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  • Association between maternal employment status and presence of children with major congenital anomalies in Denmark. BMC public health Kim, K. M., Farkas, D. K., Wong, V., Hjorth, C. F., Horváth-Puhó, E., Cahan, E., Cohen, E., Shah, N. R., Sørensen, H. T., Milstein, A. 2024; 24 (1): 715


    The burden of caring for children with complex medical problems such as major congenital anomalies falls principally on mothers, who in turn suffer a variety of potentially severe economic consequences. As well, health consequences of caregiving often further impact the social and economic prospects of mothers of children with major congenital anomalies (MCMCAs). Evaluating the long-term economic consequences of extensive in-home caregiving among MCMCAs can inform strategies to mitigate these effects.To assess whether MCMCAs face reduced employment and increased need for disability benefits over a 20-year period.A population-based matched cohort study.Denmark.All women who gave birth to a singleton child with a major congenital anomaly in Denmark between January 1, 1997 and December 31, 2017 (n = 23,637) and a comparison cohort of mothers matched by maternal age, parity, and infant's year of birth (n = 234,586).Liveborn infant with a major congenital anomaly.The primary outcome was mothers' employment status, stratified by their child's age. Employment status was categorized as employed, outside the workforce (on temporary leave, holding a flexible job, or pursuing education), or unemployed; the number of weeks in each category was measured over time. The secondary outcome was time to receipt of a disability pension, which in Denmark implies permanent exit from the labor market. We used a negative binomial regression model to estimate the number of weeks in each employment category, stratified by the child's age (i.e., 0-1 year, > 1-6 years, 7-13 years, 14-18 years). A Cox proportional hazards regression model was used to compute hazard ratios as a measure of the relative risk of receiving a disability pension. Rate ratios and hazard ratios were adjusted for maternal demographics, pregnancy history, health, and infant's year of birth.During 1-6 years after delivery, MCMCAs were outside the workforce for a median of 50 weeks (IQR, 6-107 weeks), while members of the comparison cohort were outside the workforce for a median of 48 weeks (IQR, 4-98 weeks), corresponding to an adjusted rate ratio [ARR] of 1.05 (95% confidence interval [CI], 1.04-1.07). During the first year after delivery, MCMCAs were more likely to be employed than mothers in the comparison cohort (ARR, 1.08; 95% CI, 1.06-1.10). At all timepoints thereafter, MCMCAs had a lower rate of workforce participation. The rate of being outside the workforce was 5% higher than mothers in the comparison cohort during 1-6 years after delivery (ARR, 1.05; 95% CI, 1.04-1.07), 9% higher during 7-13 years after delivery (ARR, 1.09; 95% CI, 1.06-1.12), and 12% higher during 14-18 years after delivery (ARR, 1.12; 95% CI, 1.07-1.18). Overall, MCMCAs had a 20% increased risk of receiving a disability pension during follow-up than mothers in the matched comparison cohort [incidence rates 3.10 per 1000 person-years (95% CI, 2.89-3.32) vs. 2.34 per 1000 person-years (95% CI, 2.29-2.40), adjusted hazard ratio, 1.20; 95% CI, 1.11-1.29].MCMCAs were less likely to participate in the Danish workforce, less likely to be employed, and more likely to receive disability pensions than mothers of unaffected children. The rate of leaving the workforce intensified as their affected children grew older. The high demands of caregiving among MCMCAs may have long-term employment consequences even in nations with comprehensive and heavily tax-supported childcare systems, such as Denmark.

    View details for DOI 10.1186/s12889-024-18190-w

    View details for PubMedID 38443822

    View details for PubMedCentralID 7203968

  • Disparities in Preoperative Goals of Care Documentation in Veterans. JAMA network open Wu, A., Giannitrapani, K. F., Garcia, A., Bozkurt, S., Boothroyd, D., Adams, A. S., Kim, K. M., Zhang, S., McCaa, M. D., Morris, A. M., Shreve, S., Lorenz, K. A. 2023; 6 (12): e2348235


