Neil Kamdar
Assistant Director of Analytics, Center for Population Health Sciences
Biostatistician 3, Center for Population Health Sciences
Bio
I am a health services researcher and applied methodologist focused on clinical and policy applications in disabilities research, women's health, general surgery, and mental health analyses. My focus has been on leveraging Medicare, private payer claims (Health Care Cost Institute (HCCI), MarketScan, OptumInsight, etc.) and Medicaid to understand cost, utilization, and outcomes. This work has been foundational in the development of large-scale studies on vulnerable populations that have typically been under-served or insufficiently studies in the health services research domain.
I serve as the Assistant Director of Analytics at the Center for Population Health Sciences at Stanford, focused on the development of the American Family Cohort (AFC) data, a primary care registry that provides substantial insights into clinical outcomes, utilization, and a particular focus on COVID-19 and Long COVID outcome analyses. Ancillary work would involve the development of research collaborations throughout Stanford Medicine with the interest in creating scholarship across the many domains of the Center for Population Health Sciences.
In addition to this role at Stanford, I also maintain an appointment at the University of Michigan, Institute for Healthcare Policy and Innovation, where I serve as an analytic lead in the development of administrative claims and electronic medical records analyses leading to publications in general and subject-specific journals.
I have been successful in being funded as a co-investigator with several federal and foundation agencies, including the National Institutes of Health (NIH), Department of Defense (DOD), Agency for Healthcare Research and Quality (AHRQ), Neilsen Foundation focused on traumatic spinal cord injury, among many others. I have also provided foundational analyses in the development of Clinical Quality Initiatives (CQIs), which are state-wide initiatives aimed at improving the health and efficiency of hospitals and institutions, with a focus on maternal and fetal medicine in the State of Michigan.
Contact
https://orcid.org/0000-0002-1898-1594All Publications
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Primary care screening for sexually transmitted infections in the United States from 2019 to 2021.
PloS one
2025; 20 (6): e0325097
Abstract
Early identification and treatment of sexually transmitted infections (STIs) is critical to improve patient outcomes. Barriers to healthcare seeking are potentially exacerbated by COVID-19. This study examined trends in STI testing and positivity from 2019 to 2021 in primary care in the United States.This is a retrospective study using the PRIME Registry, a national primary care EHR registry, from January 1, 2019-December 31, 2021. We calculated age-standardized monthly and annual testing rates for chlamydia, gonorrhea, syphilis, and human immunodeficiency virus stratified by gender and race/ethnicity. We also generated quarterly and annual rates for test positivity. Chi-square tests and 95% confidence intervals were used for comparison. 753 practices and 4,410,609 patients were included, with 180,558 having STI tests.We observed a substantial decline in testing rates for STIs from March-April 2020 (31% for chlamydia, 30% for gonorrhea, 23% for syphilis, 24% for HIV), followed by a rapid increase in May-June 2020 (64% for chlamydia, 65% for gonorrhea, 32% for syphilis, 48% for HIV). Testing rates per 100,000 decreased from 2019 to 2021 for chlamydia (3,592 vs 2,355 vs 2,181) while increased for gonorrhea in 2020 (2,129 vs 2,207 vs 2,057). STI testing rates from 2019 to 2021 for females and non-Hispanic Black or African American patients were higher than other groups. An increase in test positivity from 2019 to 2021 was observed for gonorrhea (0.4% vs 0.4% vs 0.5%) but no significant change for chlamydia (1.5% vs 1.6% vs 1.5%).Testing rates for STIs substantially dropped during stay-at-home orders early in the pandemic and recovered after these were relaxed. Gender and race/ethnicity STI testing differences may reflect primary care's prioritization of higher risk populations. This study emphasizes the role of primary care EHR data in monitoring and an opportunity for closer collaboration with public health agencies.
View details for DOI 10.1371/journal.pone.0325097
View details for PubMedID 40455810
View details for PubMedCentralID PMC12129226
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Emergency Department Boarding, Inpatient Census, and Interhospital Transfer Acceptances.
JAMA network open
2025; 8 (5): e2512299
Abstract
Referral hospitals in the US are experiencing unprecedented levels of crowding, leading them to increasingly refuse interhospital transfer (IHT) requests. Crowded hospitals are dangerous, but refusing IHTs undermines the role of referral hospitals and may cause harm.To measure associations of hospital crowding measures (emergency department [ED] boarding and inpatient census) with IHT acceptances overall and for prioritized conditions.This cross-sectional study from January 2019 to May 2023 analyzed data from the only academic and level I trauma center in a highly rural state in the Southwestern US, including transfer center data, ED boarding hours, and inpatient census. All transfer center calls regarding adults (age >18 years) were eligible for the study. Data were analyzed from June to October 2024.The primary outcome was the proportion of transfer requests accepted on a weekly and monthly basis. Adjusted logistic regression was used to analyze associations of ED boarding time and inpatient census with IHT acceptance, considering prioritized conditions (obstetrics, ST-elevation myocardial infarction [STEMI], stroke, and trauma) and rurality. Transfer data contained IHT request descriptors, including referring facility, date and time of call, decision (accept or decline), diagnosis, and patient demographics. ED boarding was measured daily as a sum of all boarding hours for each ED patient.The study included 26 020 IHT requests (11 267 women [43.2%]; mean [SD] age, 54.4 [19.6] years), of which 16 062 were accepted (61.7%). There were 22 119 (85.0%) requests from urban and 3901 requests (15.0%) from rural hospitals, with the majority of IHT requests (19 912 requests [76.3%]) seeking transfer from an ED. There was a negative correlation between IHT acceptance and ED boarding (Pearson r, -0.73) and inpatient census (Pearson r, -0.87). At times of worst ED boarding (highest vs lowest quartile), the odds of IHT acceptance were lower (adjusted odds ratio [aOR], 0.71; 95% CI, 0.66-0.78). Of the 3901 rural requests, 2196 (56.3%) were accepted, with lower odds of acceptance for rural vs urban requests (aOR, 0.66; 95% CI, 0.64-0.79). Prioritized diagnoses were more commonly accepted, particularly obstetrics (aOR, 5.28; 95% CI, 4.17-6.70), STEMI (aOR, 3.04; 95% CI, 1.86-4.98), and trauma (aOR, 3.19; 95% CI, 2.86, 3.57).In this cross-sectional study of IHT requests, the severity of ED boarding and inpatient census were associated with decreased IHT acceptance, suggesting that overcrowded referral hospitals face tradeoffs as they seek to fulfill seemingly conflicting obligations to safely care for locally hospitalized patients and accept regional patients seeking transfer.
View details for DOI 10.1001/jamanetworkopen.2025.12299
View details for PubMedID 40434774
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Medication and Therapy Profiles for Pain and Symptom Management Among Adults With Cerebral Palsy.
Mayo Clinic proceedings. Innovations, quality & outcomes
2025; 9 (2): 100597
Abstract
Objective: To examine the most common patterns of pain and symptom management strategies among adults living with cerebral palsy (CP), and to determine if there are differences by pain phenotype or co-occurring neurodevelopmental disorders.Patients and Methods: Federally insured beneficiaries were included if they had an ICD-9-CM/ICD-10-CM diagnosis code for CP (N=41,595). The study took place from January 10, 2024, to December 15, 2024. Medication and therapy prescription estimates for pain and CP symptom management were examined for the entire cohort, and between individuals with and without neurodevelopmental disorders and across pain phenotypes.Results: The most common pharmaceutical/nontherapy-based pain and symptom management interventions included high frequency prescriptions for antiepileptics (58%), antidepressants (49%), benzodiazepines (43%), nonsteroidal anti-inflammatories (43%), nonperioperative opioids (42%), antipsychotics (33%), muscle relaxants (31%), irritable bowel syndrome-specific drugs (20%), clonidine (12%), anticholinergics (11%), and botulinum toxin A injections (6%). Physical and occupational therapy were prescribed for 41% of the study cohort. Significant differences in treatment patterns were found for individuals with co-occurring neurodevelopmental disorders, and across pain phenotypes. Notably, for individuals with a mixed pain phenotype, nearly 80% were prescribed nonperioperative opioids.Conclusion: Adults with CP have a high prescription prevalence of nonperioperative opioids and common nonopioid pain and symptom management.
View details for DOI 10.1016/j.mayocpiqo.2025.100597
View details for PubMedID 40061300
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Trends in End-of-Life Care and Satisfaction Among Veterans Undergoing Surgery.
Annals of surgery
2025; 281 (4): 682-688
Abstract
To examine trends in end-of-life care services and satisfaction among veterans undergoing any inpatient surgery.The Veterans Health Administration has undergone system-wide transformations to improve end-of-life care yet the impacts on end-of-life care services use and family satisfaction are unknown.We performed a retrospective, cross-sectional analysis of veterans who died within 90 days of undergoing inpatient surgery between January 2010 and December 2019. Using the Veterans Affairs (VA) Bereaved Family Survey (BFS), we calculated the rates of palliative care and hospice use and examined satisfaction with end-of-life care. After risk and reliability adjustment for each VA hospital, we then performed a multivariable linear regression model to identify factors associated with the greatest change.Our cohort consisted of 155,250 patients with a mean age of 73.6 years (SD: 11.6). Over the study period, rates of palliative care consultation and hospice use increased more than two-fold (28.1%-61.1% and 18.9%-46.9%, respectively) while the rate of BFS excellent overall care score increased from 56.1% to 64.7%. There was wide variation between hospitals in the absolute change in rates of palliative care consultation, hospice use, and BFS excellent overall care scores. Rural location and Accreditation Council for Graduate Medical Education accreditation were hospital-level factors associated with the greatest changes.Among veterans undergoing inpatient surgery, improvements in satisfaction with end-of-life care paralleled increases in end-of-life care service use. Future work is needed to identify actionable hospital-level characteristics that may reduce heterogeneity between VA hospitals and facilitate targeted interventions to improve end-of-life care.
View details for DOI 10.1097/SLA.0000000000006253
View details for PubMedID 38390769
View details for PubMedCentralID PMC11341773
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Treatment of Chlamydia and Gonorrhea in Primary Care and Its Patient-Level Variation: An American Family Cohort Study.
Annals of family medicine
2025; 23 (2): 136-144
Abstract
Chlamydia and gonorrhea are the 2 most common bacterial sexually transmitted infections in the United States. Nonadherence to the Centers for Disease Control and Prevention treatment guidelines remains a concern. We examined how well chlamydia and gonorrhea treatment in primary care settings adhered to guidelines.We used electronic health records from the PRIME registry to identify patients with diagnosis codes or positive test results for chlamydia and/or gonorrhea from 2018 to 2022. Outcomes were the first dates of antibiotic administered within 30 days after a positive test result for the infection. Descriptive statistics were calculated for patient sociodemographic characteristics. We used a multivariate parametric accelerated failure time analysis with shared frailty modeling to assess associations between these characteristics and time to treatment.We identified 6,678 cases of chlamydia confirmed by a positive test and 2,206 cases of gonorrhea confirmed by a positive test; 75.3% and 69.6% of these cases, respectively, were treated. Females, individuals aged 10-29 years, suburban dwellers, and patients with chlamydia-gonorrhea coinfection had higher treatment rates than comparator groups. Chlamydia was infrequently treated with the recommended antibiotic, doxycycline (14.0% of cases), and gonorrhea was infrequently treated with the recommended antibiotic, ceftriaxone (38.7% of cases). Time to treatment of chlamydia was longer for patients aged 50-59 years (time ratio relative to those aged 20-29 years = 1.61; 95% CI, 1.12-2.30) and for non-Hispanic Black patients (time ratio relative to White patients = 1.17; 95% CI, 1.04-1.33).Guideline adherence remains suboptimal for chlamydia and gonorrhea treatment across primary care practices. Efforts are needed to develop interventions to improve quality of care for these sexually transmitted infections.
View details for DOI 10.1370/afm.240164
View details for PubMedID 40127987
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Epidemiology of urinary tract infection among community-living seniors aged 50 plus: population estimates and risk factors.
Annals of epidemiology
2025
Abstract
Urinary tract infection (UTI) is common in all ages but risk factors among adults 50 and older are not well studied. One unexplored potential risk factor is constipation, a known UTI risk factor among children.A web interview was administered October 12-16, 2023 to 1074 U.S. adults aged 50 and older participating in a probability-based panel representative of the U.S. household population age 50 or older. The primary study outcome was self-reported healthcare provider diagnosed and treated UTI in the previous 12 months. All results were weighted to represent the U.S. household population.The 12-month UTI incidence was 19.8% among women and 6.4% among men. 32% of the population reported being constipated sometimes, frequently or always. After adjusting for age, gender, having a body mass index >30 and an overnight hospital stay in the previous 12 months, those reporting sometimes being constipated were 3.69 times, and those often or always constipated were 5.48 times more likely than those never constipated to have a UTI in the previous 12 months.This is the first report of an association between UTI and constipation among older adults. Reducing constipation might reduce UTI incidence among older women and men.
View details for DOI 10.1016/j.annepidem.2025.02.010
View details for PubMedID 40024385
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Association Among Surgeon Volume, Surgical Approach, and Uterine Size for Hysterectomy for Benign Indications
OBSTETRICS AND GYNECOLOGY
2024; 144 (6): 817-825
Abstract
To assess the relationship between surgeon volume and surgical approach for patients undergoing hysterectomy for benign indications among uteri of varying sizes.This was a retrospective cohort study of patients who underwent hysterectomy for benign indications from 2012 to 2021 within the Michigan Surgical Quality Collaborative registry. For each hysterectomy, the relative annual volume of the performing surgeon was assessed by calculating the proportion of hysterectomy cases contributed by the surgeon each calendar year relative to the total number of hysterectomies in the registry for that year. Hysterectomies were stratified into tertiles: those performed by low-volume surgeons, intermediate-volume surgeons, and high-volume surgeons. Uterine size was represented by the uterine specimen weight and categorized to facilitate clinical interpretation. Multivariable logistic regression models were developed incorporating interaction terms for surgeon volume and uterine size to explore potential effect modification.A total of 54,150 hysterectomies were included. Hysterectomies performed by intermediate- and high-volume surgeons were more likely to be performed through a minimally invasive approach compared with those performed by low-volume surgeons (intermediate-volume: adjusted odds ratio [aOR] 1.68, 95% CI, 1.47-1.92; high-volume: aOR 2.14, 95% CI, 1.87-2.46). Moreover, this likelihood increased with increasing uterine weight. For uteri weighing between 1,000 g and 1,999 g, the odds of minimally invasive approach was significantly higher among intermediate-volume surgeons (aOR 3.38, 95% CI, 2.04-5.12) and high-volume (aOR 9.26, 95% CI, 5.64-15.2) surgeons, compared with low-volume surgeons. After including an interaction term for uterine weight and surgeon volume, we identified effect modification of surgeon volume on the relationship between uterine size and choice of minimally invasive surgery.For uteri up to 3,000 g in weight, hysterectomies performed by high-volume surgeons have a higher likelihood of being performed through a minimally invasive approach compared with those performed by low-volume surgeons.
