Machine Learning Prediction Models for Mobility Limitation Over Time in Older Adults: The Health ABC Study

Mobility limitation in older adults is common and associated with poor health outcomes and loss of independence. Identification of at-risk individuals remains challenging because of time-consuming clinical assessments and limitations of statistical models for dynamic outcomes over time. Therefore, we aimed to develop machine learning models for predicting mobility limitation in older adults using repeated measures and variable selection. We used nine years of follow-up data from the Health, Aging, and Body Composition study to model mobility limitation, defined as self-report of any difficulty walking ¼ mile or up a flight of stairs, assessed annually. We considered 46 predictors for modeling, including demographic, lifestyle, chronic condition and physical function variables. We developed three models with Binary Mixed Model Forest, using: 1) all 46 predictors, 2) an automated variable selection algorithm, and 3) the top five most important predictors. Area under the receiver operating curve ranged from 0.78 to 0.84 for the models for two validation datasets (with and without previous annual visit data for participants). Across the three models, the most important predictors of mobility limitation were ease of getting up from chair, gait speed, self-reported health status, body mass index and depression. Longitudinal, machine learning models predicting mobility limitation had good performance for identifying at-risk older adults based on current and previous annual visit data. Future studies should evaluate the utility and efficiency of the prediction models as a tool in a clinical setting for identifying at-risk older adults who may benefit from interventions aimed to prevent mobility limitation.

Pre-Dementia Stages and Incident Dementia in the NuAge Study

Background: Motoric cognitive risk syndrome (MCR) and mild cognitive impairment (MCI) are two pre-dementia stages with an overlap, which may influence the risk for dementia. Objective: The study aims to examine the association of MCR, MCI, and their combination with incident dementia in Quebec community-dwelling older adults. Methods: 1,063 older adults (i.e., ≥65) were selected from a population-based observational cohort study known as the “Nutrition as a determinant of successful aging: The Quebec longitudinal study” (NuAge). Participants were separated into four groups at the baseline assessment: those without MCR and MCI (i.e., cognitively healthy individual; CHI), those with MCR alone, those with MCI alone, and those with MCR plus MCI. Incident dementia was recorded at each annual visit during a 3-year follow-up. Results: The prevalence of CHI was 87.2%, MCR 3.0%, MCI 8.8%, and MCR plus MCI 0.9%. The overall incidence of dementia was 2.4% and was significantly associated with MCR alone (Odd Ratio (OR) = 5.00 with 95% Confidence interval (CI) = [1.01;24.59] and p = 0.049), MCI alone (OR = 6.04 with 95% CI = [2.36;15.47] and p≤0.001), and the combination of MCR and MCI (OR = 25.75 with 95% CI = [5.32;124.66] and p≤0.001). Conclusion: Combining MCR and MCI increased the risk for incident dementia. These results also demonstrated that this combination is a better predictor of dementia than MCI or MCR alone.

Utilization of Telemedicine for Comprehensive Visits in Patients with Inherited Bleeding Disorders during the COVID-19 Pandemic