    Preoperative goals of care discussion and documentation are important for patients undergoing surgery, a major health care stressor that incurs risk.To assess the association of race, ethnicity, and other factors, including history of mental health disability, with disparities in preoperative goals of care documentation among veterans.This retrospective cross-sectional study assessed data from the Veterans Healthcare Administration (VHA) of 229 737 veterans who underwent surgical procedures between January 1, 2017, and October 18, 2022.Patient-level (ie, race, ethnicity, medical comorbidities, history of mental health comorbidity) and system-level (ie, facility complexity level) factors.Preoperative life-sustaining treatment (LST) note documentation or no LST note documentation within 30 days prior to or on day of surgery. The standardized mean differences were calculated to assess the magnitude of differences between groups. Odds ratios (ORs) and 95% CIs were estimated with logistic regression.In this study, 13 408 patients (5.8%) completed preoperative LST from 229 737 VHA patients (209 123 [91.0%] male; 20 614 [9.0%] female; mean [SD] age, 65.5 [11.9] years) who received surgery. Compared with patients who did complete preoperative LST, patients tended to complete preoperative documentation less often if they were female (19 914 [9.2%] vs 700 [5.2%]), Black individuals (42 571 [19.7%] vs 2416 [18.0%]), Hispanic individuals (11 793 [5.5%] vs 631 [4.7%]), or from rural areas (75 637 [35.0%] vs 4273 [31.9%]); had a history of mental health disability (65 974 [30.5%] vs 4053 [30.2%]); or were seen at lowest-complexity (ie, level 3) facilities (7849 [3.6%] vs 78 [0.6%]). Over time, despite the COVID-19 pandemic, patients undergoing surgical procedures completed preoperative LST increasingly more often. Covariate-adjusted estimates of preoperative LST completion demonstrated that patients of racial or ethnic minority background (Black patients: OR, 0.79; 95% CI, 0.77-0.80; P <.001; patients selecting other race: OR, 0.78; 95% CI, 0.74-0.81; P <.001; Hispanic patients: OR, 0.78; 95% CI, 0.76-0.81; P <.001) and patients from rural regions (OR, 0.91; 95% CI, 0.90-0.93; P <.001) had lower likelihoods of completing LST compared with patients who were White or non-Hispanic and patients from urban areas. Patients with any mental health disability history also had lower likelihood of completing preoperative LST than those without a history (OR, 0.93; 95% CI, 0.92-0.94; P = .001).In this cross-sectional study, disparities in documentation rates within a VHA cohort persisted based on race, ethnicity, rurality of patient residence, history of mental health disability, and access to high-volume, high-complexity facilities.

    View details for DOI 10.1001/jamanetworkopen.2023.48235

    View details for PubMedID 38113045

    View details for PubMedCentralID PMC10731481

  • The association between cognitive ability and opioid prescribing in vulnerable older adults with chronic pain in ambulatory care: a secondary data analysis using the Medical Expenditure Panel Survey. BMC medicine Muench, U., Kim, K. M., Zimmer, Z., Monroe, T. B. 2023; 21 (1): 446


    Vulnerable older adults living with Alzheimer's disease or Alzheimer's disease and related dementia (AD/ADRD) and chronic pain generally receive fewer pain medications than individuals without AD/ADRD, especially in nursing homes. Little is known about pain management in older adults with AD/ADRD in the community. The aim of the study was to examine opioid prescribing patterns in individuals with chronic pain by levels of cognitive ability in ambulatory care.We used the Medical Expenditure Panel Survey (MEPS), years 2002-2017, and identified three levels of cognitive impairment: no cognitive impairment (NCI), individuals reporting cognitive impairment (CI) without an AD/ADRD diagnosis, and individuals with a diagnosis of AD/ADRD. We examined any receipt of an opioid prescription and the number of opioid prescriptions using a logistic and negative binomial regression adjusting for sociodemographic and health characteristics and stratifying by three types of chronic pain (any chronic pain, severe chronic pain, and chronic pain identified through ICD 9/10 chronic pain diagnoses).Among people with any chronic pain, adjusted odds of receiving an opioid for people with CI (OR 1.41, 95% confidence interval 1.31-1.52) and AD/ADRD (OR 1.23, 95% confidence interval 1.04-1.45) were higher compared to NCI. Among people with chronic pain ICD 9/10 conditions, the odds of receiving an opioid were also higher for those with CI (OR 1.43, 95% confidence interval 1.34-1.56) and AD/ADRD (OR 1.48, 95% confidence interval 1.23-1.78) compared to NCI. Among those with severe chronic pain, people with CI were more likely to receive an opioid (OR 1.17, 95% confidence interval 1.07-1.27) relative to NCI (OR 0.89, 95% confidence interval 0.75-1.06). People with AD/ADRD experiencing severe chronic pain were not more likely to receive an opioid compared to the NCI group. Adjusted predicted counts of opioid prescriptions showed more opioids in CI and AD/ADRD in all chronic pain cohorts, with the largest numbers of opioid prescriptions in the severe chronic pain and ICD 9/10 diagnoses groups.The results suggest increased opioid use in people living with CI and AD/ADRD in the ambulatory care setting and potentially indicate that these individuals either require more analgesics or that opioids may be overprescribed. Further research is needed to examine pain management in this vulnerable population.