View details for DOI 10.1097/AOG.0000000000005745
View details for Web of Science ID 001392674600008
View details for PubMedID 39361959
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Characterizing Acute Pulmonary Embolism Cases Diagnosed at an Emergency Department Revisit Using a Statewide Clinical Registry
ANNALS OF EMERGENCY MEDICINE
2024; 84 (5): 530-539
Abstract
To assess the rate and characteristics of acute pulmonary embolism (PE) cases diagnosed in the emergency department (ED) following an ED discharge visit within 10 days.This is a retrospective analysis of 40 EDs in a statewide clinical registry from 2017 to 2022. We identified adult patients with acute PEs diagnosed in the ED. We assessed PE cases wherein a prior ED visit for the same patient resulting in discharge had taken place within 10 days without interval hospitalization. We then characterized the overall rate of revisit PE cases per overall acute PE cases and per 10,000 ED discharges. We also reported on subgroups of revisit cases where the preceding visit resulted in diagnosis of COVID-19, other cardiopulmonary conditions, and cardiopulmonary symptom codes (eg, chest pain, unspecified).Of 24,525 acute PEs, 1,202 (4.9%, 95% confidence interval [CI] 4.6% to 5.2%) had an ED discharge within the preceding 10 days (2.0 per 10,000 ED discharges, 95% CI 1.9 to 2.1). Two hundred thirty-three (19.4%) were originally discharged with a COVID-19 diagnosis, 107 (8.9%) were originally discharged with another cardiopulmonary condition, and 201 (16.7%) were cases discharged with a nonspecific cardiopulmonary symptom code. Discharges with diagnoses of COVID-19, pneumonia, and pleural effusion had higher rates of revisits with acute PE.In this retrospective analysis, about 1 in 20 acute PEs and 2 in 10,000 ED discharges were associated with an ED revisit for acute PE. Some cases may represent potential diagnostic opportunities, whereas others may be progression of disease, risk factors for PE, or unrelated.
View details for DOI 10.1016/j.annemergmed.2024.06.014
View details for Web of Science ID 001339337500001
View details for PubMedID 39033451
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HEAR-MHE study: Automated speech analysis identifies minimal hepatic encephalopathy and may predict future overt hepatic encephalopathy
HEPATOLOGY
2024
Abstract
HE is a major cause of poor quality of life in patients with cirrhosis. A simple diagnostic test to identify minimal hepatic encephalopathy (MHE) and predict future overt HE (OHE) is lacking. We aimed to evaluate if analysis of speech patterns using a modern speech platform (1) correlates with validated HE tests, (2) correlates with MHE, and (3) predicts future OHE.In a two-center prospective cohort study of 200 outpatients with cirrhosis and 50 controls, patients underwent baseline speech recording and validated HE diagnostic testing with psychometric HE score. Patients were followed for 6 months to identify episodes of OHE. Seven hundred fifty-two speech variables were extracted using an automated speech analysis platform, reflecting the acoustic, lexical, and semantic aspects of speech. Patients with cirrhosis were median 63 years old (IQR 54, 68), 49.5% (99) were female. Over 100 speech variables were significantly associated with psychometric HE score ( p <0.05 with false discovery rate adjustment). A three-variable speech model (2 acoustic, 1 speech tempo variable) was similar to animal naming test in predicting MHE (AUC 0.76 vs. 0.69; p =0.11). Adding age and MELD-Na improved the accuracy of the speech model (AUC: 0.82). A combined clinical-speech model ("HEAR-MHE model") predicted time to OHE with a concordance of 0.74 ( p =0.06).Automated speech analysis is highly correlated with validated HE tests, associated with MHE, and may predict future OHE. Future research is needed to validate this tool and to understand how it can be implemented in clinical practice.
View details for DOI 10.1097/HEP.0000000000001086
View details for Web of Science ID 001335158800001
View details for PubMedID 39264936
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Decreasing Utilization of Vaginal Hysterectomy in the United States: An Analysis by Candidacy for Vaginal Approach
INTERNATIONAL UROGYNECOLOGY JOURNAL
2024; 35 (10): 1983-1991
Abstract
The objective was to assess trends in hysterectomy routes by patients who are likely and unlikely candidates for a vaginal approach.We performed a retrospective cohort study of patients who underwent vaginal, abdominal, or laparoscopic/robotics-assisted laparoscopic hysterectomy between 2017 and 2020 using the National Surgical Quality Improvement Program database. Patients undergoing hysterectomy for a primary diagnosis of benign uterine pathology, dysplasia, abnormal uterine bleeding, or pelvic floor disorders were eligible for inclusion. Patients who were parous, had no history of pelvic or abdominal surgery, and had a uterine weight ≤ 280 g on pathology were considered likely candidates for vaginal hysterectomy based on an algorithm developed to guide the surgical approach. Average annual changes in the proportion of likely vaginal hysterectomy candidates and route of hysterectomy were assessed using logistic regression.Of the 77,829 patients meeting the inclusion criteria, 13,738 (17.6%) were likely vaginal hysterectomy candidates. Among likely vaginal hysterectomy candidates, the rate of vaginal hysterectomy was 34.5%, whereas among unlikely vaginal hysterectomy candidates, it was 14.1%. The overall vaginal hysterectomy rate decreased -1.2%/year (p < 0.01). This decreasing trend was nearly twice as rapid among likely vaginal hysterectomy candidates (-1.9%/year, p < .01) compared with unlikely vaginal hysterectomy candidates (-1.1%/year, P < 0.01); the difference in trends was statistically significant (p < 0.01).The rate of vaginal hysterectomy performed for eligible indications decreased between 2017 and 2020 in a national surgical registry. This negative trend was more pronounced among patients who were likely candidates for vaginal hysterectomy based on favorable parity, surgical history, and uterine weight.
View details for DOI 10.1007/s00192-024-05908-y
View details for Web of Science ID 001308075700002
View details for PubMedID 39240369
View details for PubMedCentralID 5480952
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Pain Phenotypes and Pain Multimorbidity Among Medicare Beneficiaries With Cerebral Palsy.
JAMA neurology
2024
View details for DOI 10.1001/jamaneurol.2024.2443
View details for PubMedID 39102256
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Plasmapheresis in ANCA-Associated Vasculitis with Active Kidney Involvement in the United States (2016-2020): A Cross-Sectional Study.
Kidney360
2024
Abstract
Plasmapheresis is currently recommended when antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) presents with severe kidney and/or lung involvement. This cross-sectional study aimed at describing characteristics of hospitalized patients diagnosed with AAV with severe kidney involvement undergoing plasmapheresis in the US.We defined the study population as adults hospitalized for active kidney involvement with a new diagnosis of AAV (by subtype or unspecified). We established the cohort from the 2016-2020 National Inpatient Sample by ICD-10-CM codes. In this cross-sectional study, we described demographic and clinical characteristics, associated inpatient procedures, lengths of stay, hospital costs, and disposition at discharge comparing patients treated and not treated with plasmapheresis.We identified a total of 975 cases of hospitalized AAV with acute kidney involvement in the US treated by plasmapheresis over the 5-year period. Demographic characteristics of patients who received plasmapheresis were similar to those in patients who did not (n=5670). There were no regional differences in the proportion of patients who received plasmapheresis; however, plasmapheresis was deployed more frequently among patients admitted to urban teaching hospitals relative to rural and non-teaching hospitals. Cases treated with plasmapheresis were more likely to have had acute kidney injury (AKI) (96% vs. 90%, p=0.0007), AKI requiring dialysis (52% vs 16%, p<0.001), hypoxia (40% vs. 16%, p<0.0001), and respiratory failure requiring mechanical ventilation (13% vs. 3%, p=0.0003).During 2016-2020, plasmapheresis was deployed in approximately 20% of patients being admitted for AAV and acute kidney involvement in the US. As standards of care and practice evolve, the role of plasmapheresis in the management of AAV with acute kidney involvement will require further study.
View details for DOI 10.34067/KID.0000000000000496
View details for PubMedID 39008365
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Incident traumatic spinal cord injury and risk of Alzheimer's disease and related dementia: longitudinal case and control cohort study
SPINAL CORD
2024; 62 (8): 479-485
Abstract
Retrospective case/control longitudinal cohort study OBJECTIVES: Prevalent traumatic spinal cord injury (TSCI) is associated with Alzheimer's disease and related dementia (ADRD). We examined the hazard ratio for ADRD after incident TSCI and hypothesized that ADRD hazard is greater among adults with incident TSCI compared with their matched control of adults without TSCI.Using 2010-2020 U.S. national private administrative claims data, we identified adults aged 45 years and older with probable (likely and highly likely) incident TSCI (n = 657). Our controls included one-to-ten matched cohort of people without TSCI (n = 6553).We applied Cox survival models and adjusted them for age, sex, years of living with certain chronic conditions, exposure to six classes of prescribed medications, and neighborhood characteristics of place of residence. Hazard ratios were used to compare the results within a 4-year follow-up.Our fully adjusted model without any interaction showed that incident TSCI increased the risk for ADRD (HR = 1.30; 95% CI, 1.01-1.67). People aged 45-64 with incident TSCI were at high risk for ADRD (HR = 5.14; 95% CI, 2.27-11.67) and no significant risk after age 65 (HR = 1.20; 95% CI, .92-1.55). Our sensitivity analyses confirmed a higher hazard ratio for ADRD after incident TSCI at 45-64 years of age compared with the matched controls.TSCI is associated with a higher hazard of ADRD. This study informs the need to update clinical guidelines for cognitive screening after TSCI to address the heightened risk of cognitive decline and to shed light on the causality between TSCI and ADRD.
View details for DOI 10.1038/s41393-024-01009-1
View details for Web of Science ID 001257006200001
View details for PubMedID 38937544
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Psychiatric Residential Treatment Facilities for Child Behavioral Health Services in North Carolina Medicaid.
North Carolina medical journal
2024; 85 (3): 215-221
Abstract
Background: Psychiatric residential treatment facilities (PRTFs) are non-hospital inpatient treatment settings for children with severe be-havioral health disorders. PRTFs are a restrictive and costly form of care that can potentially be avoided with community-based behavioral health services.Methods: Statewide Medicaid enrollment and claims data for 2015-2022 were used to describe PRTF utilization in North Carolina. We examined annual episodes of care in PRTFs and compared trends before and during the COVID-19 public health emergency.Results: From 2015 to 2022, 10,038 children insured by NC Medicaid entered a PRTF across 10,966 episodes of care. In the past five years (2018-2022), care in PRTFs resulted in Medicaid expenditures of over $550 million total, or over $100 million per year. In 2022, 42% of children who entered PRTFs were in foster care and 44% of children were placed in PRTFs outside of North Carolina.Limitations: The analysis was limited to data collected for administrative purposes.Conclusions: Current trends indicate an ongoing overrepresentation of children in foster care placed in PRTFs and increased out-of-state PRTF placements. Coordinated efforts in future research, policy, and practice are needed to determine the cause of these trends and iden-tify solutions.
View details for DOI 10.18043/001c.117075
View details for PubMedID 39437358
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Post-COVID Conditions in US Primary Care: A PRIME Registry Comparison of Patients With COVID-19, Influenza-Like Illness, and Wellness Visits.
Annals of family medicine
2024; 22 (4): 279-287
Abstract
COVID-19 is a condition that can lead to other chronic conditions. These conditions are frequently diagnosed in the primary care setting. We used a novel primary care registry to quantify the burden of post-COVID conditions among adult patients with a COVID-19 diagnosis across the United States.We used the American Family Cohort, a national primary care registry, to identify study patients. After propensity score matching, we assessed the prevalence of 17 condition categories individually and cumulatively, comparing patients having COVID-19 in 2020-2021 with (1) historical control patients having influenza-like illness in 2018 and (2) contemporaneous control patients seen for wellness or preventive visits in 2020-2021.We identified 28,215 patients with a COVID-19 diagnosis and 235,953 historical control patients with influenza-like illness. The COVID-19 group had higher prevalences of breathing difficulties (4.2% vs 1.9%), type 2 diabetes (12.0% vs 10.2%), fatigue (3.9% vs 2.2%), and sleep disturbances (3.5% vs 2.4%). There were no differences, however, in the postdiagnosis monthly trend in cumulative morbidity between the COVID-19 patients (trend = 0.026; 95% CI, 0.025-0.027) and the patients with influenza-like illness (trend = 0.026; 95% CI, 0.023-0.027). Relative to contemporaneous wellness control patients, COVID-19 patients had higher prevalences of breathing difficulties and type 2 diabetes.Our findings show a moderate burden of post-COVID conditions in primary care, including breathing difficulties, fatigue, and sleep disturbances. Based on clinical registry data, the prevalence of post-COVID conditions in primary care practices is lower than that reported in subspecialty and hospital settings.
