Publications

Abstract

Purpose: Ineffective communication and limited autonomy frequently lie at the core of negative birth experiences. Numerous studies indicate a need to improve decision-making with a deliberate shift towards person-centered care. Thus, it is imperative to study the determinants of autonomy-depriving decision-making and ineffective communication through both provider and birthing people perspectives. Our study explores providers’ perceptions of and attitudes towards decision-making in birth, particularly regarding person-centeredness, autonomy, informed consent, and decision-making capacity. We conducted a qualitative interview study and employed reflexive thematic analysis. In total, 15 Swiss providers from birth hospitals and birth centers participated. Results: Analysis resulted in the development of three themes and eight subthemes. First, the “otherness of birth” encompasses providers' perception of birth as a clinical situation that is fundamentally different from other clinical situations. Second, the otherness of birth goes along with an “ethical fading”, that is ethical dimensions – to some extent – fade into the background as they are obscured by various circumstances that are related to birth, birthing people, and providers. Third, the “physiology-pathology-dichotomy” describes the permeative power of this dichotomy with respect to providers’ decision-making approaches and their normative weighing of ethical principles. Conclusions: Decision-making in birth is a critical factor in the actualization of autonomy and characterized by bioethical complexity. Our study reveals important insights into how autonomy-depriving decision-making and ineffective communication unfolds in birth. Our findings provide a framework for future research and yield points of leverage for enhancing decision-making in birth.

Abstract

Background: The COVID-19 pandemic had its first peak in the United States between April and July of 2020, with incidence and prevalence rates of the virus the greatest in the northeastern coast of the country. At the time of study implementation, there were few studies capturing the perspectives of nurses working the frontlines of the pandemic in any setting as research output in the United States focused largely on treating the disease. Objective: The purpose of this study was to capture the perspectives of nurses in the United States working the frontlines of the COVID-19 pandemic's first wave. We were specifically interested in examining the impact of the pandemic on nurses' roles, professional relationships, and the organizational cultures of their employers. Design: We conducted an online qualitative study with a pragmatic design to capture the perspectives of nurses working during the first wave of the United States COVID-19 pandemic. Through social networking recruitment, frontline nurses from across the country were invited to participate. Participants provided long form, text-based responses to four questions designed to capture their experiences. A combination of Latent Dirichlet Allocation–a natural language processing technique–along with traditional summative content analysis techniques were used to analyze the data. Setting: The United States during the COVID-19 pandemic's first wave between May and July of 2020. Results: A total of 318 nurses participated from 29 out of 50 states, with 242 fully completing all questions. Findings suggested that the place of work mattered significantly in terms of the frontline working experience. It influenced role changes, risk assumption, interprofessional teamwork experiences, and ultimately, likelihood to leave their jobs or the profession altogether. Organizational culture and its influence on pandemic response implementation was a critical feature of their experiences. Conclusions: Findings suggest that organizational performance during the pandemic may be reflected in nursing workforce retention as the risk for workforce attrition appears high. It was also clear from the reports that nurses appear to have assumed higher occupational risks during the pandemic when compared to other providers. The 2020 data from this study also offered a number of signals about potential threats to the stability and sustainability of the US nursing workforce that are now manifesting. The findings underscore the importance of conducting health workforce research during a crisis in order to discern the signals of future problems or for long-term crisis response. Tweetable abstract: @US nurses report assuming higher risks when delivering care than other healthcare personnel. @Healthcare leaders made the difference for nurses during the pandemic. How many nurses leave their employer in the next year will tell you who was good, who wasn't. @It was all about the team. Organizations with nurses' reporting effective interprofessional teamwork had a more resilient pandemic workforce.