    View details for DOI 10.1186/s12916-023-03133-w

    View details for PubMedID 37974164

    View details for PubMedCentralID 3201926

  • Effectiveness of Combined Health Coaching and Self-Monitoring Apps on Weight-Related Outcomes in People With Overweight and Obesity: Systematic Review and Meta-analysis. Journal of medical Internet research Chew, H. S., Rajasegaran, N. N., Chin, Y. H., Chew, W. S., Kim, K. M. 2023; 25: e42432


    BACKGROUND: Self-monitoring smartphone apps and health coaching have both individually been shown to improve weight-related outcomes, but their combined effects remain unclear.OBJECTIVE: This study aims to examine the effectiveness of combining self-monitoring apps with health coaching on anthropometric, cardiometabolic, and lifestyle outcomes in people with overweight and obesity.METHODS: Relevant articles published from inception till June 9, 2022, were searched through 8 databases (Embase, CINAHL, PubMed, PsycINFO, Scopus, The Cochrane Library, and Web of Science). Effect sizes were pooled using random-effects models. Behavioral strategies used were coded using the behavior change techniques taxonomy V1.RESULTS: A total of 14 articles were included, representing 2478 participants with a mean age of 39.1 years and a BMI of 31.8 kg/m2. Using combined intervention significantly improved weight loss by 2.15 kg (95% CI -3.17 kg to -1.12 kg; P<.001; I2=60.3%), waist circumference by 2.48 cm (95% CI -3.51 cm to -1.44 cm; P<.001; I2=29%), triglyceride by 0.22 mg/dL (95% CI -0.33 mg/dL to 0.11 mg/dL; P=.008; I2=0%), glycated hemoglobin by 0.12% (95% CI -0.21 to -0.02; P=.03; I2=0%), and total calorie consumption per day by 128.30 kcal (95% CI -182.67 kcal to -73.94 kcal; P=.003; I2=0%) kcal, but not BMI, blood pressure, body fat percentage, cholesterol, and physical activity. Combined interventional effectiveness was superior to receiving usual care and apps for waist circumference but only superior to usual care for weight loss.CONCLUSIONS: Combined intervention could improve weight-related outcomes, but more research is needed to examine its added benefits to using an app.TRIAL REGISTRATION: PROSPERO CRD42022345133;

    View details for DOI 10.2196/42432

    View details for PubMedID 37071452

  • Patient Characteristics Associated With Occurrence of Preoperative Goals-of-Care Conversations. JAMA network open Kim, K. M., Giannitrapani, K. F., Garcia, A., Boothroyd, D., Wu, A., Van Cleve, R., McCaa, M. D., Yefimova, M., Aslakson, R. A., Morris, A. M., Shreve, S. T., Lorenz, K. A. 2023; 6 (2): e2255407