Standard of care for individuals with inherited bleeding disorders includes an annual in person multi-disciplinary comprehensive visit at the Hemophilia Treatment Center (HTC). During the COVID-19 pandemic in person visits were restricted, with mandates to only schedule in person urgent visits and to "stay at home." In order to provide annual visits to as many patients as possible, we developed a quality improvement (QI) project to conduct annual visits via telemedicine (TM), including nursing (RN), physician (MD), social work (SW), and physical therapy (PT) assessments. Our aim was to increase annual comprehensive clinic visits conducted by TM for eligible patients from 0 to 50% between April 1 and June 30, 2020, extended through July 31, 2020 due to the prolonged pandemic. Patients due for an annual visit were contacted by medical assistants (MA) to schedule either a TM (through EPIC MyChart) or an in person visit. MAs were trained on which patients were eligible for a TM visit and how to set-up MyChart remotely. Prior to the visit patients were provided verbal, written, and video instructions on how to attend the TM visit. Quantitative and qualitative data were collected at the time of scheduling and during the visit. Forty-eight patients were scheduled for an annual visit during the QI timeframe. TM visits were not offered to 28 patients for a variety of reasons (first comprehensive clinic visit, need to re-establish or transfer care, need for required laboratory testing, or joint disease requiring in person PT evaluation). Out of the 20 patients who were eligible for a TM visit, 14 (70%) accepted. The two main reasons for declining TM visits were personal preference for an in person visit and preference to not use/activate MyChart. Table 1 compares the characteristics of patients who completed their annual visit via TM versus in person. Of the 14 patients who accepted TM visits, 11 completed the visit and 3 were no-shows. All four adolescent patients who attended their TM completed their annual transition questionnaire online prior to the visit. Of the 11 patients who completed TM visits, 4 (36.3%) saw the same providers during both their TM visit and in person visit the year prior. Of those who saw fewer providers during the TM visits, the most commonly missed providers were the dietician and genetic counselor. TM visits were primarily conducted through two-way audio and video communication within MyChart, while 1 was through Zoom and the other by audio only. Eight of the 11 (72.7%) TM visits had technical issues, including difficulty connecting to MyChart and poor internet connection requiring the remainder of the visit to be completed by audio only. Despite the technical issues, the majority of patients (81.8%) stated that they would prefer in person visits over TM visits in the future. The most common reasons for preference of TM visits in the future were convenience and ability to avoid the clinic during the pandemic. The HTC team members also perceived that TM visits ran more efficiently than the in person visits despite the technical issues during the visits. For in person visits, families were pre-screened by phone and at the time of arrival for symptoms of COVID-19, exposures, and travel outside of US. Two patients only reported potential exposure/travel to the providers in the HTC clinic, which required isolation and use of additional personal protective equipment (PPE). Overall, we increased the number of annual comprehensive clinic visits conducted by TM from 0 to 70% for eligible patients between April 1 and July 31, 2020 during the COVID-19 pandemic. Although there were technical difficulties with the TM visits, the majority of patients found the TM visit to be convenient and expressed a preference for TM for future visits. TM visits reduced potential exposures and use of PPE. Future interventions to improve TM visits include promoting MyChart utilization, additional education for patients regarding logistics of connecting to a TM visit, and additional education for providers regarding the troubleshooting of technical issues. Future QI measures may include patient satisfaction, duration of TM compared to in person visits, and need for additional care coordination post TM visit. In addition, impact on patient outcomes (such as need for return visits or bleeds) should also be evaluated. Disclosures Thornburg: Bluebird Bio: Consultancy; Biomarin: Consultancy, Speakers Bureau; Genentech: Speakers Bureau; NovoNordisk: Research Funding; Sanofi Genzyme: Consultancy, Other: Data Safety Monitoring Board, Research Funding; Spark Therapeutics: Consultancy; Ironwood Pharmaceuticals: Consultancy, Other: Data Safety Monitoring Board; National Hemophilia Foundation: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer Pharmaceuticals: Research Funding; American Thrombosis and Hemostasis Network: Research Funding.

High Demand: Identification of Dermatology Visit Trends from 1991-2016 National Ambulatory Medical Care Surveys

Background: The field of dermatology is constantly evolving and expanding to accommodate for increased demand. In order to maximize future productivity, it is important to recognize and understand how the desires of patients and the nature of physician visits have changed over time. Objective: To evaluate and provide evidence-based reasoning for the changes occurring in the field of dermatology. Methods: Analysis of the 1991-2016 National Summary Tables from the National Ambulatory Medical Care Survey (NAMCS) was performed in order to identify several trends relating to dermatology visits. Results: Annual visit rates to dermatologists have increased by 68%, while visit length has increased by 39%. Drug visits have increased by 86%, while drug mentions increased by 370.2%. Limitations: Limitations of this paper include limited a narrow timeline for data points. Conclusion: As the field of dermatology will continue to expand in the future, dermatologists can expect to be busier than ever before. We expect that more patients will seek care, physician visits will be longer, and chief complaints and treatment options will continue to expand and vary.

Retrospective Study: Malassezia Folliculitis Profile

Background: Malassezia folliculitis (MF) is a chronic infectious disease of pilosebaceous follicles caused by Malassezia sp. Clinical features of MF include erythematous papules and itchy perifollicular pustules, especially on the upper body, neck, upper arms, and face. The disease is usually reported on adolescents. Objective: To evaluate the profile of MF patients in four years (2014-2017) period in the Mycology Division of Dermatovenerology Outpatient Clinic of Dr. Soetomo General Academic Hospital Surabaya. Methods: This study was a retrospective study to examine the medical records of MF patients in the Mycology Division of Dermatovenerology Outpatient Clinic General Academic Hospital Dr. Soetomo Surabaya from January 2014 to December 2017. Results: The number of new MF patient visits during 2014-2017 was 196 patients, and the average annual visit was 55 patients in 2014, 49 patients in 2015, 65 patients in 2016, and 27 patients in 2017. The majority of patients were males, were aged 15-24 years old. The chief complaint was reddish papules accompanied by moderate itching in the predilection area and most often found in the upper body. The Wood's lamp examination revealed greenish-yellow color, and 20% KOH examination showed spores. Most systemic therapies was ketoconazole and tretinoin 0.05% cream for topical therapy. Conclusions: There was a decrease in the number of MF patients. The diagnoses of MF were based on history taking, physical examination, 20% KOH, and Wood's lamp.