Abstract

Introduction:Misalignment between lifestyle behaviors and endogenous circadian rhythms is associated with elevated nocturnal blood pressure (BP) in experimental studies; however, less is known about free-living (i.e. nonlaboratory) circadian disruption and nocturnal BP. Additionally, sex-specific cardiovascular implications of circadian disruption are unclear.Objective:To examine the associations between rest - activity rhythms (RAR), a field-based estimate of circadian disruption, and nocturnal BP characteristics in young men and women.Methods:Fifty participants (20 ± 1 years; 20 men/30 women) underwent 24-h ambulatory BP monitoring following 14 days of wrist actigraphy. RAR variables of interdaily stability (day-to-day consistency in RAR), intradaily variability (within-day fragmentation of RAR), and relative amplitude (difference between peak vs. trough activity) were derived from actigraphy. Multivariable regression models of mean nocturnal SBP, DBP, and SBP dipping were generated to test main associations with RAR variables, and sex × RAR interactions. Daytime BP, race, BMI, physical activity, sleep duration, alcohol, caffeine, and sodium intake were considered as covariates.Results:In the full sample, no main associations between RAR and nocturnal BP characteristics were found. Sex interacted with RAR such that in women, higher interdaily stability (β = -5.39, 95% CI = -10.04 to -0.73, P = 0.024) and relative amplitude (β = -4.78, 95% CI = -9.22 to -0.34, P = 0.036) were both associated with lower nocturnal SBP. Sex-stratified multivariable models of nocturnal BP also revealed associations between interdaily stability and relative amplitude with SBP dipping in women (all P ≤ 0.01). No associations were apparent in men.Conclusion:Consistent and high-amplitude RAR are favorably associated with nocturnal BP characteristics in young women.

Abstract

Background: Forty-five percent of hospice patients currently have a primary or secondary diagnosis of Alzheimer’s disease or related disorders. However, few programs have focused specifically on assisting hospices in providing evidence-based symptom management to persons living with dementia (PLWD). Objective: To adapt and pilot the training component of Aliviado Dementia Care, a dementia symptom management quality improvement program originally developed for home healthcare, for use by social workers as part of the hospice interdisciplinary team. Design: A prospective pre-post design was utilized, measuring knowledge, confidence, and attitudes at baseline, and immediately and 1-month post-training. Analysis was performed using paired t-tests and repeated measures ANOVA. Subjects: Hospice social workers currently practicing in the United States with at least 1 year of experience. Measurements: The Dementia Symptom Knowledge Assessment and a post-training continuing education evaluation form. Results: Forty-six subjects were enrolled, of whom 26 completed the first post-test and 23 both post-tests. There was a poor baseline level of knowledge and confidence in caring for PLWD. Significant improvements occurred following training, particularly in implementing non-pharmacologic interventions for behavioral and psychological symptoms of dementia (BPSD) (16.64% increase, p <.0001) and confidence in managing behavioral symptoms (16.86%, p =.01) and depression (25.18%, p <.0001). Changes were maintained over time. All respondents were either very satisfied or satisfied with the quality and content of the program. Conclusions: The training modules of Aliviado Dementia Care were successfully tailored for use by hospice social workers, showing significant improvement in knowledge and confidence in caring for behavioral symptoms in PLWD. Future work will examine whether the larger program, including this training, can subsequently improve patient outcomes in hospice.

Abstract

Objectives: To examine how immigrant status and family relationships are associated with advance care planning (ACP) engagement and end-of-life (EOL) preference in burial planning among older Chinese Americans, the largest subgroup of Asian Americans. Design: Cross-sectional survey. Setting: Communities in Honolulu, Hawai'i. Participants: Participants were 430 older Chinese Americans aged 55 years and older. Measures: Measures included ACP contemplation, ACP discussion, and EOL preference in burial planning, immigrant status, family cohesion, family conflict, demographic information, and health status. Results: Results show that in comparison to foreign-born Chinese Americans, US-born Chinese Americans were more likely to have ACP contemplation [odds ratio (OR) 2.80, 95% confidence interval (CI) 1.39-5.63], ACP discussion (OR 3.02, 95% CI 1.50-6.08), and preferences for burial plans at the end of life (OR 4.56, 95% CI 2.04-10.18). Family conflict increased the possibility of having ACP contemplation (OR 1.21, 95% CI 1.07-1.38), ACP discussion (OR 1.22, 95% CI 1.07-1.39), and EOL preference in burial planning (OR 1.22, 95% CI 1.04-1.42), whereas family cohesion was not associated with these study outcomes. Conclusions and Implications: This study suggests that ACP should be adapted to be more culturally appropriate, especially in a time of coronavirus and xenophobia, such as framing ACP as a tool to help families reduce stress while fulfilling filial obligations, in order to ensure equitable access to ACP.