    Communication about patients' goals and planned and potential treatment is central to advance care planning. Undertaking or confirming advance care plans is also essential to preoperative preparation, particularly among patients who are frail or will undergo high-risk surgery.To evaluate the association between patient risk of hospitalization or death and goals-of-care conversations documented with a completed Life-Sustaining Treatment (LST) Decisions Initiative note among veterans undergoing surgery.This retrospective cross-sectional study included 190 040 veterans who underwent operations between January 1, 2017, and February 28, 2020. Statistical analysis took place from November 1, 2021, to November 17, 2022.Patient risk of hospitalization or death, evaluated with a Care Assessment Need (CAN) score (range, 0-99, with a higher score representing a greater risk of hospitalization or death), dichotomized as less than 80 or 80 or more.Preoperative LST note completion (30 days before or on the day of surgery) or no LST note completion within the 30-day preoperative period prior to or on the day of the index operation.Of 190 040 veterans (90.8% men; mean [SD] age, 65.2 [11.9] years), 3.8% completed an LST note before surgery, and 96.2% did not complete an LST note. In the groups with and without LST note completion before surgery, most were aged between 65 and 84 years (62.1% vs 56.7%), male (94.3% vs 90.7%), and White (82.2% vs 78.3%). Compared with patients who completed an LST note before surgery, patients who did not complete an LST note before surgery tended to be female (9.3% vs 5.7%), Black (19.2% vs 15.7%), married (50.2% vs 46.5%), and in better health (Charlson Comorbidity Index score of 0, 25.9% vs 15.2%); to have a lower risk of hospitalization or death (CAN score <80, 98.3% vs 96.9%); or to undergo neurosurgical (9.8% vs 6.2%) or urologic surgical procedures (5.9% vs 2.0%). Over the 3-year interval, unadjusted rates of LST note completion before surgery increased from 0.1% to 9.6%. Covariate-adjusted estimates of LST note completion indicated that veterans at a relatively elevated risk of hospitalization or death (CAN score ≥80) had higher odds of completing an LST note before surgery (odds ratio [OR], 1.29; 95% CI, 1.09-1.53) compared with those with CAN scores less than 80. High-risk surgery was not associated with increased LST note completion before surgery (OR, 0.93; 95% CI, 0.86-1.01). Veterans who underwent cardiothoracic surgery had the highest likelihood of LST note completion before surgery (OR, 1.35; 95% CI, 1.24-1.47).Despite increasing LST note implementation, a minority of veterans completed an LST note preoperatively. Although doing so was more common among veterans with an elevated risk compared with those at lower risk, improving proactive communication and documentation of goals, particularly among higher-risk veterans, is needed. Doing so may promote goal-concordant surgical care and outcomes.

    View details for DOI 10.1001/jamanetworkopen.2022.55407

    View details for PubMedID 36757697

  • Racial Disparities in Inpatient Palliative Care Consultation among Frail Older Patients who Underwent High-Risk Elective Surgical Procedures. Health Affairs Scholar Kim, K., Muench, U., Maki, J. E., Yefimova, M., Oh, A., Jopling, J. K., Rinaldo, F., Shah, N. R., Giannitrapani,, K., Williams, M. Y., Lorenz, K. A. 2023; 1 (2)

    View details for DOI 10.1093/haschl/qxad026

  • Evaluation of Clinical and Economic Outcomes Following Implementation of a Medicare Pay-for-Performance Program for Surgical Procedures. JAMA network open Kim, K. M., White, J. S., Max, W., Chapman, S. A., Muench, U. 2021; 4 (8): e2121115


