Preventable Hospitalization in Dementia: The Impact of Neuropsychiatric Symptoms (K08)
Investigators: Donovan Maust, Helen C. Kales, Frederic C. Blow, Kenneth M. Langa, Hyungjin Myra Kim
Funding: National Institute on Aging, 2014-2018 (1 K08 AG 048321 01)
Older adults with dementia are at increased risk of hospitalization when compared to adults without dementia of similar age and medical comorbidity. The increased risk of hospitalization for patients with dementia extends to potentially preventable hospitalizations (PPH [e.g., urinary tract infection or asthma exacerbation]), suggesting difficulty in outpatient management of these older adults. As a geriatric psychiatrist, I hypothesize that the neuropsychiatric symptoms (NPS) of dementia such as agitation or delusions account for a significant amount of this risk, given both their prevalence and potential to cause caregiver distress. There are multiple effective interventions that improve these symptoms, but the profile of patients with dementia at highest risk for PPH is unknown, while the workforce shortage in geriatrics and geriatric mental health limit the ability to deliver such interventions. I propose a coordinated program of mentorship, didactics, and research through which I will develop advanced skills to use administrative, claims, and clinical encounter data derived from the electronic health record (EHR) to prospectively identify those patients with dementia at highest risk for hospitalization. Going forward, the ability to pair the patient-level risk phenotype I characterize with the wealth of information now available in the EHR will allow patients in distress to more effectively be targeted for intervention, a development of critical public health importance given both financial and geriatric work force constraints.
Over the next four years, my short-term training goals include: (1) addressing gaps in my formal research skills training, specifically in using: (a) observational analyses using large-scale claims and administrative data; (b) natural language processing to derive clinical data; and (c) applying advanced methods of data analysis for risk prediction; (2) training in presentations, manuscript writing, and grantsmanship that culminate with a R01 proposal; (3) establishing further connections with potential collaborators in the U-M Pepper Center and broader community of aging researchers, national geriatrics and geriatric psychiatry communities, and the Beeson Scholar community; and (4) engaging in leadership development with an emphasis on skills to lead a research team, mentor junior investigators, and communicate findings in research and clinical care settings.
These short-term goals will be paired with research aims that focus on elaborating the PPH risk profile for patients with dementia. Such research objectives can only be achieved when: (1) full clinical risk characteristics are available for the at-risk (i.e., non-hospitalized) population including (2) NPS data, which are rarely indicated in standard administrative claims (e.g., diagnostic codes). These conditions are uniquely met in the VA health system, which has one of the nation?s most advanced systems of electronic health records. Drawing matched cases (patients with dementia + PPH) and controls (unhospitalized patients with dementia) from a national case repository (N=269,565), Aim 1 will use claims and administrative data to explore patient, treatment, and facility risk factors associated with PPH; Aim 2 will use natural language processing to explore the association of NPS with PPH. Using the risk phenotype described in Aims 1 and 2, Aim 3 will develop a logistic risk-prediction model to prospectively identify patients with dementia at highest risk for PPH.
My long-term career goals are to: (1) establish myself as independent investigator and national leader in geriatric mental health services research; (2) develop a programmatic line of funded health services research that develops risk-stratification models for late-life mental health and cognitive disorders; (3) translate knowledge from these research endeavors to improve the targeting and impact of future interventions research and health system delivery strategies; and (4) co