View details for DOI 10.1370/afm.3131
View details for PubMedID 39038980
View details for PubMedCentralID PMC11268691
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Use of preventive service and potentially preventable hospitalization among American adults with disability: Longitudinal analysis of Traditional Medicare and commercial insurance
PREVENTIVE MEDICINE REPORTS
2024; 40: 102663
Abstract
Examine the association between traditional Medicare (TM) vs. commercial insurance and the use of preventive care and potentially preventable hospitalization (PPH) among adults (18+) with disability [cerebral palsy/spina bifida (CP/SB); multiple sclerosis (MS); traumatic spinal cord injury (TSCI)] in the United States.Using 2008-2016 Medicare and commercial claims data, we compared adults with the same disability enrolled in TM vs. commercial insurance [Medicare: n = 21,599 (CP/SB); n = 7,605 (MS); n = 4,802 (TSCI); commercial: n = 11,306 (CP/SB); n = 6,254 (MS); n = 5,265 (TSCI)]. We applied generalized estimating equations to address repeated measures, comparing cases with controls. All models were adjusted for age, sex, race/ethnicity, and comorbid conditions.Compared with commercial insurance, enrolling in TM reduced the odds of using preventive services. For example, adjusted odds ratios (OR) of annual wellness visits in TM vs. commercial insurance were 0.31 (95% confidence interval (CI): 0.28-0.34), 0.32 (95% CI: 0.28-0.37), and 0.19 (95% CI: 0.17-0.22) among adults with CP/SB, TSCI, and MS, respectively. Furthermore, PPH risks were higher in TM vs. commercial insurance. ORs of PPH in TM vs. commercial insurance were 1.50 (95% CI: 1.18-1.89), 1.83 (95% CI: 1.40-2.41), and 2.32 (95% CI: 1.66-3.22) among adults with CP/SB, TSCI, and MS, respectively. Moreover, dual-eligible adults had higher odds of PPH compared with non-dual-eligible adults [CP/SB: OR = 1.47 (95% CI: 1.25-1.72); TSCI: OR = 1.61 (95% CI: 1.35-1.92), and MS: OR = 1.80 (95% CI: 1.55-2.10)].TM, relative to commercial insurance, was associated with lower receipt of preventive care and higher PPH risk among adults with disability.
View details for DOI 10.1016/j.pmedr.2024.102663
View details for Web of Science ID 001206898400001
View details for PubMedID 38464419
View details for PubMedCentralID PMC10920729
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The Impact of COVID-19 on Rates of Pressure Injuries Among Hospitalized Patients across the US
ADVANCES IN SKIN & WOUND CARE
2024; 37 (3): 5-9
Abstract
To determine the impact of the COVID-19 pandemic on hospital-acquired pressure injury (HAPI) rates and composition of HAPI stages among hospitalized patients across the US.Using encounter-level data from a nationwide healthcare insurance claims database, the authors conducted a retrospective cohort study and an interrupted time-series analysis to determine HAPI rates among hospitalized patients within 90 days of admission before (January 2018 to February 2020) and after (March 2020 to December 2020) the onset of the COVID-19 pandemic. Of 3,418,438 adult patients assessed for inclusion in the study, 1,750,494 met the inclusion criteria. Outcomes measured included the presence of a HAPI within 90 days of admission and HAPI stage based on the International Classification of Diseases, 10th Revision diagnosis codes.The authors identified HAPIs in 59,175 episodes of care, representing 59,019 unique patients and corresponding to an overall HAPI rate of 2.65%. Baseline characteristics did not vary significantly across the two time periods. Further, HAPI rates were consistent across the time periods analyzed with no significant differences in rates following the onset of the pandemic (P = .303). Composition of HAPI stages remained consistent across the pandemic (unspecified, stages 1-4, Ps = .62, .80, .22, .23, and .52, respectively) except for a significant decrease in unstageable/deep tissue pressure injuries (-0.088%, P = .0134).Although hospital resources were strained at the peak of the COVID-19 pandemic, no differences were identified in HAPI rates among the study's cohort of privately insured patients.
View details for DOI 10.1097/ASW.0000000000000109
View details for Web of Science ID 001181653600009
View details for PubMedID 38393707
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Disparities in the Delivery of Prostate Cancer Survivorship Care in the USA: A Claims-based Analysis of Urinary Adverse Events and Erectile Dysfunction Among Prostate Cancer Survivors
EUROPEAN UROLOGY OPEN SCIENCE
2024; 62: 26-35
Abstract
Incidence rates for prostate cancer (PCa) diagnosis and mortality are higher for Black men. It is unknown whether similar disparities exist in survivorship care. We assessed the delivery and quality of survivorship care for Black men undergoing PCa therapy in terms of the burden of and treatment for urinary adverse events (UAEs) and erectile dysfunction (ED).We queried Optum Clinformatics data for all patients diagnosed with PCa from January 1, 2002 to December 31, 2017 and identified those who underwent primary PCa treatment. Index cohorts were identified in each year and followed longitudinally until 2017. Data for UAE diagnoses, UAE treatments, and ED treatments were analyzed in index cohorts. Cox proportional-hazards regression models were used to examine associations of race with UAE diagnosis, UAE treatment, and ED treatment.We identified 146, 216 patients with a PCa diagnosis during the study period, of whom 55, 149 underwent primary PCa treatment. In the primary treatment group, 32.7% developed a UAE and 28.2% underwent UAE treatment. The most common UAEs were urinary incontinence (11%), ureteral obstruction/stricture (4.5%), bladder neck contracture (4.5%), and urethral stricture (3.7%). The most common UAE treatments were cystoscopy (13%), suprapubic tube placement (6%), and urethral dilation (5%). Overall, UAE diagnosis rates were higher for Black patients, who had significantly higher risk of urethral obstruction, rectourethral fistula, urinary incontinence, cystitis, urinary obstruction, and ureteral fistula. Overall, UAE treatment rates were lower for Black patients, who had significantly higher risk of fecal diversion and/or rectourethral fistula repair (adjusted hazard ratio [aHR] 1.71, 95% confidence interval [CI] 1.04-2.79). Regarding ED treatments, Black patients had higher risk of penile prosthesis placement (aHR 1.591, 95% CI 1.26-2.00) and intracavernosal injection (aHR 1.215, 95% CI 1.08-1.37).Despite a high UAE burden, treatment rates were low in a cohort with health insurance. Black patients had a higher UAE burden and lower UAE treatment rates. Multilevel interventions are needed to address this stark disparity. ED treatment rates were higher for Black patients.We reviewed data for patients treated for prostate cancer (PCa) and found that 32.7% were diagnosed with a urinary adverse event (UAE) following their PCa treatment. The overall treatment rate for these UAEs was 28.2%. Analysis by race showed that the UAE diagnosis rate was higher for Black patients, who were also more likely to receive treatment for erectile dysfunction.
View details for DOI 10.1016/j.euros.2024.01.003
View details for Web of Science ID 001198302600001
View details for PubMedID 38585209
View details for PubMedCentralID PMC10998258
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Survival Characteristics of Older Patients Hospitalized With COVID-19: Insights From the American Heart Association COVID-19 Cardiovascular Disease Registry
JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION
2024; 25 (2): 348-350
View details for DOI 10.1016/j.jamda.2023.11.027
View details for Web of Science ID 001179685600001
View details for PubMedID 38211937
View details for PubMedCentralID PMC11072581
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Location Matters: The Role of the Neighborhood Environment for Incident Cardiometabolic Disease in Adults Aging With Physical Disability
AMERICAN JOURNAL OF HEALTH PROMOTION
2024; 38 (5): 633-640
Abstract
People aging with disability may be limited in their ability to engage in healthy behaviors to maintain cardiometabolic health. We investigated the role of health promoting features in the neighborhood environment for incident cardiometabolic disease in adults aging with physical disability in the United States.Retrospective cohort study.Optum's Clinformatics® Data Mart Database (2007-2018) of administrative health claims.ICD-9-CM codes were used to identify 15 467 individuals with a diagnosis of Cerebral Palsy, Spina Bifida, Multiple Sclerosis, or Spinal Cord Injury.Cardiometabolic disease was identified using ICD-9-CM/ICD-10-CM codes over 3 years of follow-up. Measures of the neighborhood environment came from the National Neighborhood Data Archive and linked to individual residential ZIP codes over time. Covariates included age, sex, and comorbid health conditions.Cox regression models estimated hazard ratios (HR) for incident cardiometabolic disease. Using a 1-year lookback period, individuals with pre-existing cardiometabolic disease were excluded from the analysis.Net of individual risk factors, residing in neighborhoods with a greater density of broadband Internet connections (HR = .88, 95% CI: .81, .97), public transit stops (HR = .89, 95% CI: .83, .95), recreational establishments (HR = .89, 95% CI: .83, .96), and parks (HR = .88, 95% CI: .82, .94), was associated with reduced risk of 3-year incident cardiometabolic disease.Findings identify health-promoting resources that may mitigate health disparities in adults aging with disability.
View details for DOI 10.1177/08901171241228017
View details for Web of Science ID 001144888600001
View details for PubMedID 38236090
View details for PubMedCentralID PMC11076158
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Oncological Safety of Autologous Fat Grafting for Breast Reconstruction
ANNALS OF PLASTIC SURGERY
2024; 92 (1): 21-27
Abstract
Autologous fat grafting has become a vital component of breast reconstruction. However, concerns remain regarding the safety of fat grafting after oncological resection and breast reconstruction. The purpose of the study was to evaluate the association of fat grafting after breast reconstruction with metastasis and death in breast cancer patients.A retrospective, population-based cohort study was conducted using deidentified claims data from 2001 to 2018 and included privately insured patients with breast cancer who underwent breast reconstruction after surgical resection. Breast reconstruction patients who underwent fat grafting were compared with those not undergoing fat grafting, evaluating metastasis and death up to 15 years after reconstruction. One-to-one propensity score matching was used to account for selection bias on patient risk factors comparing those with and without fat grafting.A total of 4709 patients were identified who underwent breast reconstruction after lumpectomy or mastectomy, of which 368 subsequently underwent fat grafting. In the propensity score-matched patients, fat grafting was not associated with an increased risk of lymph node metastasis (9.7% fat-grafted vs 11.4% in non-fat-grafted, P = 0.47) or distant metastasis (9.1% fat-grafted vs 10.5% in non-fat-grafted, P = 0.53). There was no increased risk of all-cause mortality after fat grafting for breast reconstruction (3.9% fat-grafted vs 6.6% non-fat-grafted, P = 0.10).Among breast cancer patients who subsequently underwent fat grafting, compared with no fat grafting, no significant increase was observed in distant metastasis or all-cause mortality. These findings suggest that autologous fat grafting after oncologic resection and reconstruction was not associated with an increased risk of future metastasis or death.
View details for DOI 10.1097/SAP.0000000000003772
View details for Web of Science ID 001142905900014
View details for PubMedID 38117044
View details for PubMedCentralID PMC10752252
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Emergency Department Care for Children During the 2022 Viral Respiratory Illness Surge
JAMA NETWORK OPEN
2023; 6 (12): e2346769
Abstract
Pediatric readiness is essential for all emergency departments (EDs). Children's experience of care may differ according to operational challenges in children's hospitals, community hospitals, and rural EDs caused by recurring and sometimes unpredictable viral illness surges.To describe wait times, lengths of stay (LOS), and ED revisits across diverse EDs participating in a statewide quality collaborative during a surge in visits in 2022.This retrospective cohort study included 25 EDs from the Michigan Emergency Department Improvement Collaborative data registry from January 1, 2021, through December 31, 2022. Pediatric (patient age <18 years) encounters for viral and respiratory conditions were analyzed, comparing wait times, LOS, and ED revisit rates for children's hospital, urban pediatric high-volume (≥10% of overall visits), urban pediatric low-volume (<10% of overall visits), and rural EDs.Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022.Prolonged ED visit wait times (arrival to clinician assigned, >4 hours), prolonged LOS (arrival to departure, >12 hours), and ED revisit rate (ED discharge and return within 72 hours).A total of 2 761 361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301 688 pediatric visits for viral and respiratory illness, an increase of 71.8% over the 4 preceding months and 15.7% over the same period in 2021. At children's hospitals during the surge, 8.0% of visits had prolonged wait times longer than 4 hours, 8.6% had prolonged LOS longer than 12 hours, and 42 revisits occurred per 1000 ED visits. Prolonged wait times were rare among other sites. However, prolonged LOS affected 425 visits (2.2%) in urban high-pediatric volume EDs, 133 (2.6%) in urban pediatric low-volume EDs, and 176 (3.1%) in rural EDs. High visit volumes were associated with increased ED revisits across sites.In this cohort study of more than 2.7 million ED visits, a pediatric viral illness surge was associated with different pediatric acute care across EDs in the state. Clinical management pathways and quality improvement efforts may more effectively mitigate dangerous clinical conditions with strong collaborative relationships across EDs and setting of care.
View details for DOI 10.1001/jamanetworkopen.2023.46769
View details for Web of Science ID 001117136200007
View details for PubMedID 38060222
View details for PubMedCentralID PMC10704279
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Sex, Racial, and Geographic Disparities in Pulmonary Embolism-related Mortality Nationwide
ANNALS OF THE AMERICAN THORACIC SOCIETY
2023; 20 (11): 1571-1577
Abstract
Rationale: Acute pulmonary embolism is a leading cause of cardiovascular death. There are limited data on the national mortality trends from pulmonary embolism. Understanding these trends is crucial for addressing the mortality and associated disparities associated with pulmonary embolism. Objectives: To analyze the national mortality trends related to acute pulmonary embolism and determine the overall age-adjusted mortality rate (AAMR) per 100,000 population for the study period and assess changes in AAMR among different sexes, races, and geographic locations. Methods: We conducted a retrospective cohort analysis using mortality data of individuals aged ⩾15 years with pulmonary embolism listed as the underlying cause of death in the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from January 2006 to December 2019. These data are produced by the National Center for Health Statistics. Results: A total of 109,992 pulmonary embolism-related deaths were noted in this dataset nationwide between 2006 and 2019. Of these, women constituted 60,113 (54.7%). The AAMR per 100,000 was not significantly changed, from 2.84 in 2006 to 2.81 in 2019 (average annual percentage change [AAPC], 0.2; 95% confidence interval [CI], -0.1 to 0.5; P = 0.15). AAMR increased for men throughout the study period compared with women (AAPC, 0.7 for men; 95% CI, 0.3 to 1.2; P = 0.004 vs. AAPC, -0.4 for women; 95% CI, -1.1 to 0.3; P = 0.23, respectively). Similarly, AAMR for pulmonary embolism increased for Black compared with White individuals, from 5.18 to 5.26 (AAPC, 0.4; 95% CI, 0.0 to 0.7; P = 0.05) and 2.82 to 2.86 (AAPC, 0.0; 95% CI, -0.6 to 0.6; P = 0.99), respectively. Similarly, AAMR for pulmonary embolism was higher in rural areas than in micropolitan and large metropolitan areas during the study period (4.07 [95% CI, 4.02 to 4.12] vs. 3.24 [95% CI, 3.21 to 3.27] vs. 2.32 [95% CI, 2.30-2.34], respectively). Conclusions: Pulmonary embolism mortality remains high and unchanged over the past decade, and enduring sex, racial and socioeconomic disparities persist in pulmonary embolism. Targeted efforts to decrease pulmonary embolism mortality and address such disparities are needed.