Abstract

Context: Persons from underrepresented racial and ethnic groups experience disparities in access to and quality of palliative and end-of-life care. Objectives: To summarize and evaluate existing palliative and end-of-life care interventions that aim to improve outcomes for racial and ethnic underrepresented populations in the United States. Methods: We conducted a systematic review of the literature in the English language from four databases through January 2020. Peer-reviewed studies that implemented interventions on palliative care, advance care planning, or end-of-life care were considered eligible. Data were extracted from 16 articles using pre-specified inclusion and exclusion criteria. Quality was appraised using the modified Downs and Black tool for assessing risk of bias in quantitative studies. Results: Five studies were randomized controlled trials, and the remainder were quasi-experiments. Six studies targeted Latino/Hispanic Americans, five African Americans, and five, Asian or Pacific Islander Americans. The two randomized control trials reviewed and rated “very high” quality, found educational interventions to have significant positive effects on advance care planning and advance directive completion and engagement for underrepresented racial or ethnic groups. Conclusion: The effectiveness of advance care planning, end-of-life, and palliative care interventions in improving outcomes for underrepresented racial and ethnic populations remains uncertain. Randomized controlled trials and educational interventions indicate that interventions targeting underrepresented groups can have significant and positive effects on advance directives and/or advance care planning-related outcomes. More high-quality intervention studies that address racial and ethnic health disparities in palliative care are needed, particularly those that address systemic racism and other complex multilevel factors that influence disparities in health.

Abstract

Objectives: To examine the factors of advance directive (AD) completion among older Chinese Americans. Design: Cross-sectional survey. Setting and Participants: Data came from 435 Chinese Americans aged 55 years and older living in 2 metropolitan areas through self-administered questionnaires and research assistant–administered interviews in 2018. Participants' average age was 75 years (standard deviation = 9.4). Methods: Logistic regression was used to examine factors associated with AD completion. Results: Approximately 14% of participants completed an AD. Older age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.02-1.12], higher level of acculturation (OR 2.15, 95% CI 1.39-3.33), higher expectation for intergenerational support (OR 1.52, 95% CI 1.02-2.27), and having US citizenship (OR 3.02, 95% CI 1.26-7.23) were positively associated with AD completion. Physical and mental health needs were not significantly associated with AD completion. Conclusions and Implications: This study is among the first focusing on AD completion among Chinese Americans, one of the fastest-growing older minority populations in the United States. Findings highlight the influence of socioeconomic and cultural factors on AD completion and illustrate the importance of developing culturally sensitive interventions to promote end-of-life care decision making among older Chinese Americans.

Abstract

Background: Little is known about advance directives (ADs) and end-of-life (EOL) care preferences among the general population in Mainland China. This study aimed to describe knowledge and attitudes of ADs and EOL care preferences, and to explore factors related to preferences for ADs among Chinese adults. Methods: The sample included 1114 adult participants in Wuhan, Mainland China. A brief message including the link to the online survey was sent to local residents who were registered at household registration management centers in Wuhan. The questionnaire included information regarding demographics, self-rated health, views on ADs and EOL care. Bivariate analyses and binary forward logistic regression were conducted to examine factors related to ADs preferences of Chinese adults. Results: The average age of the sample was 48.0 years and more than half of the sample was female. 81.8% had never heard of ADs, but 86.6% indicated that they might create one after learning what ADs were. 58% would choose hospice care if they were terminally ill whereas 48.7% of the participants wanted to die at home. 92.3% would want to know their diagnosis and prognosis if ill; however, if their family members were diagnosed with an incurable disease, 50.5% would not tell their ill family member the actual diagnosis and prognosis. Those who had heard of ADs (OR = 1.567, p < 0.001), earned an associate’s degree (OR = 2.448, p < 0.001) or a bachelor’s degree or higher (OR = 2.382, p < 0.001), and self-rated their health as very poor/poor (OR = 1.002, p = 0.001) were more likely to be willing to make an AD than their counterparts. However, those who were single (OR = 0.149, p < 0.001) or widowed /divorced/separated (OR = 0.405, p = 0.001) were less likely to be willing to make an AD than the married ones. Conclusions: Chinese adults showed positive attitudes towards ADs. There is an urgent need to promote more educational initiatives and raise awareness on the importance of ADs. It is important to develop more policies and legislation about ADs to improve the quality of EOL care in Mainland China.

Abstract

Objectives: This study addressed two questions: (1) Is age at migration associated with cognitive function among Chinese older immigrants? and (2) what personal and environmental factors confound the above relationship? Methods: Data were derived from the Population Study of Chinese Elderly (N = 2957). Quantile and linear regressions were used to examine the associations between age at migration and Mini-Mental State Examination (MMSE) and global cognitive function, respectively. Results: Migration in late middle age (50–64) or late adulthood (65 or older) was associated with lower MMSE scores. Global cognition did not vary by age at migration. Associations between age at migration and MMSE were stronger among individuals with lower education or social engagement. Discussion: Migrating late in one’s life has important implications for cognitive health over the life course. Findings are helpful to identify vulnerable older immigrant segments and provide tailored interventions to promote their cognitive health.

