Objective To describe clinical characteristics and risk factors associated with coronavirus disease 2019 (COVID-19) in long-stay nursing home residents. Design and Participants Retrospective cohort study (March 16, 2020 to May 8, 2020). Setting Academic long-term chronic care facility (Boston, MA). Participants Long-term care residents. Methods Patient characteristics and clinical symptoms were obtained via electronic medical records and Minimum Data Set. Staff residence was inferred by zip codes. COVID-19 infection was confirmed by polymerase chain reaction testing using nasopharyngeal swabs. Residents were followed until discharge from facility, death, or up to 21 days. Risks of COVID-19 infection were modeled by generalized estimating equation to estimate the relative risk (RR) and 95% confidence intervals (CI) of patient characteristics and staff community of residence. Results Overall 146 of 389 (37.5%) long-stay residents tested positive for COVID-19. At the time of positive test, 66 of 146 (45.5%) residents were asymptomatic. In the subsequent illness course, the most common symptom was anorexia (70.8%), followed by delirium (57.6%). During follow-up, 44 (30.1%) of residents with COVID-19 died. Mortality increased with frailty (16.7% in pre-frail, 22.2% in moderately frail, and 50.0% in frail; P < .001). The proportion of residents infected with COVID-19 varied across the long-term care units (range: 0%‒90.5%). In adjusted models, male sex (RR 1.80, 95% CI 1.07, 3.05), bowel incontinence (RR 1.97, 95% CI 1.10, 3.52), and staff residence remained significant predictors of COVID-19. For every 10% increase in the proportion of staff living in a high prevalence community, the risk of testing positive increased by 6% (95% CI 1.04, 1.08). Conclusions and Implications Among long-term care residents diagnosed with COVID-19, nearly one-half were asymptomatic at the time of diagnosis. Predictors of COVID-19 infection included male sex, bowel incontinence, and staff residence in a community with a high burden of COVID-19. Universal testing of patients and staff in communities with high COVID-19 rates is essential to mitigate outbreaks.

BACKGROUND Home time, the number of days alive and spent out of hospital and skilled nursing facility, has been proposed as a patient‐centered outcome that can be readily calculated in administrative claims data. OBJECTIVES To compare home time against existing patient‐centered outcome measures. DESIGN Retrospective cohort study. SETTING Community. PARTICIPANTS A total of 4594 Medicare beneficiaries 65 years or older with complete survey and claims data in the Medicare Current Beneficiary Survey 2010 to 2011. MEASUREMENTS Home time was calculated from the 2011 claims data (range, 0‐365 days). The 1‐year incidence of patient‐centered outcomes (poor self‐rated health, mobility impairment, depression, limited social activity, and difficulty in self‐care) was measured. The minimum clinically important difference (MCID) was derived by contrasting the mean home time between those who experienced functional decline or death and those who did not. RESULTS The mean home time was 355.8 days (SD, 42.1 days); 84.1% had a home time of 365 days, and 5.7% had a home time of 336 days or fewer. The incidence of poor self‐rated health ranged from 2% (home time, 365 days) to 21% (home time, less than 337 days). Similarly, the corresponding incidence risks were 11% to 59% for mobility impairment, 5% to 19% for depression, 17% to 67% for limited social activity, and 13% to 68% for difficulty in self‐care. The risk of mobility impairment, depression, and difficulty in self‐care increased steeply after home time loss of 15 days or greater. The MCID of home time was 18.6 days. CONCLUSION A loss in home time is associated with decline in several patient‐centered outcome measures in community‐dwelling Medicare beneficiaries. These results provide empirical evidence to promote adoption of home time and its clinical interpretation for database studies of medical interventions. J Am Geriatr Soc 67:347–351, 2019.

IMPORTANCEFunctional status is a patient-centered outcome that is important for a meaningful gain in health-related quality of life after aortic valve replacement.OBJECTIVE To determine functional status trajectories in the year after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). DESIGN, SETTING, AND PARTICIPANTSA prospective cohort study with a 12-month follow-up was conducted at a single academic center in 246 patients undergoing TAVR or SAVR for severe aortic stenosis. The study was conducted between