View details for DOI 10.1513/AnnalsATS.202302-091OC
View details for Web of Science ID 001098194100007
View details for PubMedID 37555732
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Conceptualizing lifer versus destination patients for optimized care delivery
BMC HEALTH SERVICES RESEARCH
2023; 23 (1): 1190
Abstract
Patients presenting to academic medical centers (AMC) typically receive primary care, specialty care, or both. Resources needed for each type of care vary, requiring different levels of care coordination. We propose a novel method to determine whether a patient primarily receives primary or specialty care to allow for optimization of care coordination.We aimed to define the concepts of a Lifer Patient and Destination Patient and analyze the current state of care utilization in those groups to inform opportunities for improving care coordination.Using AMC data for a 36-month study period (FY17-19), we evaluated the number of unique patients by residence zip code. Patients with at least one primary care visit and patients without a primary care visit were classified as Lifer and Destination patients, respectively. Cohen's effect sizes were used to evaluate differences in mean utilization of different care delivery settings.The AMC saw 35,909 Lifer patients and 744,037 Destination patients during the study period. Most patients were white, non-Hispanic females; however, the average age of a Lifer was seventy-two years whereas that of a Destination patient was thirty-eight. On average, a Lifer had three times more ambulatory care visits than a Destination patient. The proportion of Inpatient encounters is similar between the groups. Mean Inpatient length of stay (LOS) is similar between the groups, but Destination patients have more variance in LOS. The rate of admission from the emergency department (ED) for Destination patients is nearly double Lifers'.There were differences in ED, ambulatory care, and inpatient utilization between the Lifer and Destination patients. Furthermore, there were incongruities between rate of hospital admissions and LOS between two groups. The Lifer and Destination patient definitions allow for identification of opportunities to tailor care coordination to these unique groups and to allocate resources more efficiently.
View details for DOI 10.1186/s12913-023-10214-2
View details for Web of Science ID 001091544900002
View details for PubMedID 37915060
View details for PubMedCentralID PMC10619315
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Symptoms Suggestive of Postpulmonary Embolism Syndrome and Utilization of Diagnostic Testing.
Journal of the Society for Cardiovascular Angiography & Interventions
2023; 2 (6Part A): 101063
Abstract
Background: Persistent symptoms of chest pain, dyspnea, fatigue, lightheadedness, and/or syncope more than 3 months after an acute pulmonary embolism (PE) are collectively classified as postpulmonary embolism syndrome (PPES). Although PPES is increasingly recognized as an important long-term sequel of acute PE, its contemporary incidence is unclear. Furthermore, the utilization of diagnostic testing for further phenotypic characterization of these patients is unknown. This study aimed to define the incidence of PPES and evaluate the utilization of diagnostic tests among a national cohort of patients with PE.Methods: Retrospective cohort study was performed using the national administrative database, Clinformatics DataMart Database (Optum Insight), and included adult patients (18 years or older) with no history of acute PE or pulmonary hypertension, diagnosed with acute PE between October 1, 2016, and December 31, 2018. With acute PE event as the exposure, the incidence of symptoms consistent with PPES and diagnostic test utilization among patients with PPES were evaluated.Results: Of 21,297 incident patients with acute PE, 11,969 (56.2%) showed ≥1 symptom of PPES, which was new since their pre-PE baseline. New dyspnea was the most common and noted in 3268/15,203 (21.5%) patients, followed by new malaise or fatigue in 2894/15,643 (18.5%) patients. Among the 11,969 patients with PPES, 5128 (42.8%) received ≥1 diagnostic test, with 3242 (27%) receiving a computed tomography pulmonary angiogram, 2997 (25%) receiving an echocardiogram, and 325 (2.7%) received a ventilation-perfusion scan within 3-12 months after PE. Significantly lower use of diagnostic testing was noted in patients older than 65 years (adjusted odds ratio, 0.89; 95% CI, 0.81-0.98).Conclusions: Symptoms consistent with PPES are common after acute PE, occurring in more than half of the patients. Diagnostic imaging for further phenotypic characterization is used in less than half of such patients with PPES.
View details for DOI 10.1016/j.jscai.2023.101063
View details for PubMedID 39129881
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Type 2 Diabetes Increases the Risk of Serious and Life-Threatening Conditions Among Adults With Traumatic Spinal Cord Injury.
Mayo Clinic proceedings. Innovations, quality & outcomes
2023; 7 (5): 452-461
Abstract
Objective: To compare the incidence of and adjusted hazards for serious and life-threatening morbidities among adults with traumatic spinal cord injury (TSCI) with and without type 2 diabetes (T2D).Participants and Methods: A retrospective longitudinal cohort study was conducted from September 1, 2022 to February 2, 2023, among privately insured beneficiaries if they had an International Classification of Diseases, 9th Revision or 10th Revision, Clinical Modification diagnostic code for TSCI (n=9081). Incidence estimates of serious and life-threatening morbidities, and more common secondary and long-term health conditions, were compared at 5 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for serious and life-threatening morbidities.Results: Adults living with TSCI and T2D had a higher incidence of all of the morbidities assessed as compared with nondiabetic adults with TSCI. Fully adjusted survival models reported that adults with TSCI and T2D had a greater hazard for most of the serious and life-threatening conditions assessed, including sepsis (hazard ratio [HR]: 1.65), myocardial infarction (HR: 1.63), osteomyelitis (HR: 1.9), and stroke or transient ischemic attack (HR: 1.59). Rates for comorbid and secondary conditions were higher for individuals with TSCI and T2D, such as pressure sores, urinary tract infections, and depression, even after controlling for sociodemographic and comorbid conditions.Conclusion: Adults living with TSCI and T2D have a significantly higher incidence of and risk of developing serious and life-threatening morbidities as compared with nondiabetic adults with TSCI.
View details for DOI 10.1016/j.mayocpiqo.2023.08.002
View details for PubMedID 37818139
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Extracorporeal Membrane Oxygenation for Cardiac Arrest: Does Age Matter?
Critical care medicine
2023
Abstract
The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database.Retrospective analysis of the Extracorporeal Life Support Organization registry.Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020.The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81).This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.
View details for DOI 10.1097/CCM.0000000000006039
View details for PubMedID 37782526
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Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2023; 229 (3): 320e1-320e7
Abstract
There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization.This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy.We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated.There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001).This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.
View details for DOI 10.1016/j.ajog.2023.05.025
View details for Web of Science ID 001069918000001
View details for PubMedID 37244455
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Potentially Preventable Hospitalization Among Adults with Hearing, Vision, and Dual Sensory Loss: A Case and Control Study.
Mayo Clinic proceedings. Innovations, quality & outcomes
2023; 7 (4): 327-336
Abstract
Objective: To evaluate the risk of potentially preventable hospitalizations (PPHs) among adults with sensory loss. We hypothesized a greater PPH risk among people with a sensory loss (hearing, vision, and dual) compared with controls.Patients and Methods: Using 2007-2016 Medicare fee-for-service claims, this retrospective, case-control study examined the risk of PPH among adults aged 65 years and older with hearing, vision, and dual sensory loss compared with their corresponding counterparts without sensory loss (between June 1, 2022, and February 1, 2023). We ran 3 step-in regression models for the 3 case and control cohorts examining PPH risk. Our generalized linear regression models controlled for age, sex, race, Elixhauser comorbidity count, rurality, neighborhood characteristics, and the number of primary care physicians and hospitals at the county level.Results: People with vision (adjusted odds ratio [aOR], 1.21; 95% CI, 0.84-0.87) and dual sensory loss (aOR, 1.26; 95% CI, 1.14-1.40) showed a higher PPH risks than their corresponding controls. For people with hearing loss, our unadjusted models showed a higher PPH risk (OR, 1.40; 95% CI, 1.38-1.43) but after adjustment, hearing loss showed a protective association against PPH risk (OR, 0.85; 95% CI, 0.84-0.87). Moreover, in all models, annual wellness visits reduced the PPH risk by about half (eg, aOR, 0.54; 95% CI, 0.52-0.55), whereas living in disadvantaged neighborhood increased the PPH risk (eg, aOR, 1.13; 95% CI, 1.10-1.15) for cases and controls.Conclusion: People with vision and dual sensory loss were at greater PPH risk. This study has important health policy implications in reducing PPH and is indicative of a need for more incentivized and systematic approaches to facilitating the use of preventive care, particularly among older adults living in a disadvantaged neighborhood.
View details for DOI 10.1016/j.mayocpiqo.2023.06.004
View details for PubMedID 37533599
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Performance of Perioperative Tasks for Women Undergoing Anti-incontinence Surgery Developed by the AUGS Quality Improvement and Outcomes Research Network
UROGYNECOLOGY
2023; 29 (8): 660-669
Abstract
Surgery for the correction of stress urinary incontinence is an elective procedure that can have a dramatic and positive impact on quality of life. Anti-incontinence procedures, like inguinal hernia repairs or cholecystectomies, can be classified as high-volume/low-morbidity procedures. The performance of a standard set of perioperative tasks has been suggested as one way to optimize quality of care in elective high-volume/low-morbidity procedures. Our primary objective was to evaluate the performance of 5 perioperative tasks-(1) offering nonsurgical treatment, (2) performance of a standard preoperative prolapse examination, (3) cough stress test, (4) postvoid residual test, and (5) intraoperative cystoscopy for women undergoing surgery for stress urinary incontinence-compared among surgeons with and without board certification in female pelvic medicine and reconstructive surgery (FPMRS).This study was a retrospective chart review of anti-incontinence surgical procedures performed between 2011 and 2013 at 9 health systems. Cases were reviewed for surgical volume, adverse outcomes, and the performance of 5 perioperative tasks and compared between surgeons with and without FPMRS certification.Non-FPMRS surgeons performed fewer anti-incontinence procedures than FPMRS-certified surgeons. Female pelvic medicine and reconstructive surgery surgeons were more likely to perform all 5 perioperative tasks compared with non-FPMRS surgeons. After propensity matching, FPMRS surgeons had fewer patients readmitted within 30 days of surgery compared with non-FPMRS surgeons.Female pelvic medicine and reconstructive surgery surgeons performed higher volumes of anti-incontinence procedures, were more likely to document the performance of the 5 perioperative tasks, and were less likely to have their patients readmitted within 30 days.
View details for DOI 10.1097/SPV.0000000000001392
View details for Web of Science ID 001036234900002
View details for PubMedID 37490706
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Health-Care Patterns for Three Common Elective Surgeries: Implications for Bundled Payment Models
JOURNAL OF SURGICAL RESEARCH
2023; 291: 414-422
Abstract
The study objectives were to assess the timing, duration, and nature of health-care service utilization before and after three common elective surgical procedures not currently included in federal episode-based bundled payment programs.We performed a retrospective cohort study of patients undergoing one of three low-risk surgical procedures (breast reduction, upper extremity nerve decompression, and panniculectomy) between 2010 and 2017 using a private insurer's national claims database. All professional and facility billing claims for health-care services were identified during the 12-mo preoperative and 12-mo postoperative periods for each patient. We compared trends in monthly utilization of health-care services to estimate surgery-related utilization patterns with interrupted time series analyses.The cohort included 7885 patients receiving breast reduction, 99,404 patients receiving upper extremity nerve decompression, and 955 patients receiving panniculectomy. The mean monthly encounters gradually increased before each procedure, with a gradual decline in services postoperatively. Claims in the preoperative period for all procedures were primarily diagnostic testing and outpatient evaluation and management. There was limited use of postacute care services across the surgical procedures. There were notable differences in service utilization between the three surgeries, including differing inflection points for preoperative services (approximately 7 mo for breast reduction and panniculectomy, compared with at least 9 mo for nerve decompression) and postoperative services (up to 3 mo for panniculectomy and 4 mo for nerve decompression, compared with 6 mo for breast reduction).This study highlights important differences in utilization of health-care services by type of surgery. These findings suggest that prior to expanding episode-based bundled payment models to surgical conditions with limited utilization of postacute care services and fewer complications, the Centers for Medicare and Medicaid Services and private payers should consider tailoring the timing and duration of clinical episodes to individual surgical procedures.
View details for DOI 10.1016/j.jss.2023.06.028
View details for Web of Science ID 001057539000001
View details for PubMedID 37517349
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Evaluating the pediatric mental health care continuum at an American health system
SAGE OPEN MEDICINE
2023; 11: 20503121231181939
Abstract
To describe trends in the pediatric mental health care continuum and identify potential gaps in care coordination.We used electronic medical record data from October 2016 to September 2019 to characterize the prevalence of mental health issues in the pediatric population at a large American health system. This was a single institution case study. From the electronic medical record data, primary mental health discharge and readmission diagnoses were identified using International Classification of Diseases (ICD-9-CM, ICD-10-CM) codes. The electronic medical record was queried for mental health-specific diagnoses as defined by International Classification of Diseases classification, analysis of which was facilitated by the fact that only 176 mental health codes were billed for. Additionally, prevalence of care navigation encounters was assessed through electronic medical record query, as care navigation encounters are specifically coded. These encounter data was then segmented by care delivery setting.Major depressive disorder and other mood disorders comprised 49.6% and 89.4% of diagnoses in the emergency department and inpatient settings respectively compared to 9.0% of ambulatory care diagnoses and were among top reasons for readmission. Additionally, only 1% of all ambulatory care encounters had a care navigation component, whereas 86% of care navigation encounters were for mental health-associated reasons.Major depressive disorder and other mood disorders were more common diagnoses in the emergency department and inpatient settings, which could signal gaps in care coordination. Bridging potential gaps in care coordination could reduce emergency department and inpatient utilization through increasing ambulatory care navigation resources, improving training, and restructuring financial incentives to facilitate ambulatory care diagnosis and management of major depressive disorder and mood disorders. Furthermore, health systems can use our descriptive analytic approach to serve as a reasonable measure of the current state of pediatric mental health care in their own patient population.