Abstract

After decades of working in the medical field, physicians have gathered an extensive knowledge of human pathology as well as effective courses of treatment for illnesses. However, aging may also bring about cognitive deterioration, which may compromise the quality of care physicians provide to their patients. In 2015, 23 percent of physicians were above the age of 65. An estimated 25,000 to 50,000 active physicians are expected to suffer from mild cognitive impairment and up to 25,000 from dementia. Currently, physicians are not held to a mandatory retirement age and are not subject to oversight of their cognitive abilities and physical health as they age. However, the current system of self-regulation for cognitive impairment is insufficient for protecting patient safety; on the other hand, mandatory retirement or screening of aging physicians may be ethically or legally problematic. An optimal solution would balance the safety of patients and the dignity of aging physicians. It is likely to be multipronged and multifactorial, involving multiple screening steps and continued development to assess the quality of validation. Adoption of healthy lifestyle practices and financial literacy, as well as providing opportunities for retired physicians to stay involved with the medical profession, may encourage successful aging among physicians and ease the transition to retirement.

Abstract

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

Abstract

The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

Abstract

Disruptive forces are challenging the future of medicine. One of the key forces bringing change is the development of artificial intelligence (AI). AI is a technological system designed to perform tasks that are commonly associated with human intelligence and ability. Machine learning is a subset of AI, and deep learning is an aspect of machine learning. AI can be categorized as either applied or generalized. Machine learning is key to applied AI; it is dynamic and can become more accurate through processing different results. Other new technologies include blockchain, which allows for the storage of all of patients’ records to create a connected health ecosystem. Medical professionals ought to be willing to accept new technology, while also developing the skills that technology will not be able to replicate.

Abstract

Objective: Coronavirus disease 2019 (COVID-19) has disproportionately impacted nursing homes (NHs) with large shares of Black residents. We examined the associations between the proportion of Black residents in NHs and COVID-19 infections and deaths, accounting for structural bias (operationalized as county-level factors) and stratifying by urbanicity/rurality. Design: This was a cross-sectional observational cohort study using publicly available data from the LTCfocus, Centers for Disease Control and Prevention Long-Term Care Facility COVID-19 Module, and the NYTimes county-level COVID-19 database. Four multivariable linear regression models omitting and including facility characteristics, COVID-19 burden, and county-level fixed effects were estimated. Setting and Participants: In total, 11,587 US NHs that reported data on COVID-19 to the Centers for Disease Control and Prevention and had data in LTCfocus and NYTimes from January 20, 2020 through July 19, 2020. Measures: Proportion of Black residents in NHs (exposure); COVID-19 infections and deaths (main outcomes). Results: The proportion of Black residents in NHs were as follows: none= 3639 (31.4%), <20% = 1020 (8.8%), 20%-49.9% = 1586 (13.7%), ≥50% = 681 (5.9%), not reported = 4661 (40.2%). NHs with any Black residents showed significantly more COVID-19 infections and deaths than NHs with no Black residents. There were 13.6 percentage points more infections and 3.5 percentage points more deaths in NHs with ≥50% Black residents than in NHs with no Black residents (P <.001). Although facility characteristics explained some of the differences found in multivariable analyses, county-level factors and rurality explained more of the differences. Conclusions and Implications: It is likely that attributes of place, such as resources, services, and providers, important to equitable care and health outcomes are not readily available to counties where NHs have greater proportions of Black residents. Structural bias may underlie these inequities. It is imperative that support be provided to NHs that serve greater proportions of Black residents while considering the rurality of the NH setting.