    Importance: Surgical complications increase hospital costs by approximately $20 000 per admission and extend hospital stays by 9.7 days. Improving surgical care quality and reducing costs is needed for patients undergoing surgery, health care professionals, hospitals, and payers.Objective: To evaluate the association of the Hospital-Acquired Conditions Present on Admission (HAC-POA) program, a mandated national pay-for-performance program by the Centers for Medicare & Medicaid Services, with surgical care quality and costs.Design, Setting, and Participants: A cross-sectional study of Medicare inpatient surgical care stays from October 2004 through September 2017 in the US was conducted. The National Inpatient Sample and a propensity score-weighted difference-in-differences analysis of hospital stays with associated primary surgical procedures was used to compare changes in outcomes for the intervention and control procedures before and after HAC-POA program implementation. The sample consisted of 1 317 262 inpatient surgical episodes representing 1 198 665 stays for targeted procedures and 118 597 stays for nontargeted procedures. Analyses were performed between November 1, 2020, and May 7, 2021.Exposures: Implementation of the HAC-POA program for the intervention procedures included in this study (fiscal year 2009).Main Outcomes and Measures: Incidence of surgical site infections and deep vein thrombosis, length of stay, in-hospital mortality, and hospital costs. Analyses were adjusted for patient and hospital characteristics and indicators for procedure type, hospital, and year.Results: In our propensity score-weighted sample, the intervention procedures group comprised 1 047 351 (88.5%) individuals who were White and 742 734 (60.6%) women; mean (SD) age was 75 (6.9) years. The control procedures group included 94 715 (88.0%) individuals who were White, and 65 436 (60.6%) women; mean (SD) age was 75 (7.1) years. After HAC-POA implementation, the incidence of surgical site infections in targeted procedures decreased by 0.3 percentage points (95% CI, -0.5 to -0.1 percentage points; P=.02) compared with nontargeted procedures. The program was associated with a reduction in length of stay by 0.5 days (95% CI, -0.6 to -0.4 days; P<.001) and hospital costs by 8.1% (95% CI, -10.2% to -6.1%; P<.001). No significant changes in deep vein thrombosis incidence and mortality were noted.Conclusions and Relevance: The findings of this study suggest that the HAC-POA program is associated with small decreases in surgical site infection and length of stay and moderate decreases in hospital costs for patients enrolled in Medicare. Policy makers may consider these findings when evaluating the continuation and expansion of this program for other surgical procedures, and payers may want to consider adopting a similar policy.

    View details for DOI 10.1001/jamanetworkopen.2021.21115

    View details for PubMedID 34406402

  • Mothers of children with major congenital anomalies have increased health care utilization over a 20-year post-birth time horizon. PloS one Shah, N. R., Kim, K. M., Wong, V., Cohen, E., Rosenbaum, S., Cahan, E. M., Milstein, A., Sorensen, H. T., Horvath-Puho, E. 2021; 16 (12): e0260962


    OBJECTIVE: This population-based, matched cohort study aimed to evaluate utilization of health care services by mothers of children with major congenital anomalies (MCAs), compared to mothers of children without MCAs over a 20-year post-birth time horizon in Denmark.METHODS: Our analytic sample included mothers who gave birth to an infant with a MCA (n = 23,927) and a cohort of mothers matched to them by maternal age, parity and infant's year of birth (n = 239,076). Primary outcomes were period prevalence and mothers' quantity of health care utilization (primary, inpatient, outpatient, surgical, and psychiatric services) stratified by their child's age (i.e., ages 0-6 = before school, ages 7-13 = pre-school + primary education, and ages 14-18 = secondary education or higher). The secondary outcome measure was length of hospital stays. Outcome measures were adjusted for maternal age at delivery, parity, marital status, income quartile, level of education in the year prior to the index birth, previous spontaneous abortions, maternal pregnancy complications, maternal diabetes, hypertension, alcohol-related diseases, and maternal smoking.RESULTS: In both cohorts the majority of mothers were between 26 and 35 years of age, married, and employed, and 47% were primiparous. Mothers of infants with anomalies had greater utilization of outpatient, inpatient, surgical, and psychiatric services, compared with mothers in the matched cohort. Inpatient service utilization was greater in the exposed cohort up to 13 years after a child's birth, with the highest risk in the first six years after birth [adjusted risk ratio, 1.13; 95% confidence interval (CI), 1.12-1.14], with a decrease over time. Regarding the quantity of health care utilization, the greatest difference between the two groups was in inpatient service utilization, with a 39% increased rate in the exposed cohort during the first six years after birth (adjusted rate ratio, 1.39; 95% CI, 1.37-1.42). During the first 6 years after birth, mothers of children with anomalies stayed a median of 6 days (interquartile range [IQR], 3-13) in hospital overall, while the comparison cohort stayed a median of 4 days (IQR, 2-7) in hospital overall. Rates of utilization of outpatient clinics (adjusted rate ratio, 1.36; 95% CI, 1.29-1.42), as well as inpatient (adjusted rate ratio, 1.77; 95% CI, 1.68-1.87), and surgical services (adjusted rate ratio, 1.33; 95% CI, 1.26-1.41) was higher in mothers of children with multiple-organ MCAs during 0 to 6 years after birth. Among mothers at the lowest income levels, utilization of psychiatric clinic services increased to 59% and when their child was 7 to 13 years of age (adjusted rate ratio, 1.59; 95% CI, 1.24-2.03).CONCLUSION: Mothers of infants with a major congenital anomaly had greater health care utilization across services. Health care utilization decreased over time or remained stable for outpatient, inpatient, and surgical care services, whereas psychiatric utilization increased for up to 13 years after an affected child's birth. Healthcare utilization was significantly elevated among mothers of children with multiple MCAs and among those at the lowest income levels.

    View details for DOI 10.1371/journal.pone.0260962

    View details for PubMedID 34879106

  • Do penalty-based pay-for-performance programs improve surgical care more effectively than other payment strategies? A systematic review. Annals of medicine and surgery (2012) Kim, K. M., Max, W. n., White, J. S., Chapman, S. A., Muench, U. n. 2020; 60: 623–30


    The aim of this systematic review is to assess if penalty-based pay-for-performance (P4P) programs are more effective in improving quality and cost outcomes compared to two other payment strategies (i.e., rewards and a combination of rewards and penalties) for surgical care in the United States. Penalty-based programs have gained in popularity because of their potential to motivate behavioral change more effectively than reward-based programs to improve quality of care. However, little is known about whether penalties are more effective than other strategies.A systematic literature review was conducted according to the PRISMA guideline to identify studies that evaluated the effects of P4P programs on quality and cost outcomes for surgical care. Five databases were used to search studies published from 2003 to March 1, 2020. Studies were selected based on the PRISMA guidelines. Methodological quality of individual studies was assessed based on ROBINS-I with GRADE approach.This review included 22 studies. Fifteen cross-sectional, 1 prospective cohort, 4 retrospective cohort, and 2 case-control studies were found. We identified 11 unique P4P programs: 5 used rewards, 3 used penalties, and 3 used a combination of rewards and penalties as a payment strategy. Five out of 10 studies reported positive effects of penalty-based programs, whereas evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null.This review highlights that P4P programs with a penalty design could be more effective than programs using rewards or a combination of rewards and penalties to improve quality of surgical care.

    View details for DOI 10.1016/j.amsu.2020.11.060

    View details for PubMedID 33304576

    View details for PubMedCentralID PMC7711081

  • Work-Related Perceptions, Injuries, and Musculoskeletal Symptoms: Comparison Between U.S.-Educated and Foreign-Educated Nurses. Workplace health & safety Kim, K. M., Lee, S. J. 2019; 67 (7): 326-337


    Immigrants account for a significant proportion of the nursing workforce in the United States (U.S.). Although different cultural backgrounds may affect immigrant nurses' perceptions of work and occupational health risks, little research has been conducted. Defining immigrant nurses as those who received initial nursing education in foreign countries, this study examined the differences in work-related perceptions and experiences of musculoskeletal (MS) symptoms and injuries between U.S.-educated and foreign-educated nurses. We analyzed data from a cross-sectional study using a statewide random sample of 419 California registered nurses. Foreign-educated nurses reported a more positive safety climate (p = .017) and perceived their jobs as less demanding (p = .008) than did U.S.-educated nurses. The prevalence of work-related MS symptoms was significantly lower in foreign-educated nurses than in U.S.-educated nurses (p = .044), but the difference was not significant in the multivariable analyses. Positive safety climate was significantly associated with a decreased risk of work-related MS symptoms and injuries, and this relationship was greater among U.S.-educated nurses than among foreign-educated nurses. Our findings suggest that immigrant nurses may have different perceptions about safety climate and job demand, which may modify their occupational health risks.

    View details for DOI 10.1177/2165079918821699

    View details for PubMedID 30836855