View details for DOI 10.1177/20503121231181939
View details for Web of Science ID 001012460200001
View details for PubMedID 37362613
View details for PubMedCentralID PMC10288394
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Continuity of Care in Adults Aging with Cerebral Palsy and Spina Bifida: The Importance of Community Healthcare and Socioeconomic Context
DISABILITIES
2023; 3 (2): 295-306
Abstract
Continuity of care is considered a key metric of quality healthcare. Yet, continuity of care in adults aging with congenital disability and the factors that contribute to care continuity are largely unknown. Using data from a national private administrative health claims database in the United States (2007-2018). we examined continuity of care in 8596 adults (mean age 48.6 years) with cerebral palsy or spina bifida. Logistic regression models analyzed how proximity to health care facilities, availability of care providers, and community socioeconomic context were associated with more continuous care. We found that adults aging with cerebral palsy or spina bifida saw a variety of different physician specialty types and generally had discontinuous care. Individuals who lived in areas with more hospitals and residential care facilities received more continuous care than those with limited access to these resources. Residence in more affluent areas was associated with receiving more fragmented care. Findings suggest that over and above individual factors, community healthcare resources and socioeconomic context serve as important factors to consider in understanding continuity of care patterns in adults aging with cerebral palsy or spina bifida.
View details for DOI 10.3390/disabilities3020019
View details for Web of Science ID 001274739000001
View details for PubMedID 38223395
View details for PubMedCentralID PMC10786460
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TEMPORAL MORTALITY TRENDS IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION, STROKE, AND PULMONARY EMBOLISM IN THE UNITED STATES
ELSEVIER SCIENCE INC. 2023: 2022
View details for Web of Science ID 000990866102034
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RACIAL DISPARITIES IN PULMONARY EMBOLISM MORTALITY AMONGST US ADULTS BEFORE AND DURING COVID-19 PANDEMIC.
ELSEVIER SCIENCE INC. 2023: 2031
View details for Web of Science ID 000990866102043
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Readmission Rates and Episode Costs for Alzheimer Disease and Related Dementias Across Hospitals in a Statewide Collaborative
JAMA NETWORK OPEN
2023; 6 (3): e232109
Abstract
There has been a paucity of research examining the risk and cost of readmission among patients with Alzheimer disease and related dementias (ADRD) after a planned hospitalization for a broad set of medical and surgical procedures.To examine 30-day readmission rates and episode costs, including readmission costs, for patients with ADRD compared with their counterparts without ADRD across Michigan hospitals.This retrospective cohort study used 2012 to 2017 Michigan Value Collaborative data across different medical and surgical services stratified by ADRD diagnosis. A total of 66 676 admission episodes of care that occurred between January 1, 2012, and June 31, 2017, were identified for patients with ADRD using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes for ADRD, along with 656 235 admission episodes in patients without ADRD. Using a generalized linear model framework, this study risk adjusted, price standardized, and performed episode payment winsorization. Payments were risk adjusted for age, sex, Hierarchical Condition Categories, insurance type, and prior 6-month payments. Selection bias was accounted for using multivariable logistic regression with propensity score matching without replacement using calipers. Data analysis was performed from January to December 2019.Presence of ADRD.Main outcomes were 30-day readmission rate at the patient and county levels, 30-day readmission cost, and 30-day total episode cost across 28 medical and surgical services.The study included 722 911 hospitalization episodes, of which 66 676 were related to patients with ADRD (mean [SD] age, 83.4 [8.6] years; 42 439 [63.6%] female) and 656 235 were related to patients without ADRD (mean [SD] age, 66.0 [15.4] years; 351 246 [53.5%] female). After propensity score matching, 58 629 hospitalization episodes were included for each group. Readmission rates were 21.5% (95% CI, 21.2%-21.8%) for patients with ADRD and 14.7% (95% CI, 14.4%-15.0%) for patients without ADRD (difference, 6.75 percentage points; 95% CI, 6.31-7.19 percentage points). Cost of 30-day readmission was $467 higher (95% CI of difference, $289-$645) among patients with ADRD ($8378; 95% CI, $8263-$8494) than those without ($7912; 95% CI, $7776-$8047). Across all 28 service lines examined, total 30-day episode costs were $2794 higher for patients with ADRD vs patients without ADRD ($22 371 vs $19 578; 95% CI of difference, $2668-$2919).In this cohort study, patients with ADRD had higher readmission rates and overall readmission and episode costs than their counterparts without ADRD. Hospitals may need to be better equipped to care for patients with ADRD, especially in the postdischarge period. Considering that any type of hospitalization may put patients with ADRD at a high risk of 30-day readmission, judicious preoperative assessment, postoperative discharge, and care planning are strongly advised for this vulnerable patient population.
View details for DOI 10.1001/jamanetworkopen.2023.2109
View details for Web of Science ID 001059402300002
View details for PubMedID 36929401
View details for PubMedCentralID PMC10020873
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Risk of type 2 diabetes mellitus among adults aging with vision impairment: The role of the neighborhood environment
DISABILITY AND HEALTH JOURNAL
2023; 16 (1): 101371
Abstract
Vision impairment (VI) affects approximately 1 in 28 Americans over the age of 40 and the prevalence increases sharply with age. However, experiencing vision loss with aging can be very different from aging with VI acquired earlier in life. People aging with VI may be at increased risk for diabetes due to environmental barriers in accessing health care, healthy food, and recreational resources that can facilitate positive health behaviors.This study examined the relationship between neighborhood characteristics and incident type 2 diabetes mellitus (T2DM) among a cohort of 22,719 adults aging with VI.Data are from Optum® Clinformatics® DataMart, a private administrative claims database (2008-2017). Individuals 18 years of age and older at the time of their initial VI diagnosis were eligible for analysis. VI was determined using vision impairment, low vision, and blindness codes (ICD-9-CM, ICD-10-CM). Covariates included age, sex, and comorbidities. Cox models estimated adjusted hazard ratios (HRs) for incident T2DM. Stratified models examined differences in those aging with (age 18-64) and aging into (age 65+) vision impairment.Residence in neighborhoods with greater intersection density (HR = 1.26) and high-speed roads (HR = 1.22) were associated with increased risk of T2DM among older adults with VI. Living in neighborhoods with broadband internet access (HR = 0.67), optical stores (HR = 0.62), supermarkets (HR = 0.78), and gyms/fitness centers (HR = 0.63) was associated with reduced risk of T2DM for both younger and older adults with VI.Findings emphasize the importance of neighborhood context for mitigating the adverse consequences of vision loss for health.
View details for DOI 10.1016/j.dhjo.2022.101371
View details for Web of Science ID 000900934200007
View details for PubMedID 36130856
View details for PubMedCentralID PMC9772041
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Equity enhancing policies that increase access and affordability of cervical cancer screening in the United States: A Preventive Medicine Golden Jubilee Commentary
PREVENTIVE MEDICINE
2023; 166: 107383
View details for DOI 10.1016/j.ypmed.2022.107383
View details for Web of Science ID 001062730400001
View details for PubMedID 36495923
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Do Not Attempt Resuscitation Order Rates in Hospitalized Patients With Heart Failure, Acute Myocardial Infarction, Chronic Obstructive Pulmonary Disease, and Pneumonia
JOURNAL OF THE AMERICAN HEART ASSOCIATION
2022; 11 (23): e025730
Abstract
Background Descriptions of do not attempt resuscitation (DNAR) orders in heart failure (HF) are limited. We describe use of DNAR orders in HF hospitalizations relative to other common conditions, focusing on race. Methods and Results This was a retrospective study of all adult hospitalizations for HF, acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia from 2010 to 2016 using the California State Inpatient Dataset. Using a hierarchical multivariable logistic regression model with random effects for the hospital, we identified factors associated with DNAR orders for each condition. For racial variation, hospitals were divided into quintiles based on proportion of Black patients cared for. Our cohort comprised 399 816 HF, 190 802 AMI, 192 640 COPD, and 269 262 pneumonia hospitalizations. DNAR orders were most prevalent in HF (11.9%), followed by pneumonia (11.1%), COPD (7.9%), and AMI (7.1%). Prevalence of DNAR orders did not change from 2010 to 2016 for each condition. For all conditions, DNAR orders were more common in elderly people, women, and White people with significant site-level variation across 472 hospitals. For HF and COPD, hospitalizations at sites that cared for a higher proportion of Black patients were less likely associated with DNAR orders. For AMI and pneumonia, conditions such as dementia and malignancy were strongly associated with DNAR orders. Conclusions DNAR orders were present in 12% of HF hospitalizations, similar to pneumonia but higher than AMI and COPD. For HF, we noted significant variability across sites when stratified by proportion of Black patients cared for, suggesting geographic and racial differences in end-of-life care.
View details for DOI 10.1161/JAHA.122.025730
View details for Web of Science ID 000893866000003
View details for PubMedID 36382963
View details for PubMedCentralID PMC9851455
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<i>Post-pulmonary embolism syndrome: contemporary incidence and utilization of diagnostic testing in a national cohort</i>
SAGE PUBLICATIONS LTD. 2022: 636-637
View details for Web of Science ID 000923957000068
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Potentially Preventable Hospitalizations Among Adults With Pediatric-Onset Disabilities.
Mayo Clinic proceedings
2022; 97 (12): 2226-2235
Abstract
OBJECTIVE: To examine the risk of any and specific potentially preventable hospitalizations (PPHs) for adults with cerebral palsy (CP) or spina bifida (SB). We hypothesize that PPH risk is greater among adults with CP/SB compared with the general population.PATIENTS AND METHODS: Using January 1, 2007, to December 31, 2017, national private administrative claims data (OptumInsight) in the United States, we identified adults with CP/SB (n=10,617). Adults without CP/SB were included as controls (n=1,443,716). To ensure a similar proportion in basic demographics, we propensity-matched our controls with cases in age and sex (n=10,617). Generalized estimating equation models were applied to examine the risk of CP/SB on PPHs. All models were adjusted for age, sex, race/ethnicity, health indicators, US Census Division data, and socioeconomic variables. Adjusted odds ratios were compared within a 4-year follow-up.RESULTS: Adults with CP/SB had higher risk for any PPH (odds ratio [OR], 4.10; 95% CI, 2.31 to 7.31), and PPHs due to chronic obstructive pulmonary disease/asthma (OR, 1.85; CI, 1.23 to 2.76), pneumonia (OR, 3.01; 95% CI, 2.06 to 4.39), and urinary tract infection (OR, 6.48; 95% CI, 3.91 to 10.75). Cases and controls who had an annual wellness visit had lower PPH risk (OR, 0.52; 95% CI, 0.41 to 0.67); similarly, adults with CP/SB who had an annual wellness visit compared with adults with CP/SB who did not had lower odds of PPH (OR, 0.75; 95% CI, 0.60 to 0.94).CONCLUSION: Adults with pediatric-onset disabilities are at a greater risk for PPHs. Providing better access to preventive care and health-promoting services, especially for respiratory and urinary outcomes, may reduce PPH risk among this patient population.
View details for DOI 10.1016/j.mayocp.2022.07.026
View details for PubMedID 36336517
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Post-pulmonary embolism syndrome: contemporary incidence and utilization of diagnostic testing in a national cohort
SAGE PUBLICATIONS LTD. 2022: 636-637
View details for Web of Science ID 001128318500014
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Low to Moderate Risk Non-orthopedic Surgical Patients Do Not Benefit From VTE Chemoprophylaxis
ANNALS OF SURGERY
2022; 276 (6): E691-E697
Abstract
This retrospective cohort study analyzes venous thromboembolism (VTE) incidence, morbidity, and mortality amongst postsurgical patients with and without VTE chemoprophylaxis within a quality collaborative. Postoperative thromboprophylaxis was broadly applied, yet was associated with no decrease in VTE, without affecting transfusion or mortality. Predictors of breakthrough VTE development despite evidence-based thromboprophylaxis are identified.We hypothesized that a high rate of prescription of VTE chemoprophylaxis would be associated with decreased VTE incidence and mortality.Recommendations for VTE prevention in surgical patients include chemoprophylaxis based upon preoperative risk stratification.This retrospective cohort study analyzed VTE incidence, morbidity, and mortality amongst postsurgical patients with and without VTE chemoprophylaxis between April 2013 and September 2017 from 63 hospitals within the Michigan Surgical Quality Collaborative. A VTE risk assessment survey was distributed to providers. Bivariate and multivariate comparisons were made, as well as using propensity score matched cohorts to determine if VTE chemoprophylaxis was associated with decreased VTE events. Hospitals were compared using risk-reliability adjusted VTE prophylaxis and postoperative VTE event rates.Within the registry, 80% of practitioners reported performing formal VTE risk assessment. Amongst 32,856 operations, there were 480 (1.46%) postoperative VTE, and an overall mortality of 609 (1.85%) patients. Using a propensity matched cohort, we found that rates of VTE were similar in those receiving unfractionated heparin or low molecular weight heparin compared to those not receiving chemoprophylaxis (1.22 vs 1.13%, P = 0.57). When stratified further by VTE risk scoring, even the highest risk patients did not have an associated lower VTE rate (3.68 vs 4.22% P = 0.092). Postoperative transfusion (8.28 vs 7.50%, P = 0.057) and mortality (2.00% vs 1.62%, P = 0.064) rates were similar amongst those receiving and those not receiving chemoprophylaxis. No correlation was found between postoperative VTE chemoprophylaxis application and hospital specific risk adjusted postoperative VTE rates.In modern day postsurgical care, VTE remains a significant occurrence, despite wide adoption of VTE risk assessment. Although postoperative VTE chemoprophylaxis was broadly applied, after adjusting for confounders, no reduction in VTE was observed in at-risk surgical patients.