Abstract

This study examined the association between childhood conditions and arthritis among middle-aged and older adults in China. The data were derived from the 2015 wave and the life-history module of the China Health and Retirement Longitudinal Study. Face-to-face interviews were conducted with respondents age 45 and over across China. Multiple imputation was used to handle the missing data, generating a final analytic sample of 19,800. Doctor-diagnosed arthritis was the main outcome variable. Random-effects logistic regression models were used to test the proposed models. Approximately 8 per cent of the respondents had better family financial status in childhood than their neighbours. Close to 8 per cent had been hospitalised or encountered similar conditions (e.g. confined to bed or home) for at least one month in childhood. Around one-third reported better subjective health in childhood than their peers. The majority of the respondents (80%) reported that they had stable health resources, and that their mothers were illiterate during their childhood. Childhood family financial status, subjective health, mother's education, access to health care and medical catastrophic events were found to be significant factors associated with arthritis in later life, after controlling for adulthood and older-age conditions (family financial status: odds ratio (OR) = 0.885, 95 per cent confidence interval (95% CI) = 0.848-0.924; subjective health: OR = 0.924, 95% CI = 0.889-0.960; mother's education: OR = 0.863, 95% CI = 0.750-0.992; access to health care: OR = 0.729, 95% CI = 0.552-0.964; medical catastrophic events: OR = 1.266, 95% CI = 1.108-1.446). The study results highlight an important role that childhood conditions play in affecting the onset of arthritis in late life in China. Health-care providers may consider childhood conditions as a valuable screening criterion to identify risk populations, which could be used to guide health promotion and prevention programmes, and promote healthy ageing.

Abstract

South Asians, who are at a disproportionately greater risk of atherosclerotic CVD (ASCVD), represent a rapidly growing population in the USA. The relationship between dairy products, a major component of South Asian diets, and body composition - an established risk factor for ASCVD, is unclear. The aim of the present study was to examine associations between dairy intake and multiple measures of body composition (BMI, waist and hip circumference, waist:hip ratio, abdominal lean mass, subcutaneous, visceral, and intermuscular fat areas) among South Asian adults in the USA. A baseline analysis was conducted using existing data from the Mediators of Atherosclerosis in South Asians Living in America cohort. In women, the highest (>1.9 servings/d) v. lowest (<1 serving/d) tertile of dairy intake was associated with 53 % lower odds of a waist circumference >80 cm (95 % CI 0.25, 0.89, P for trend<0.05). No associations were observed between dairy intake and measures of body composition. However, >3 servings of low-fat yogurt/week was associated with a 9.9 cmlower visceral fat area (95 % CI -19.07, -0.72, P<0.05) and 2.3 cmlower intermuscular fat area (95 % CI -3.76, -0.79, P<0.05) as compared with those with three servings/week. Milk and cheese were not associated with body composition measures. These analyses suggest that higher consumption of low-fat yogurt is associated with lower visceral and intermuscular fat in the whole sample, and women with higher dairy intake have lower waist circumference. Our study supports dietary incorporation of dairy products, and recognises the utility of multidimensional measures of central adiposity.

Abstract

To investigate the association of ownership status, discharge rate and length of stay (LOS) of home health care (HH) services under the prospective payment system (PPS). We used 2016–2018 Outcome Assessment and Information Set (OASIS) data sets for Medicare beneficiaries. Two outcome variables were investigated: rate of discharge from an HH agency and LOS. Our main independent variable was ownership status: for-profit (FP) versus not-for-profit (NFP). FP agencies were 4.2% (p <.01) less likely to discharge patients to the community but more likely (7.3%; p <.001) to have longer LOS (>99 days) compared to NFPs. Findings that FP agencies were less likely to discharge patients to the community and more likely to have a longer length of stay than NFP agencies have implications for quality of care initiatives by the Medicare Post-Acute Transformation Act 2014.

