number: NCT07016178 .

BACKGROUND: Many injury survivors experience persistent biopsychosocial morbidity after hospital discharge. The trauma medical home (TMH), a multidisciplinary coordinated care model, demonstrated modest benefit in a multicenter randomized trial, but its effectiveness across rural and socioeconomically deprived populations remains unclear. METHODS: This post hoc retrospective analysis of the TMH parent randomized trial included patients aged older than or equal to 50 years with an Injury Severity Score ≥9 across four level I trauma centers. For this study, patients were categorized by rurality and Area Deprivation Index (ADI). Outcomes included the SF-36 Physical and Mental Component Scores (PCS, MCS), depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety [Generalized Anxiety Disorder (GAD-7)], physical function [Short Physical Performance Battery (SPPB)], and health care utilization. Interaction effects between TMH and rural/urban status or ADI were evaluated at baseline, 6 months, and 12 months RESULTS: Four hundred thirty patients were included [216 TMH and 214 in usual care (UC)]. On the basis of urbanicity, the effectiveness of TMH on quality of life, psychological, physical, and health care utilization was similar at 6 and 12 months. ADI stratification showed greater differences. In high-ADI urban areas, baseline MCS scores were similar between TMH (47.5 ± 13.0) and UC (48.6 ± 12.8). By 6 months, TMH patients improved to 54.9 ± 8.8 compared with 49.0 ± 13.1 in UC, with a predicted difference of 7.7 (95% CI: 1.32, 12.83, P =0.016), demonstrating a clinically and statistically significant benefit of TMH CONCLUSIONS: The TMH was associated with greater mental health improvement among patients with high area deprivation, particularly in urban settings, suggesting a potential role in reducing disparities through coordinated care. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III

Introduction: The Trauma Medical Home (TMH) randomized clinical trial tested the efficacy of a collaborative care intervention on the biopsychosocial recovery of older injured adults compared to usual care. Study enrollment occurred between 11 October 2017 and 13 October 2021 and study operations were impacted by the COVID-19 pandemic. It is important to measure the potential effects of COVID-19 on research study participants to ensure accurate reporting of results. The purpose of this secondary analysis was to compare depression and anxiety symptoms and health-related quality of life in older adults at TMH study enrollment pre-COVID-19 and during COVID-19. We hypothesized that those enrolled during COVID-19 would have worse symptoms and quality of life. Methods: This study was a secondary analysis of data from a multicenter randomized clinical trial (R01AG052493-01A1) TMH, that examined the ability of a collaborative care model to enhance the recovery of older injured adults compared to usual care. It was hypothesized that the TMH intervention would improve biopsychosocial recovery for injured older adults compared to usual care. The enrollment periods pre-COVID-19 and during COVID-19 were compared. Chi-square tests and Wilcoxon Rank Sum tests, then multivariable linear and logistic regressions were completed with SF-36 component scores and depression (PHQ-9) and anxiety (GAD-7) scores as the dependent variables, respectively. Results: A total of 429 participants were analyzed. There was no significant difference in anxiety and depression symptoms between the pre-COVID-19 and during-COVID-19 enrollment periods. Perceived limitations due to physical health problems were worse for those enrolled during COVID-19 (adjusted β = −9.8, 95% CI −18.3 to −1.4), but other health-related quality of life measures were similar between the two groups. Conclusions: These findings support the conclusion that the negative psychological impacts of the pandemic are likely due to individual factors other than age or COVID-19. These results suggest a high degree of psychological resiliency in older adults under stress. Future research should focus on the potential effects of socioeconomic status, demographic background, and level of physical functioning on psychological outcomes.

INTRODUCTION: Little is known about the effect of proton-pump inhibitor (PPI) metabolism, based on CYP2C19 genotype, on treatment response in pediatric eosinophilic esophagitis (EoE). METHODS: We conducted a cohort study of pediatric subjects with active histologic EoE treated with PPI therapy. Whole blood samples were tested for CYP2C19 genotype. RESULTS: Among subjects prescribed high dose PPI > 1 mg/kg/d, intermediate/slow PPI metabolizers were significantly more likely to have histologic response to PPI therapy compared with normal and rapid PPI metabolizers. No ultrarapid metabolizers responded to PPI therapy. DISCUSSION: Knowing CYP2C19 genotype may optimize PPI dose for the treatment of EoE in individual patients.