View details for DOI 10.1097/SLA.0000000000004646
View details for Web of Science ID 000889667600010
View details for PubMedID 33214487
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Association of Prophylaxis and Length of Stay With Venous Thromboembolism in Abdominopelvic Surgery
JOURNAL OF SURGICAL RESEARCH
2023; 282: 198-209
Abstract
Extended venous thromboembolism prophylaxis (eVTEp) is recommended for select patients who have undergone major abdominopelvic surgery to prevent postdischarge venous thromboembolism (pdVTE). Criteria for selection of these patients are untested for this purpose and may be ineffective. To address this gap, we investigated the effectiveness of eVTEp on pdVTE rates.A retrospective cohort study of patients undergoing abdominopelvic surgery from January 2016 to February 2020 was performed using data from the Michigan Surgical Quality Collaborative. pdVTE was the main outcome. Our exposure variable, eVTEp, was compared dichotomously. Length of stay (LOS) was compared categorically using clinically relevant groups. Age, race, cancer occurrence, inflammatory bowel disease, surgical approach, and surgical time were covariates among other variables. Descriptive statistics, propensity score matching, and multivariable logistic regression were performed to compare pdVTE rates.A total of 45,637 patients underwent abdominopelvic surgery. Of which, 3063 (6.71%) were prescribed eVTEp. Two hundred eighty-five (0.62%) had pdVTE. Of the 285, 59 (21%) patients received eVTEp, while 226 (79%) patients did not. After propensity score matching, multivariable logistic regression analysis showed pdVTE was associated with eVTEp and LOS of 5 d or more (P < 0.001). eVTEp was not associated with LOS. Further analysis showed increased risk of pdVTE with increasing LOS independent of prescription of eVTEp based on known risk factors.pdVTE was associated with increasing LOS but not with other VTE risk factors after propensity score matching. Current guidelines for eVTEp do not include LOS. Our findings suggest that LOS >5 d should be added to the criteria for eVTEp.
View details for DOI 10.1016/j.jss.2022.10.001
View details for Web of Science ID 000883043500007
View details for PubMedID 36327702
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Use and Out-of-Pocket Cost of Sacubitril-Valsartan in Patients With Heart Failure
JOURNAL OF THE AMERICAN HEART ASSOCIATION
2022; 11 (17): e023950
Abstract
Background Current guidelines recommend use of sacubitril-valsartan in patients with heart failure with reduced ejection fraction (HFrEF). Early data suggested low uptake of sacubitril-valsartan, but contemporary data on real-world use and their associated cost are limited. Methods and Results This was a retrospective study of individuals enrolled in Optum Clinformatics, a national insurance claims data set from 2016 to 2018. We included all adult patients with HFrEF with 2 outpatient encounters or 1 inpatient encounter with an International Classification of Diseases, Tenth Revision (ICD-10), diagnosis of HFrEF and 6 months of continuous enrollment, also receiving β-blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers within 6 months of HFrEF diagnosis. We included 70 245 patients with HFrEF, and 5217 patients (7.4%) received sacubitril-valsartan prescriptions. Patients receiving care through a cardiologist compared with a primary care physician alone were more likely to receive sacubitril-valsartan (odds ratio, 1.61 [95% CI, 1.52-1.71]). Monthly out-of-pocket (OOP) cost for sacubitril-valsartan, compared with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, was higher for both commercially insured patients (mean, $69 versus $6.74) and Medicare Advantage (mean, $62 versus $2.52). For patients with commercial insurance, OOP cost was lower in 2016 than in 2018. For patients with Medicare Advantage, there was a significant geographic variation in the OOP costs across the country, ranging from $31 to $68 per month across different regions, holding all other patient-related factors constant. Conclusions Sacubitril-valsartan use was infrequent among patients with HFrEF. Patients receiving care with a cardiologist were more likely to receive sacubitril-valsartan. OOP costs remain high, potentially limiting use. Significant geographic variation in OOP costs, unexplained by patient factors, was noted.
View details for DOI 10.1161/JAHA.121.023950
View details for Web of Science ID 000850275600044
View details for PubMedID 36000415
View details for PubMedCentralID PMC9496420
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Racial and Ethnic Inequities in Use of Preventive Services Among Privately Insured Adults With a Pediatric-Onset Disability
ANNALS OF FAMILY MEDICINE
2022; 20 (5): 430-437
Abstract
Cerebral palsy (CP) and spina bifida (SB) are pediatric-onset disabilities. Adults living with CP/SB are in a greater need of preventive care than the general population due to their increased risk for chronic diseases. Our objective was to compare White/Black and White/Hispanic inequities in the use of preventive services.Using 2007-2017 private claims data, we identified a total of 11,635 adults with CP/BS. Of these, 8,935 were White, 1,457 Black, and 1,243 Hispanic. We matched health-related variables (age, sex, comorbid conditions) between White adults and those in each minority subpopulation. Generalized estimating equations were used and all models were adjusted for age, sex, comorbidities, income, education, and US Census divisions. Outcomes of interest were: (1) any office visit; (2) any physical/occupational therapy; (3) wellness visit; (4) bone density screening; (5) cholesterol screening; and (6) diabetes screening.The rate of recommended services for all subpopulations of adults with CP/SB was low. Compared with White adults, Hispanic adults had lower odds of wellness visits (odds ratio [OR] = 0.71, 95% CI, 0.53-0.96) but higher odds of diabetes screening (OR = 1.48, 95% CI, 1.13-1.93). Compared with White adults, Black adults had lower odds of wellness visits (OR = 0.50, 95% CI, 0.24-1.00) and bone density screening (OR = 0.54, 95% CI, 0.31-0.95).Preventive service use among adults with CP/SB was low. Large White-minority disparities in wellness visits were observed. Interventions to address physical accessibility, adoption of telehealth, and increased clinician education may mitigate these disparities, particularly if initiatives target minority populations.
View details for DOI 10.1370/afm.2849
View details for Web of Science ID 000884476900006
View details for PubMedID 36228076
View details for PubMedCentralID PMC9512552
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Effects of Pharmacologic Venous Thromboembolism Prophylaxis in Benign Hysterectomy
OBSTETRICAL & GYNECOLOGICAL SURVEY
2022; 77 (9): 522-523
View details for DOI 10.1097/OGX.0000000000001084
View details for Web of Science ID 000855628200009
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Impact of Weight and Race on Renal Response to Cyclophosphamide in the Abatacept and Cyclophosphamide Combination Efficacy and Safety Study (ACCESS)
WILEY. 2022: 1950-1952
View details for Web of Science ID 000877386501500
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Potentially preventable hospitalizations and use of preventive services among people with multiple sclerosis: Large cohort study, USA
MULTIPLE SCLEROSIS AND RELATED DISORDERS
2022; 68: 104105
Abstract
Individuals with multiple sclerosis (MS) report barriers to accessing care, including receipt of preventive services. Potentially preventable hospitalization (PPH) is an important marker for access to, and receipt of timely care. However, few national studies have examined PPH risk in people with MS or considered the role of preventive care in reducing PPH risk among this patient population. Our objective was to examine PPH risk among adults with MS compared with their counterparts without MS.Optum® Clinformatics® Data Mart (2007-2017) was used to identify 6198 individuals with an MS diagnosis and their propensity-score matched counterparts without MS. Diagnostic and procedural codes were used to identify the presence of preventive hospitalizations, which were defined as quality indicators by the Agency for Healthcare Research and Quality (AHRQ) during the 4-year follow-up period since the diagnosis of MS. Information on receipt of preventive services and office visits was also extracted. Adjusted generalized estimating equations were used to examine the association between MS diagnosis and PPHs. To examine the role of preventive services on odds of PPH amongst people with MS, we reported the adjusted marginal odds ratio (OR) and 95% confidence intervals (CI).The rate of any PPH among people with MS was double that of those without MS (131.6 vs 62.5 per 10,000). We identified higher odds of specific PPH indicators among people with MS compared to those without. Individuals with MS had 65% higher odds of hospitalization for pneumonia (OR=1.65, 95% CI: 1.01, 2.30), with similar significant findings observed for urinary tract infections (OR=4.90, 95% CI: 2.51, 9.57). In MS patients, receipt of preventive services, namely cholesterol screening (OR=0.76, 95% CI: 0.60, 0.95) and annual wellness visits were associated with lower odds of any PPH (OR=0.57, 95% CI: 0.43, 0.76).People with MS were at a higher risk for PPHs compared with their counterparts without MS. Use of appropriate preventive services reduced the risk of PPH among the general population and among those with MS. More efforts are needed to encourage and facilitate the use of preventive care among people with MS. Receipt of timely and appropriate preventive care in this population may reduce the risk for PPH.
View details for DOI 10.1016/j.msard.2022.104105
View details for Web of Science ID 000863069600012
View details for PubMedID 36031692
View details for PubMedCentralID PMC10424261
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Vaccination Against Measles, Mumps, Rubella and Incident Inflammatory Bowel Disease in a National Cohort of Privately Insured Children
INFLAMMATORY BOWEL DISEASES
2023; 29 (3): 430-436
Abstract
Infection is believed to be a potential trigger for inflammatory bowel disease (IBD). Whether vaccination against childhood infections including measles, mumps, and rubella may reduce risk of IBD is uncertain.We conducted a retrospective cohort study using de-identified claims data from a national private payer (Optum Clinformatics Data Mart). Eligible infants were born between 2001 and 2018 and were continuously enrolled with medical and pharmacy coverage from birth for at least 2 years (n = 1 365 447). Measles, mumps, and rubella vaccination or MMR is administered beginning at 12 months of age. Cox proportional hazard regression models were used to compare time with incident disease in children by category of vaccination, after adjustment for sex, birth year, region of country, history of allergy to vaccines, and seizure history.The incidence of early pediatric IBD increased between 2001 and 2018. Ten percent (n = 141 230) of infants did not receive MMR, and 90% (n = 1 224 125) received at least 1 dose of MMR. There were 334 cases of IBD, 219 cases of Crohn's disease, and 164 cases of ulcerative colitis. Children who had received at least 1 dose of MMR had lower risk for IBD than children who did not (hazard ratio, 0.71; 95% confidence interval, 0.59-0.85). These associations did not change after further adjustment for childhood comorbid conditions, preterm birth, or older siblings affected with IBD. Similar associations were observed for MMR with Crohn's disease and ulcerative colitis, although these did not reach statistical significance.MMR is associated with decreased risk for childhood IBD.
View details for DOI 10.1093/ibd/izac176
View details for Web of Science ID 000842079600001
View details for PubMedID 35986719
View details for PubMedCentralID PMC9977230
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Assessment of telecommunicator cardiopulmonary resuscitation performance during out-of-hospital cardiac arrest using a standardized tool for audio review
RESUSCITATION
2022; 178: 102-108
Abstract
Telecommunicator cardiopulmonary resuscitation (T-CPR) is a critical component of optimized out-of-hospital cardiac arrest (OHCA) care. We assessed a pilot tool to capture American Heart Association (AHA) T-CPR measures and T-CPR coaching by telecommunicators using audio review.Using a pilot tool, we conducted a retrospective review of 911 call audio from 65 emergency medical services-treated out-of-hospital cardiac arrest (OHCA) patients. Data collection included events (e.g., OHCA recognition), time intervals, and coaching quality measures. We calculated summary statistics for all performance and quality measures.Among 65 cases, the patients' mean age was 64.7 years (SD: 14.6) and 17 (26.2%) were women. Telecommunicator recognition occurred in 72% of cases (47/65). Among 18 non-recognized cases, reviewers determined 12 (66%) were not recognizable based on characteristics of the call. Median time-to-recognition was 76 seconds (n = 40; IQR:39-138), while median time-to-first-instructed-compression was 198 seconds (n = 26; IQR:149-233). In 36 cases where coaching was needed, coaching on compression-depth occurred in 27 (75%); -rate in 28 (78%); and chest recoil in 10 (28%) instances. In 30 cases where repositioning was needed, instruction to position the patient's body flat occurred in 18 (60%) instances, on-back in 22 (73%) instances, and on-ground in 22 (73%) instances.Successful collection of data to calculate AHA T-CPR measures using a pilot tool for audio review revealed performance near AHA benchmarks, although coaching instructions did not occur in many instances. Application of this standardized tool may aid in T-CPR quality review.
View details for DOI 10.1016/j.resuscitation.2022.04.015
View details for Web of Science ID 000877458000002
View details for PubMedID 35483496
View details for PubMedCentralID PMC11249783
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Rotavirus vaccination is not associated with incident celiac disease or autoimmune thyroid disease in a national cohort of privately insured children
SCIENTIFIC REPORTS
2022; 12 (1): 12941
Abstract
Rotavirus infection is a potential trigger for autoimmune diseases, and previous reports note associations between rotavirus vaccination and type 1 diabetes. In this report, we examine the association between rotavirus vaccination and autoimmune diseases associated with type 1 diabetes: celiac disease and autoimmune thyroiditis. We conducted a retrospective cohort study using de-identified claims data (Optum Clinformatics® Data Mart). Eligible infants were born between 2001 and 2018 and continuously enrolled from birth for at least 365 days (n = 2,109,225). Twenty-nine percent (n = 613,295) of infants were born prior to the introduction of rotavirus vaccine in 2006; 32% (n = 684,214) were eligible for the vaccine but were not vaccinated; 9.6% (n = 202,016) received partial vaccination, and 28.9% received full vaccination (n = 609,700). There were 1379 cases of celiac disease and 1000 cases of autoimmune thyroiditis. Children who were born prior to the introduction of rotavirus vaccine in 2006 had lower risk of celiac disease compared to unvaccinated children born after 2006 (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.59, 0.85). However, children who were partially vaccinated (HR 0.90, 95% CI 0.73, 1.11) or fully vaccinated (HR 1.03, 95% CI 0.88, 1.21) had similar risk to eligible, unvaccinated children. Risk of autoimmune thyroiditis was similar by vaccination status. We conclude that rotavirus vaccination is not associated with increased or decreased risk for celiac disease or autoimmune thyroiditis.
View details for DOI 10.1038/s41598-022-17187-y
View details for Web of Science ID 000833071900015
View details for PubMedID 35902684
View details for PubMedCentralID PMC9334581
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Predictors of same-day discharge following benign minimally invasive hysterectomy
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2022; 227 (2): 320.e1-320.e9
Abstract
Same-day discharge following minimally invasive hysterectomy has been shown to be safe and feasible in select populations, but many nonclinical factors influencing same-day discharge remain unexplored.To develop prediction models for same-day discharge following minimally invasive hysterectomy using both clinical and nonclinical attributes and to compare model concordance of individual attribute groups.We performed a retrospective study of patients who underwent elective minimally invasive hysterectomy for benign gynecologic indications at 69 hospitals in a statewide quality improvement collaborative between 2012 and 2019. Potential predictors of same-day discharge were determined a priori and placed into 1 of 7 attribute groupings: intraoperative, surgeon, hospital, surgical timing, patient clinical, patient socioeconomic, and patient geographic attributes. To account for clustering of same-day discharge practices among surgeons and within hospitals, hierarchical multivariable logistic regression models were fitted using predictors from each attribute group individually and all predictors in a composite model. Receiver operator characteristic curves were generated for each model. The Hanley-McNeil test was used for comparisons, 95% confidence intervals for the areas under the receiver operator characteristic curve were calculated, and a P value of <.05 was considered significant.Of the 23,513 patients in our study, 5062 (21.5%) had same-day discharge. The composite model had an area under the receiver operator characteristic curve of 0.770 (95% confidence interval, 0.763-0.777). Among models using factors from individual attribute groups, the model using intraoperative attributes had the highest concordance for same-day discharge (area under the receiver operator characteristic curve, 0.720; 95% confidence interval, 0.712-0.727). The models using surgeon and hospital attributes were the second and third most concordant, respectively (area under the receiver operator characteristic curve, 0.678; 95% confidence interval, 0.670-0.685; area under the receiver operator characteristic curve, 0.655; 95% confidence interval, 0.656-0.664). Models using surgical timing and patient clinical, socioeconomic, and geographic attributes had poor predictive ability (all areas under the receiver operator characteristic curve <0.6).Clinical and nonclinical attributes contributed to a composite prediction model with good discrimination in predicting same-day discharge following minimally invasive hysterectomy. Factors related to intraoperative, hospital, and surgeon attributes produced models with the strongest predictive ability. Focusing on these attributes may aid efforts to improve utilization of same-day discharge following minimally invasive hysterectomy.
View details for DOI 10.1016/j.ajog.2022.05.026
View details for Web of Science ID 000836681800051
View details for PubMedID 35580633
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Physical and occupational therapy utilization and associated factors among adults with cerebral palsy: Longitudinal modelling to capture distinct utilization groups
DISABILITY AND HEALTH JOURNAL
2022; 15 (3): 101279
Abstract
Adults with cerebral palsy (CP) experience functional declines. Clinical rehabilitation may preserve function for this population.To identify longitudinal physical/occupational therapy use and associated factors among adults with CP, to inform health promotion strategies.A retrospective cohort study including adults ≥ 18 years of age with CP was performed using a random 20% Medicare fee-for-service dataset. Participants with continuous medicare enrolment from 01/01/2016-12/31/2018 were included: 2016 was the one-year baseline period; 2017-2018 was the two-year follow-up. Therapy included an indication of physical, occupational, or other forms of therapy. Two-year therapy use patterns were identified using group-based trajectory modeling. Multivariable multinomial logistic regression models identified associations between baseline characteristics with trajectory groups.Of 17,441, 7231 (41.5%) adults with CP had therapy use across the three-year period, and six longitudinal therapy trajectories were identified: the majority (42.5%) were low-consistent users, 13.4% moderate-consistent users, 4.4% high-consistent users, and the remaining variable users. Associations between baseline characteristics (e.g., age, sex, comorbidities) with trajectory groups varied. For example, using the low-consistent users as the reference, Black versus White were 49% less likely, Northeast versus South residency were 7.52-fold more likely, and co-occurring neurologic conditions versus CP only were up to 118% more likely to be high-consistent users (all, P < 0.05). Bone fragility and some chronic comorbidities were associated with moderate consistent users.The majority of adults with CP were not using physical/occupational therapy. Of those that did, there were unique longitudinal trajectories which associated differently with demographics and comorbidities.
View details for DOI 10.1016/j.dhjo.2022.101279
View details for Web of Science ID 000852951200010
View details for PubMedID 35264292
View details for PubMedCentralID PMC9308687
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Opioid prescription patterns among adults with cerebral palsy and spina bifida
HELIYON
2022; 8 (7): e09918
Abstract
Pain is the most common symptom of cerebral palsy and spina bifida (CP/SB). The objective of this study was to compare the opioid prescription patterns for differing pain types and overlapping pain among adults living with and without CP/SB.Privately-insured beneficiaries were included if they had CP/SB (n = 22,647). Adults without CP/SB were also included as controls (n = 931,528). Oral morphine equivalents (OMEs) were calculated. A multivariable logistic regression was used to analyze the association between CP/SB and OMEs, across the three pain categories: (1) no pain, (2) isolated pain, and (3) pain multimorbidity.Adults living with CP/SB had a higher OME prescription pattern per year than adults without CP or SB (8,981.0 ± 5,183.0 vs. 4,549.1 ± 2,988.0), and for no pain (4,010.8 ± 828.1 vs. 1,623.53 ± 47.5), isolated pain (7,179.9 ± 378.8 vs. 3,531.0 ± 131.0), and pain multimorbidity (15,752.4 ± 1,395.5 vs. 8,492.9 ± 398.0) (all p < 0.001), and differences were to a clinically meaningful extent. Adjusted odds ratios (OR) for prescribed OMEs were higher for adults with CP/SB vs. control and (1) no pain (OR: 1.51; 95%CI: 1.46, 1.56), (2) isolated pain (OR: 1.48; 95%CI: 1.44, 1.52), and (3) pain multimorbidity (OR: 1.79; 95%CI: 1.72, 1.86).Adults with CP/SB obtain significantly higher prescription of OMEs than adults without CP/SB.
View details for DOI 10.1016/j.heliyon.2022.e09918
View details for Web of Science ID 000843515600017
View details for PubMedID 35847615
View details for PubMedCentralID PMC9284449
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Preventative Services Use and Risk Reduction for Potentially Preventative Hospitalizations Among People With Traumatic Spinal Cord Injury
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2022; 103 (7): 1255-1262
Abstract
To examine the risk of potentially preventable hospitalizations (PPHs) for adults (18 years or older) with traumatic spinal cord injury (TSCI) to identify the most common types of preventable hospitalizations and their associative risk factors.Cohort study.Using 2007-2017 U.S. claims data from the Optum Clinformatics Data Mart, we identified adults (18 years or older) with diagnosis of TSCI (n=5380). Adults without TSCI diagnosis were included as controls (n=1,074,729). Using age and sex, we matched individuals with and without TSCI (n=5173) with propensity scores to address potential selection bias. Generalized linear regression was applied to examine the risk of TSCI on PPHs. Models were adjusted for age; sex; race and ethnicity; Elixhauser comorbidity count; any cardiometabolic, psychological, and musculoskeletal chronic conditions; U.S. Census Division; socioeconomic variables; and use of certain preventative care services. Adjusted odds ratios were compared within a 4-year follow-up period.Adults with and without TSCI (N=5,173).Not applicable.Any PPH and specific PPHs RESULTS: Adults with TSCI had higher risk for any PPH (odds ratio [OR], 1.67; 95% CI,1.20-2.32), as well as PPHs because of urinary tract infection (UTI) (OR, 3.78; 95% CI, 2.47-5.79), hypertension (OR, 3.77; 95% CI, 1.54-9.21), diabetes long-term complications (OR, 2.54; 95% CI, 1.34-4.80), and pneumonia (OR, 1.71; 95% CI. 1.21-2.41). Annual wellness visit was associated with reduced PPH risk compared with cases and controls without annual wellness visit (OR, 0.57; 95% CI, 0.46-0.71) and among people with TSCI (OR, 0.69; 95% CI, 0.55-0.86) compared with cases without annual wellness visit.Adults with TSCI are at a heightened risk for PPH. They are also more susceptible to certain PPHs such as UTIs, pneumonia, and heart failure. Encouraging the use of preventative or health-promoting services, especially for respiratory and urinary outcomes, may reduce PPHs among adults with TSCI.
View details for DOI 10.1016/j.apmr.2021.12.004
View details for Web of Science ID 000838733300002
View details for PubMedID 35691712
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Effects of Pharmacologic Venous Thromboembolism Prophylaxis in Benign Hysterectomy
ELSEVIER SCIENCE INC. 2022: 776-783
Abstract
To evaluate whether the addition of pharmacologic prophylaxis to mechanical prophylaxis for venous thromboembolism (VTE) is associated with changes in perioperative outcomes in hysterectomy for benign indications.Retrospective cohort study.Michigan Surgical Quality Collaborative database.Patients who underwent hysterectomy between July 2012 and June 2015 when VTE prophylaxis data were collected.Patients who received mechanical prophylaxis alone were compared with those receiving dual prophylaxis (mechanical and pharmacologic). Minimally invasive surgeries (MIS) included laparoscopic, vaginal, robotic-assisted, and laparoscopic-assisted vaginal hysterectomies and were analyzed separately from abdominal (ABD) hysterectomy.Propensity score matching was used to minimize confounding because of the differences in demographic and perioperative characteristics. The primary outcome was estimated blood loss (EBL). The secondary outcomes were operative time, postoperative blood transfusion, VTE, surgical site infection, reoperation, readmission, and death. There were 1803 matched pairs in the MIS analysis. In the ABD hysterectomy analysis, 2:1 matching was used with a total of 1168 patients receiving mechanical prophylaxis alone matched to 616 patients receiving dual prophylaxis. EBL was higher by 54.5 mL (95% confidence interval [CI], 16.9-92.1) in those receiving dual prophylaxis in the ABD hysterectomy analysis but did not differ between groups in the MIS analysis. Operative time was significantly longer with dual prophylaxis in both MIS (18.3 minutes; 95% CI, 13.8-22.8) and ABD (15.3 minutes; 95% CI, 9.0-21.6) surgical approaches. There was no difference in other secondary outcomes.The addition of pharmacologic prophylaxis to mechanical prophylaxis in benign hysterectomy was associated with longer operative time, regardless of surgical approach and increased EBL in ABD hysterectomy. Given very low rates of VTE, no difference in other perioperative outcomes, and possible harm, it seems reasonable to encourage individualized rather than routine use of pharmacologic prophylaxis in patients undergoing benign hysterectomy receiving mechanical prophylaxis.
View details for DOI 10.1016/j.jmig.2022.02.009
View details for Web of Science ID 000812987500017
View details for PubMedID 35227913
View details for PubMedCentralID PMC9284594
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Disparities in Morbidity After Spinal Cord Injury Across Insurance Types in the United States.
Mayo Clinic proceedings. Innovations, quality & outcomes
2022; 6 (3): 279-290
Abstract
Objective: To compare the prevalence and incidence of, and adjusted hazards for comorbidities among adults with traumatic spinal cord injuries (TSCIs) across insurance types (private vs governmental insurance) in the United States.Patients and Methods: Privately insured (N=9081) and Medicare (N=7645) beneficiaries with a diagnosis of TSCI were included. Prevalence and incidence estimates of common psychological, cardiometabolic, and musculoskeletal morbidities were compared at baseline and at 4-years after index diagnosis, respectively. Survival models were used to quantify hazard ratios (HRs) for outcomes, controlling for insurance type, sociodemographic characteristics, and other comorbidities. Sensitivity analyses were conducted to determine the effects of insurance and race/ethnicity.Results: Adults with TSCIs on Medicare had a higher prevalence of any psychological (54.7% vs 35.4%), cardiometabolic (74.7% vs 70.1%), and musculoskeletal (72.8% vs 66.3%) morbidity than privately insured adults with TSCIs. Similarly, the 4-year incidences of most psychological (eg, depression: 37.6% [Medicare] vs 24.2% [private]), cardiometabolic (eg, type 2 diabetes: 22.5% [Medicare] vs 12.9% [private], and musculoskeletal (eg, osteoarthritis: 42.1% [Medicare] vs 34.6% [private]) morbidities were considerably higher among adults with TSCIs on Medicare. Adjusted survival models found that adults with TSCIs on Medicare had a greater hazard for developing psychological (HR, 1.40; 95% CI, 1.31-1.50) and cardiometabolic (HR, 1.21; 95% CI, 1.10-1.33) morbidities compared with privately insured adults with TSCI. There was evidence of both insurance and racial disparities.Conclusion: Adults with TSCIs on Medicare had significantly higher prevalence and risk for developing common physical and mental health comorbidities, compared with privately insured adults with TSCIs.
View details for DOI 10.1016/j.mayocpiqo.2022.04.004
View details for PubMedID 36532826
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Musculoskeletal Morbidity Among Adults Living With Spina Bifida and Cerebral Palsy
TOPICS IN SPINAL CORD INJURY REHABILITATION
2022; 28 (3): 73-84
Abstract
Individuals living with cerebral palsy (CP) or spina bifida (SB) are at heightened risk for chronic health conditions that may develop or be influenced by the impairment and/or the process of aging.The objective of this study was to compare the incidence of and adjusted hazards for musculoskeletal (MSK) morbidities among adults living with and without CP or SB.A retrospective, longitudinal cohort study was conducted among adults living with (n = 15,302) CP or SB and without (n = 1,935,480) CP or SB. Incidence estimates of common MSK morbidities were compared at 4 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident MSK morbidities. The analyses were performed in 2019 to 2020.Adults living with CP or SB had a higher 4-year incidence of any MSK morbidity (55.3% vs. 39.0%) as compared to adults without CP or SB, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with CP or SB had a greater hazard for all MSK disorders; this ranged from hazard ratio (HR) 1.40 (95% CI, 1.33 to 1.48) for myalgia to HR 3.23 (95% CI, 3.09 to 3.38) for sarcopenia and weakness.Adults with CP or SB have a significantly higher incidence of and risk for common MSK morbidities as compared to adults without CP or SB. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of MSK disease onset/progression in these higher risk populations.
View details for DOI 10.46292/sci21-00078
View details for Web of Science ID 000919930800007
View details for PubMedID 36017121
View details for PubMedCentralID PMC9394067
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Rapid response systems The association of fire or police first responder initiated interventions with out of hospital cardiac arrest survival
RESUSCITATION
2022; 174: 9-15
Abstract
Fire and police first responders are often the first to arrive in medical emergencies and provide basic life support services until specialized personnel arrive. This study aims to evaluate rates of fire or police first responder-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, as well as their associated impact on out-of-hospital cardiac arrest (OHCA) outcomes.We completed a secondary data analysis of the MI-CARES registry from 2014 to 2019. We reported rates of CPR initiation and AED use by fire or police first responders. Multilevel modeling was utilized to evaluate the relationship between fire/police first responder-initiated interventions and outcomes of interest: ROSC upon emergency department arrival, survival to hospital discharge, and good neurologic outcome.Our cohort included 25,067 OHCA incidents. We found fire or police first responders initiated CPR in 31.8% of OHCA events and AED use in 6.1% of OHCA events. Likelihood of sustained ROSC on ED arrival after CPR initiated by a fire/police first responder was not statistically different as compared to EMS initiated CPR (aOR 1.01, CI 0.93-1.11). However, fire/police first responder interventions were associated with significantly higher odds of survival to hospital discharge and survival with good neurologic outcome (aOR 1.25, 95% CI 1.08-1.45 and aOR 1.40, 95% CI 1.18-1.65, respectively). Similar associations were see when examining fire or police initiated AED use.Fire or police first responders may be an underutilized, potentially powerful mechanism for improving OHCA survival. Future studies should investigate barriers and opportunities for increasing first responder interventions by these groups in OHCA.