Abstract

BACKGROUND: While mental health conditions such as postpartum depression are common, little is known about how mental healthcare utilization varies after term versus preterm delivery. OBJECTIVE: This study aimed to determine whether preterm birth is associated with postpartum inpatient and emergency mental healthcare utilization. STUDY DESIGN: The study sample was obtained from a database of live-born neonates delivered in California between the years of 2011 and 2017. The sample included all people giving birth to singleton infants between the gestational age of 20 and 44 weeks. Preterm birth was defined as <37 weeks’ gestation. Emergency department visits and hospitalizations with a mental health diagnosis within 1 year after birth were identified using International Classification of Diseases codes. Logistic regression was used to compare relative risks of healthcare utilization among people giving birth to preterm infants vs term infants, adjusting for the following covariates: age, race or ethnicity, parity, previous preterm birth, body mass index, tobacco use, alcohol or drug use, hypertension, diabetes mellitus, adequacy of prenatal care, education, insurance payer, and the presence of a mental health diagnosis before birth. Results were then stratified by mental health diagnosis before birth to determine whether associations varied based on mental health history. RESULTS: Of our sample of 3,067,069 births, 6.7% were preterm. In fully adjusted models, compared with people giving birth to term infants, people giving birth to preterm infants had a 1.5 times (relative risk; 95% confidence interval, 1.4–1.7) and 1.3 times (relative risk; 95% confidence interval, 1.2–1.4) increased risk of being hospitalized with a mental health diagnosis within 3 months and 1 year after delivery, respectively. People giving birth to preterm infants also had 1.4 times (95% confidence interval, 1.3–1.5) and 1.3 times (95% confidence interval, 1.2–1.4) increased risk of visiting the emergency department for a mental health diagnosis within 3 months and 1 year after birth, respectively. Stratifying by preexisting mental health diagnosis, preterm birth was associated with an elevated risk of mental healthcare utilization for people with and without a previous mental health diagnosis. CONCLUSION: We found that preterm birth is an independent risk factor for postpartum mental healthcare utilization. Our findings suggest that screening for and providing mental health resources to birthing people after delivery are crucial, particularly among people giving birth to preterm infants, regardless of mental health history.

Abstract

Background: Socio-demographic transitions have dramatically changed the traditional family care settings in China, caused unmet care needs among older adults. However, whether different primary caregiver types have different influences on disabled older adults’ health outcomes remain poorly understood. We aimed to examine the association between the type of primary caregiver (e.g., spouse and children) and death among community-dwelling Chinese older adults disabled in activities of daily living. Methods: We used data from Chinese Longitudinal Healthy Longevity Survey. The analytic sample comprised 4278 eligible adults aged ≥ 80 years. We classified primary caregiver type into five categories: spouse, son/daughter-in-law, daughter/son-in-law, grandchildren, and domestic helper. We used Cox regression model to examine the association between primary caregiver type and all-cause mortality. Covariates included age, sex, residence, years of education, co-residence status, financial independence, whether living with children, number of ADL disability, number of chronic conditions, and self-reported health, cognitive impairment, and caregiving quality. Results: Married older adults whose primary caregivers were son/daughter-in-law had a 38% higher hazard of death than those who had spouse as the primary caregiver. Married men who received care primarily from son/daughter-in-law or daughter/son-in-law had a 64 and 68% higher hazard of death, respectively, than those whose primary caregiver was spouse. The association between primary caregiver type and mortality among widowed older adults differed between urban and rural areas. Urban residents who had domestic helpers as the primary caregiver had an 16% lower hazard of death, while those living in rural areas had a 50% higher hazard of death, than those having son/daughter-in-law as the primary caregiver. Conclusions: The quality of care of the primary caregiver may be a risk factor for mortality of disabled older adults in China. Interventions are necessary for reducing unmet needs and managing care burden.

Abstract

Objective: We hypothesized that infants with fetal growth restrictions have increased mortality and morbidity after congenital heart disease surgery. Methods: The study included patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2016) who underwent cardiac surgery at a corrected gestational age of ≤44 weeks. Patients were classified as severely (birth weight Z-score −4 to −2), moderately (Z-score −2 to −1), and mildly growth restricted (Z-score −1.0 to −0.5) and compared with a reference population (Z-score 0-0.5). Multivariable logistic regression clustering on center was used to evaluate the association of birth weight Z-score with operative mortality and postoperative complications and its interaction with gestational age was assessed. Results: In 25,244 patients, operative mortality was 8.6% and major complications occurred in 19.4%. Compared with the reference group, the adjusted odds ratio (AOR) of mortality was increased in infants with severe (AOR, 2.4; 95% confidence interval [CI], 2.0-3.0), moderate (AOR, 1.7; 95% CI, 1.4-2.0), and mild growth restriction (AOR, 1.4; 95% CI, 1.2-1.6). The AOR for major postoperative complications was increased for severe (AOR, 1.4; 95% CI, 1.2-1.7) and moderate growth restriction (AOR, 1.2; 95% CI, 1.1-1.4). There was significant interaction between birth weight Z-score and gestational age (P = .007). Conclusions: Even birth weight Z-scores slightly below average are independent risk factors for mortality and morbidity in infants who undergo cardiac surgery. The strongest association between poor fetal growth and operative mortality exists in early-term infants. These novel findings might account for some of the previously unexplained variation in cardiac surgical outcomes.

Abstract

Introduction: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited. Methods: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB. Findings: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity. Interpretation: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons. Funding: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff.