Unstable Housing and Mortality Among US Veterans Receiving Dialysis.
Unstable Housing and Mortality Among US Veterans Receiving Dialysis.
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DOI：
10.1001/jamanetworkopen.2023.44448
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发表时间：
2023-11-01
影响因子：
13.8
通讯作者：
Crews DC
中科院分区：
文献类型：
--
作者：
Novick TK;Mader MJ;Johansen KL;Matsui EC;Montgomery E;Jacobs EA;Crews DC
在接受透析的美国退伍军人中，不稳定的住房是否与死亡率相关？风险是否因年龄而异？在这项对 25-689 名接受透析的退伍军人进行的队列研究中，不稳定的住房与全因死亡风险增加相关，并且这种风险随着年龄的增长而增加。这些发现表明，不稳定的住房可能会导致接受透析的美国退伍军人死亡率的社会经济差异，其中老年人尤其容易受到影响。这项队列研究确定了接受透析的美国退伍军人与不稳定住房相关的特征，并估计了不稳定住房与死亡风险之间的关联。住房状况是一个重要的健康决定因素，但人们对接受透析的个人的不稳定住房状况知之甚少。确定与接受透析的美国退伍军人住房不稳定相关的因素，并估计不稳定住房与死亡风险的关联。这项回顾性队列研究使用了美国退伍军人健康管理局 (VHA) 和美国肾脏数据系统针对 2012 年 10 月 1 日至 2018 年 12 月 31 日期间开始透析的患者的数据。如果退伍军人使用 VHA 门诊服务并在开始透析前的 3 年内完成 1 次或多次不稳定住房筛查，则纳入该研究。数据分析时间为2023年1月24日至6月16日。不稳定住房定义为自我报告的过去2个月内没有稳定住房或对未来2个月内稳定住房有担忧的情况。主要结果是全因死亡率。检查了透析开始时与不稳定外壳相关的特征。使用多变量 Fine 和 Gray 累积发生率模型，将移植视为竞争风险，将年龄视为效果调节剂，以检查与不稳定住房相关的死亡风险。这项研究包括 25 689 名退伍军人，中位年龄为 68（IQR，62-74）岁。大多数参与者是男性（98%），超过一半（52%）是白人。在开始透析之前的 3 年内，有 771 名退伍军人 (3%) 的不稳定住房筛查结果呈阳性。与拥有稳定住房的退伍军人相比，住房不稳定的退伍军人更年轻（平均[SD]年龄，61 [8] vs 68 [10]岁），更有可能是黑人（45% vs 32%）或西班牙裔（9% vs 7%），并且更有可能开始使用中心静脉导管透析（77% vs 66%），接受中心血液透析（96% vs 66%） 91%），并且拥有非医疗保险（53% vs 28%）。与不稳定住房相关的因素包括西班牙裔、非动静脉瘘血管通路、缺乏透析前肾病护理和非医疗保险。住房不稳定的退伍军人的全因死亡率较高（调整后的风险比 [AHR] 为 1.20 [95% CI，1.04 至 1.37]，中位年龄为 68 岁），并且风险随着年龄的增长而增加（交互作用的 P = .01）。在年龄分层分析中，不稳定的住房与 75 至 85 岁退伍军人的较高死亡率相关（AHR，1.64 [95% CI，1.18 至 2.28]），但在其他年龄组中没有观察到这种关联。在这项针对接受透析的退伍军人的队列研究中，开始透析前经历的不稳定住房与全因死亡风险增加相关，并且风险随着年龄的增长而增加。需要进一步努力了解住房不稳定的老年人的经历，并估计所有接受透析的个人中不稳定住房的范围。
Among US veterans receiving dialysis, is unstable housing associated with mortality and does risk differ according to age? In this cohort study of 25 689 veterans receiving dialysis, unstable housing was associated with an increased risk of all-cause mortality, and this risk increased with age. These findings suggest that unstable housing may contribute to socioeconomic disparities in mortality among US veterans receiving dialysis, with older adults being particularly vulnerable. This cohort study identifies characteristics associated with unstable housing among US veterans receiving dialysis and estimates the association between unstable housing and mortality risk. Housing status is an important health determinant, yet little is known about unstable housing among individuals receiving dialysis. To determine factors associated with unstable housing among US veterans receiving dialysis and to estimate the association of unstable housing with risk of death. This retrospective cohort study used data from the US Veterans Health Administration (VHA) and the US Renal Data System for patients who initiated dialysis between October 1, 2012, and December 31, 2018. Veterans were included if they used VHA outpatient services and completed 1 or more unstable housing screenings within a 3-year period before starting dialysis. Data analysis was conducted from January 24 to June 16, 2023. Unstable housing was defined as self-report of not having stable housing within the past 2 months or having concerns about stable housing in the next 2 months. The main outcome was all-cause mortality. Characteristics associated with unstable housing at the time of dialysis initiation were examined. The multivariate Fine and Gray cumulative incidence model was used, treating transplant as a competing risk and age as an effect modifier, to examine the risk of death associated with unstable housing. This study included 25 689 veterans, with a median age of 68 (IQR, 62-74) years. Most participants were men (98%), and more than half (52%) were White. There were 771 veterans (3%) with a positive screen for unstable housing within a 3-year period before starting dialysis. Compared with veterans with stable housing, those with unstable housing were younger (mean [SD] age, 61 [8] vs 68 [10] years), were more likely to be Black (45% vs 32%) or Hispanic (9% vs 7%), and were more likely to start dialysis with a central venous catheter (77% vs 66%), receive in-center hemodialysis (96% vs 91%), and have non-Medicare insurance (53% vs 28%). Factors associated with unstable housing included Hispanic ethnicity, non–arteriovenous fistula vascular access, lack of predialysis nephrology care, and non-Medicare insurance. Veterans with unstable housing had higher all-cause mortality (adjusted hazard ratio [AHR], 1.20 [95% CI, 1.04 to 1.37] for a median age of 68 years), and risks increased with age (P = .01 for interaction). In age-stratified analyses, unstable housing was associated with higher mortality among veterans aged 75 to 85 years (AHR, 1.64 [95% CI, 1.18 to 2.28]), but associations were not observed for other age groups. In this cohort study of veterans receiving dialysis, unstable housing experienced before starting dialysis was associated with increased risk of all-cause mortality, and risks increased with age. Further efforts are needed to understand the experiences of older adults with unstable housing and to estimate the scope of unstable housing among all individuals receiving dialysis.
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5.5
作者：
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