29 Association between Risk of Falling and History of a Previous Falls over Four Years’ Annual Follow-up

Introduction Falls in older persons lead to psychological as well as physical effects resulting in loss of quality of life, functional impairment and institutionalization. Previous studies have established falls in the previous 12 months as a risk factor for subsequent falls, but few have evaluated sequentially. This study aims to determine the sequential trend of 12-month retrospective fall recall over a four-year follow-up period. Methods The Promoting Independence in our Seniors with Arthritis (PISA) study recruited individuals aged >=60 years followed up over four year. Participants were asked about presence of any fall in the preceding 12 months during each annual visit. Assessment performed during each visit included weight and the Knee Injury and Osteoarthritis Outcome Score (KOOS), hand grip strength, timed-up-and-go test, functional reach and Hospital Anxiety and Depression Scale. Results Falls data were available for 218, 156, 117 and 100 individuals with 22.5%, 23.1%, 24.7% and 29.3% reporting falls at the first, second, third and fourth visits respectively. The mean age (standard deviation) at recruitment was 66.9 (7.1) years and 166 (74.1%) were women. The odds ratio (OR) (95% confidence interval, CI) for falls in the first, second and third years for fallers at recruitment were 2.45 (1.07-5.59), 3.55 (1.49-8.84) and 1.14 (0.43-3.05) respectively. Fallers at the second follow-up, were more likely to falls during second [OR (95%CI) = 2.41(1.94-12.90)] and third years [5.20 (1.91-14.13)]. Faller at the third visit for falls were more likely to fall in the third yaer [OR (95%CI) = 3.88(1.55-9.69)]. Conclusion Falls in the preceding 12 months was associated with increased risk of falls in the subsequent two years. Faller at recruitment, however. were no longer at increased risk of falls at the third year of follow-up. This has implications for resource planning in terms to determine whether intervention is still useful with long waiting lists in overcrowded public health facilities.

The Dynamic Relationship Between Asthma and Obesity in Schoolchildren

Asthma and obesity are among the most prevalent chronic health conditions in children. Although there has been compelling evidence of co-occurrence of asthma and obesity, it is uncertain whether asthma contributes to the development of obesity or obesity contributes to the onset of asthma or both. In this study, we used a joint transition modeling approach with cross-lagged structure to understand how asthma and obesity influence each other dynamically over time. Subjects for this study included 5,193 kindergarten and first-grade students enrolled from 13 communities in 2002–2003 in the Southern California Children’s Health Study, with up to 10 years of follow-up. We found that nonobese children with diagnosed asthma at a study visit were at 37% higher odds of becoming obese by the next annual visit compared with children without asthma (odds ratio = 1.38; 95% credible interval: 1.12, 1.71). However, the presence of obesity at the current visit was not statistically significantly associated with asthma onset in the next visit (odds ratio = 1.25; 95% credible interval: 0.94, 1.62). In conclusion, childhood asthma appears to drive an increase in the onset of obesity among schoolchildren, while the onset of obesity does not necessarily imply the future onset of asthma, at least in the short term.

Stress Testing Corporations and Municipalities and Supply Chains

In this chapter, the authors address a very real issue of current business life, and that is the prediction and prevention of corporate and municipal insolvencies and bankruptcies. The concept of stress testing banks for capital sufficiency under conditions of plausible risks is by now an accepted governmental mandate. Stress testing corporations and municipalities however is relatively new. The authors present a process for both corporate and municipal stress testing together with a review of legal considerations. Over time, it is expected that stress testing corporations and municipalities will become as routine as an annual visit to the family physician. This chapter is designed to establish the ground work for stress testing corporations and municipalities, including supply chains and not-for-profit organizations. This discussion applies equally well to global supply chains.

Socializing children into pop culture: A visit to Santa

Investigating children’s pop cultures that rely on myth-making provide understandings about how children are active agents in the socialization into cultural and moral practices in their everyday lives. An annual visit to Santa Claus is important in children’s pop culture in the Western world, however, the social practices associated with the continuation of the myth are under-reported. Drawing on the related methodologies of ethnomethodology, conversation analysis and membership categorization analysis, this article examines video-recordings of children talking to Santa at a North American shopping mall. An inherent problem for Santa across the interactions is how to talk about the children’s wished-for item without actually promising the gift. Analyses show that Santa manages this problem through the design of his turn and responses, which allows him to mitigate and propose why certain items might not be delivered. Despite the infrequency of the interaction between Santa Claus and a child, a visit to Santa highlights the interplay between child, adult and societal agendas. Findings presented focus on how culture-in-action is produced through the resources of conversation and permeating cultural practices.