IMPORTANCE: Delirium is a neuropsychiatric syndrome characterized by fluctuating disturbances in attention and awareness, associated with worse clinical outcomes and higher mortality. Previous research studies have noted an association between geographic disadvantage and delirium, but it is unknown if this association extends to critically ill adults. OBJECTIVES: This study aimed to explore the relationship between geographic disadvantage and ICU delirium characteristics. DESIGN, SETTING, AND PARTICIPANTS: We performed a secondary analysis of data collected from an National Institutes of Health-funded clinical trial, the Pharmacologic Management of Delirium study. Adults 18 years old or older admitted to the ICU who experienced delirium based on the Confusion Assessment Method for the ICU (CAM-ICU) were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The study population included 326 participants: 54.5% were female and 48% Black, with a mean age of 60.3 years, mean Acute Physiology and Chronic Health Evaluation II score of 20, and in-hospital mortality rate of 12.3%. The area deprivation index (ADI), a composite measure of geographic disadvantage derived from census data that yields a national percentile score ranging from 1 to 100 (with higher scores representing greater disadvantage), was obtained for each participant’s address. Main outcome variables included delirium duration, which was assessed by the number of delirium- and coma-free days (DCFDs), and delirium severity, which was assessed by mean CAM-ICU-7 scores. Analysis of covariance models were used to examine differences in DCFDs and mean CAM-ICU-7 scores between ADI quintiles while controlling for demographic and clinical variables. Other clinical outcomes of interest included discharge home rates and in-hospital mortality. The sample was heavily skewed toward higher national ADI percentile scores (indicating greater disadvantage); only 11.7% of patients had an ADI score lower than 50. Our regression analyses did not reveal any associations between ADI quintile and DCFDs or mean CAM-ICU-7 scores, or between ADI quintile and discharge home rates or in-hospital mortality. However, the Black race was associated with longer delirium duration and greater delirium severity in the first week of ICU hospitalization. CONCLUSIONS: Our study did not find an association between geographic disadvantage and delirium duration or severity in the ICU. However, an association with race was observed, highlighting the need for further research into how socioeconomic determinants of health relate to delirium.

Background: Sleep disturbances are common among older adults recovering from traumatic injury and are associated with delayed psychological and functional recovery. Despite their prevalence, few studies have examined sleep disturbances early after injury in this population. This study evaluated the prevalence of self-reported sleep disturbances among older trauma survivors using PROMIS-based assessments within the Trauma Medical Home (TMH) care model to identify modifiable factors that may inform early, patient-centered interventions. Methodology: In this cross-sectional study, we conducted a secondary analysis of data from the Collaborative Care for Injured Older Adults: The Trauma Medical Home Randomized Clinical Trial (TMH) study. 144 patients 50 years of age and older admitted for traumatic injury into four trauma centers reported their sleep quality using Patient-Reported Outcomes Measurement Information System Sleep Disturbance Short Form 4a (PROMIS-SF). Symptoms of depression and anxiety were assessed using the Hospital Anxiety and Depression Scale (HADS), of post-traumatic stress using Post Traumatic Stress Disorder (PTSD) Checklist-Civilian Version (PCL-C), and pain intensity using Pain, Enjoyment of Life, and General Activity Scale (PEG) scale. Comorbidities were quantifiedusing the Charlson Comorbidity Index (CCI), and trauma severity using the Injury Severity Score (ISS). Logistic regression was used to examine associations between sleep disturbances and psychological and clinical factors. Results: Approximately 22% of patients reported sleep disturbances. Patients with PTSD or pain symptoms had significantly higher odds of reporting sleep disturbances (OR for PTSD = 13.21, 95% CI = [2.90, 61.17], p = 0.001; OR for pain = 1.33, 95% CI = [1.11, 1.60], p = 0.002). Conclusion: This study extends prior research by focusing on older adult trauma survivors and assessing sleep disturbances during the immediate post-injury period using PROMIS-based patient-reported outcomes within the Trauma Medical Home (TMH) care model. This approach provides new insight into early, multidimensional symptom patterns and identifies modifiable factors that can inform timely, patient-centered interventions to improve recovery.