Objectives Despite evidence, frailty is not routinely assessed before cardiac surgery. We compared five brief frailty tests for predicting poor outcomes after aortic valve replacement and evaluated a strategy of performing comprehensive geriatric assessment (CGA) in screen‐positive patients. Design Prospective cohort study. Setting A single academic center. Participants Patients undergoing surgical aortic valve replacement (SAVR) (n = 91; mean age = 77.8 y) or transcatheter aortic valve replacement (TAVR) (n = 137; mean age = 84.5 y) from February 2014 to June 2017. Measurements Brief frailty tests (Fatigue, Resistance, Ambulation, Illness, and Loss of weight [FRAIL] scale; Clinical Frailty Scale; grip strength; gait speed; and chair rise) and a deficit‐accumulation frailty index based on CGA (CGA‐FI) were measured at baseline. A composite of death or functional decline and severe symptoms at 6 months was assessed. Results The outcome occurred in 8.8% (n = 8) after SAVR and 24.8% (n = 34) after TAVR. The chair rise test showed the highest discrimination in the SAVR (C statistic = .76) and TAVR cohorts (C statistic = .63). When the chair rise test was chosen as a screening test (≥17 s for SAVR and ≥23 s for TAVR), the incidence of outcome for screen‐negative patients, screen‐positive patients with CGA‐FI of .34 or lower, and screen‐positive patients with CGA‐FI higher than .34 were 1.9% (n = 1/54), 5.3% (n = 1/19), and 33.3% (n = 6/18) after SAVR, respectively, and 15.0% (n = 9/60), 14.3% (n = 3/21), and 38.3% (n = 22/56) after TAVR, respectively. Compared with routinely performing CGA, targeting CGA to screen‐positive patients would result in 54 fewer CGAs, without compromising sensitivity (routine vs targeted: .75 vs .75; P = 1.00) and specificity (.84 vs .86; P = 1.00) in the SAVR cohort; and 60 fewer CGAs with lower sensitivity (.82 vs.65; P = .03) and higher specificity (.50 vs .67; P < .01) in the TAVR cohort. Conclusions The chair rise test with targeted CGA may be a practical strategy to identify older patients at high risk for mortality and poor recovery after SAVR and TAVR in whom individualized care management should be considered. J Am Geriatr Soc 67:2031–2037, 2019

Background Transcatheter aortic valve replacement (TAVR) may be associated with less delirium and allow faster recovery than surgical aortic valve replacement (SAVR). Objective To examine the association of delirium and its severity with clinical and functional outcomes after SAVR and TAVR. Design Prospective cohort study. Setting An academic medical center. Participants A total of 187 patients, aged 70 years and older, undergoing SAVR (N = 77) and TAVR (N = 110) in 2014 to 2016. Measurements Delirium was assessed daily using the Confusion Assessment Method (CAM), with severity measured by the CAM‐Severity (CAM‐S) score (range = 0‐19). Outcomes were prolonged hospitalization (9 days or more); institutional discharge; and functional status, measured by ability to perform 22 daily activities and physical tasks over 12 months. Results SAVR patients had a higher incidence of delirium than TAVR patients (50.7% vs 25.5%; P < .001), despite younger mean age (77.9 vs 83.7 years) and higher baseline Mini‐Mental State Examination score (26.9 vs 24.7). SAVR patients with delirium had a shorter duration (2.2 vs 3.4 days; P = .04) with a lower mean CAM‐S score (4.5 vs 5.7; P = .01) than TAVR patients with delirium. The risk of prolonged hospitalization in no, mild, and severe delirium was 18.4%, 30.8%, and 61.5% after SAVR (P for trend = .009) and 26.8%, 38.5%, and 73.3% after TAVR (P for trend = .001), respectively. The risk of institutional discharge was 42.1%, 58.3%, and 84.6% after SAVR (P for trend = .01) and 32.5%, 69.2%, and 80.0% after TAVR (P for trend <.001), respectively. Severe delirium was associated with delayed functional recovery after SAVR and persistent functional impairment after TAVR at 12 months. Conclusion Less invasive TAVR was associated with lower incidence of delirium than SAVR. Once delirium developed, TAVR patients had more severe delirium and worse functional status trajectory than SAVR patients did. Registration NCT01845207.

Deficit-accumulation FI provides better prediction of death or poor recovery than frailty phenotype in older patients undergoing SAVR and TAVR.

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OBJECTIVESDetermine the effects of missing data in frailty identification and risk prediction.DESIGNAnalysis of the National Health in Aging Trends Study.SETTINGCommunity.PARTICIPANTSAbout 6206 older adults.MEASUREMENTSA 41‐variable frailty index (FI) was constructed with the following domains: comorbidities, activities of daily living (ADLs), instrumental activities of daily living, self‐reported physical limitations, physical performance, and neuropsychiatric tests. We evaluated discrimination after removing single and multiple domains, comparing C‐statistics for predicting 5‐year risk of mortality and 1‐year risks of disability and falls.RESULTSThe full FI yielded a mean of .18 and C‐statistics of .72 (95% confidence interval, .70‐.74) for mortality, .80 (.77‐.82) for disability, and .66 (.64‐.68) for falls. Removal of any single domain shifted the FI distribution, resulting in a mean FI ranging from .13 (removing comorbidities) to .20 (removing ADLs) and frailty prevalence (FI ≥ .25) from 16.0% to 28.7%. Among robust participants models missing ADLs misclassified most often, (19% as pre‐frail). Among pre‐frail and frail participants missing comorbidities misclassified most often(69.2% from pre‐frail to robust, 24% from frail to pre‐frail, and 4.9% from frail to robust). Removal of any single domain minimally changed C‐statistics: mortality, .71‐.73; disability, .79‐.80; and falls, .64‐.66. Removing neuropsychiatric testing and physical performance yielded comparable C‐statistics of .70, .78, and .66 for mortality, ADLs, and falls, respectively. However, removal of three or four domains based on likely availability decreased C‐statistics for mortality (.69, .66),disability (.75, .70), and falls (.64, .63), respectively.CONCLUSIONWhile FI discrimination is robust to missing information in any single domain, risk prediction is affected by absence of multiple domains. This work informs the application of FI as a clinical and research tool. J Am Geriatr Soc 68:1771‐1777, 2020.