View details for DOI 10.1016/j.resuscitation.2022.02.026
View details for Web of Science ID 000912458900001
View details for PubMedID 35257834
View details for PubMedCentralID PMC9050861
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Development of a Preoperative Clinical Risk Assessment Tool for Postoperative Complications After Hysterectomy
ELSEVIER SCIENCE INC. 2022: 401-+
Abstract
To develop a preoperative risk assessment tool that quantifies the risk of postoperative complications within 30 days of hysterectomy.Retrospective analysis.Michigan Surgical Quality Collaborative hospitals.Women who underwent hysterectomy for gynecologic indications.Development of a nomogram to create a clinical risk assessment tool.Postoperative complications within 30 days were the primary outcome. Bivariate analysis was performed comparing women who had a complication and those who did not. The patient registry was randomly divided. A logistic regression model developed and validated from the Collaborative database was externally validated with hysterectomy cases from the National Surgical Quality Improvement Program, and a nomogram was developed to create a clinical risk assessment tool. Of the 41,147 included women, the overall postoperative complication rate was 3.98% (n = 1638). Preoperative factors associated with postoperative complications were sepsis (odds ratio [OR] 7.98; confidence interval [CI], 1.98-32.20), abdominal approach (OR 2.27; 95% CI, 1.70-3.05), dependent functional status (OR 2.20; 95% CI, 1.34-3.62), bleeding disorder (OR 2.10; 95% CI, 1.37-3.21), diabetes with HbA1c ≥9% (OR 1.93; 95% CI, 1.16-3.24), gynecologic cancer (OR 1.86; 95% CI, 1.49-2.31), blood transfusion (OR 1.84; 95% CI, 1.15-2.96), American Society of Anesthesiologists Physical Status Classification System class ≥3 (OR 1.46; 95% CI, 1.24-1.73), government insurance (OR 1.3; 95% CI, 1.40-1.90), and body mass index ≥40 (OR 1.25; 95% CI, 1.04-1.50). Model discrimination was consistent in the derivation, internal validation, and external validation cohorts (C-statistics 0.68, 0.69, 0.68, respectively).We validated a preoperative clinical risk assessment tool to predict postoperative complications within 30 days of hysterectomy. Modifiable risk factors identified were preoperative blood transfusion, poor glycemic control, and open abdominal surgery.
View details for DOI 10.1016/j.jmig.2021.10.008
View details for Web of Science ID 000819807000017
View details for PubMedID 34687927
View details for PubMedCentralID PMC8917981
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Patient, Surgeon, or Hospital: Explaining Variation in Outcomes after Colectomy
LIPPINCOTT WILLIAMS & WILKINS. 2022: 300-309
Abstract
Complication rates after colectomy remain high. Previous work has failed to establish the relative contribution of patient comorbidities, surgeon performance, and hospital systems in the development of complications after elective colectomy.We identified all patients undergoing elective colectomy between 2012 and 2018 at hospitals participating in the Michigan Surgical Quality Collaborative. The primary outcome was development of a postoperative complication. We used risk- and reliability-adjusted generalized linear mixed models to estimate the degree to which variance in patient-, surgeon-, and hospital-level factors contribute to complications.A total of 15,755 patients were included in the study. The mean hospital-level complication rate was 15.8% (range, 8.7% to 30.2%). The proportion of variance attributable to the patient level was 35.0%, 2.4% was attributable to the surgeon level, and 1.8% was attributable to the hospital level. The predicted probability of complication for the least comorbid patient was 1.5% (CI 0.7-3.1%) at the highest performing hospital with the highest performing surgeon, and 6.6% (CI 3.2-12.2%) at the lowest performing hospital with the lowest performing surgeon. By contrast, the most comorbid patient in the cohort had a 66.3% (CI 39.5-85.6%) or 89.4% (CI 73.7-96.2%) risk of complication.This study demonstrated that variance from measured factors at the patient level contributed more than 8-fold more to the development of complications after colectomy compared with variance at the surgeon and hospital level, highlighting the impact of patient comorbidities on postoperative outcomes. These results underscore the importance of initiatives that optimize patient foundational health to improve surgical care.
View details for DOI 10.1097/XCS.0000000000000063
View details for Web of Science ID 000765912000008
View details for PubMedID 35213493
View details for PubMedCentralID PMC10369366
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Longitudinal Associations Between Vision Neuropsychiatric, Musculoskeletal, and Cardiometabolic Chronic Diseases
AMERICAN JOURNAL OF OPHTHALMOLOGY
2022; 235: 163-171
Abstract
To compare the incidence and hazard of neuropsychiatric, musculoskeletal, and cardiometabolic conditions among adults with and without vision impairment (VI).Retrospective cohort study.The sample comprised enrollees in a large private health insurance provider in the United States, including 24 657 adults aged ≥18 years with VI and age- and sex-matched controls. The exposure variable, VI, was based on low vision and blindness International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM), diagnosis codes. Physician-diagnosed incident neuropsychiatric, musculoskeletal, and cardiometabolic diseases were identified using ICD codes. Separate Cox proportional hazards regression models were used to assess the association of VI with incidence of 30 chronic conditions, adjusting for Elixhauser Comorbidity Index. Analyses were stratified by age 18-64 years and ≥65 years.In individuals with VI aged 18-64 years (n=7478), the adjusted hazard of neuropsychiatric (HR 2.1, 95% CI 1.9, 2.4), musculoskeletal (HR 1.8, 95% CI 1.7, 2.0), and cardiometabolic (HR 1.8, 95% CI 1.7, 2.0) diseases was significantly greater than in matched controls (mean 5.5 years follow-up). Similar associations were seen between patients with VI aged ≥65 years (n=17 179) for neuropsychiatric (HR 2.4, 95% CI 2.1, 2.7), musculoskeletal (HR 1.8, 95% CI 1.6, 1.9), and cardiometabolic (HR 1.7, 95% CI 1.4, 2.0) diseases. VI was associated with a higher hazard of each of the 30 conditions we assessed, with similar results in both age cohorts.Across the life span, adults with VI had an approximately 2-fold greater adjusted hazard for common neuropsychiatric, musculoskeletal, and cardiometabolic disorders compared with matched controls without VI.
View details for DOI 10.1016/j.ajo.2021.09.004
View details for Web of Science ID 000808112700004
View details for PubMedID 34543661
View details for PubMedCentralID PMC8863581
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Physical and Mental Health Comorbidities Among Adults With Multiple Sclerosis.
Mayo Clinic proceedings. Innovations, quality & outcomes
2022; 6 (1): 55-68
Abstract
OBJECTIVE: To compare the incidence of and adjusted hazard ratios for common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities among adults with and without multiple sclerosis (MS).PATIENTS AND METHODS: Beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for MS (n=9815) from a national private insurance claims database (Clinformatics Data Mart; OptumInsight). Adults without MS were also included (n=1,474,232) as a control group. Incidence estimates of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities were compared at 5 years of continuous enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident morbidities.RESULTS: Adults with MS had a higher incidence of any common cardiometabolic disease (51.6% [2663 of 5164] vs 36.4% [328,690 of 904,227]), musculoskeletal disorder (68.8% [3411 of 4959] vs 47.5% [512,422 of 1,077,737]), and psychological morbidity (49.4% [3305 of 6691] vs 30.8% [380,893 of 1,235,388]) than adults without MS, and differences were clinically meaningful (all P<.001). Fully adjusted survival models revealed that adults with MS had a greater risk for any (hazard ratio [HR], 1.37; 95% CI, 1.32 to 1.43) and all (HR, 1.19 to 1.48) common cardiometabolic diseases, any (HR, 1.59; 95% CI, 1.53 to 1.64) and all (HR, 1.22 to 2.77) musculoskeletal disorders, and any (HR, 1.57; 95% CI, 1.51 to 1.62) and all (HR, 1.20 to 2.51) but one (impulse control disorders) psychological morbidity.CONCLUSION: Adults with MS have a significantly higher risk for development of common cardiometabolic diseases, musculoskeletal disorders, and psychological morbidities (all P<.001) than adults without MS. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of chronic physical and mental disease onset/progression in this higher risk population.
View details for DOI 10.1016/j.mayocpiqo.2021.11.004
View details for PubMedID 35005438
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Increased Intraoperative Faculty Entrustment and Resident Entrustability Does Not Compromise Patient Outcomes After General Surgery Procedures
ANNALS OF SURGERY
2022; 275 (2): E366-E374
Abstract
Intraoperative resident autonomy has been compromised secondary to expectations for increased supervision without defined parameters for safe progressive independence, diffusion of training experience, and more to learn with less time. Surgical residents who are insufficiently entrusted during training attain less autonomy, confidence, and even clinical competency, potentially affecting future patient outcomes.To determine if OpTrust, an educational intervention for increasing intraoperative faculty entrustment and resident entrustability, negatively impacts patient outcomes after general surgery procedures.Surgical faculty and residents received OpTrust training and instruction to promote intraoperative faculty entrustment and resident entrustability. A post-intervention OpTrust cohort was compared to historical and pre-intervention OpTrust cohorts. Multivariable logistic and negative binomial regression was used to evaluate the impact of the OpTrust intervention and time on patient outcomes.Single tertiary academic center.General surgery faculty and residents.Thirty-day postoperative outcomes, including mortality, any complication, reoperation, readmission, and length of stay.A total of 8890 surgical procedures were included. After risk adjustment, overall patient outcomes were similar. Multivariable regression estimating the effect of the OpTrust intervention and time revealed similar patient outcomes with no increased risk (P > 0.05) of mortality {odds ratio (OR), 2.23 [95% confidence interval (CI), 0.87-5.6]}, any complication [OR, 0.98 (95% CI, 0.76-1.3)], reoperation [OR, 0.65 (95% CI, 0.42-1.0)], readmission [OR, 0.82 (95% CI, 0.57-1.2)], and length of stay [OR, 0.99 (95% CI, 0.86-1.1)] compared to the historic and pre-intervention OpTrust cohorts.OpTrust, an educational intervention to increase faculty entrustment and resident entrustability, does not compromise postoperative patient outcomes. Integrating faculty and resident development to further enhance entrustment and entrustability through OpTrust may help facilitate increased resident autonomy within the safety net of surgical training without negatively impacting clinical outcomes.
View details for DOI 10.1097/SLA.0000000000004052
View details for Web of Science ID 000740824400039
View details for PubMedID 32541221
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Psychological morbidity following spinal cord injury and among those without spinal cord injury: the impact of chronic centralized and neuropathic pain
SPINAL CORD
2022; 60 (2): 163-169
Abstract
Longitudinal cohort study of privately insured beneficiaries with and without traumatic spinal cord injury (SCI).Compare the incidence of and adjusted hazards for psychological morbidities among adults with and without traumatic SCI, and examine the effect of chronic centralized and neuropathic pain on outcomes.Privately insured beneficiaries were included if they had an ICD-9-CM diagnostic code for traumatic SCI (n = 9081). Adults without SCI were also included (n = 1,474,232).Incidence of common psychological morbidities were compared at 5-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident psychological morbidities.Adults with SCI had a higher incidence of any psychological morbidity (59.1% vs. 30.9%) as compared to adults without SCI, and differences were to a clinically meaningful extent. Survival models demonstrated that adults with SCI had a greater hazard for any psychological morbidity (HR: 1.67; 95%CI: 1.61, 1.74), and all but one psychological disorder (impulse control disorders), and ranged from HR: 1.31 (1.24, 1.39) for insomnia to HR: 2.10 (1.77, 2.49) for post-traumatic stress disorder. Centralized and neuropathic pain was associated with all psychological disorders, and ranged from HR: 1.31 (1.23, 1.39) for dementia to HR: 3.83 (3.10, 3.68) for anxiety.Adults with SCI have a higher incidence of and risk for common psychological morbidities, as compared to adults without SCI. Efforts are needed to facilitate the development of early interventions to reduce risk of chronic centralized and neuropathic pain and psychological morbidity onset/progression in this higher risk population.
View details for DOI 10.1038/s41393-021-00731-4
View details for Web of Science ID 000744831100001
View details for PubMedID 35058578
View details for PubMedCentralID PMC8828667
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Diagnosis of Alzheimer's disease and related dementia among people with multiple sclerosis: Large cohort study, USA
MULTIPLE SCLEROSIS AND RELATED DISORDERS
2022; 57: 103351
Abstract
Alzheimer's disease and related dementia (ADRD) and multiple sclerosis (MS) are two neurodegenerative diseases with some shared pathophysiological characteristics. While the salient attribute of ADRD is a progressive decline in cognitive function, MS is mainly known for causing physical weakness, vision loss, and muscle stiffness. Progressive cognitive decline, however, is not uncommon among MS patients, and many case reports of MS were indicative of ADRD coexistence. Due to a lack of large epidemiological studies on this topic, we aimed to examine time to diagnosis of and adjusted hazard for ADRD using administrative claims data, comparing adults with and without MS.Using 2007-2017 private claims data from Optum Clinformatics Data Mart in the U.S., we identified adults (45+) with a MS diagnosis (n = 6151) as well as adults without MS for comparison (n = 916,143). We propensity score matched people with MS with those without (n = 6025) using age, sex, race/ethnicity, chronic conditions including cardiometabolic, psychologic, and musculoskeletal, U.S. Census Division, and socioeconomic variables. In addition to incidence estimates of ADRD diagnosis compared at 4-years, survival models were utilized to quantify unadjusted, fully adjusted, and adjusted propensity-matched hazard ratios.Unmatched data revealed that incidence of early-onset ADRD diagnosis was 7 times higher among adults 45-64 years old with MS (1.4%) compared to those without (0.2%); among older adults (65+) with MS, incident ADRD was 4.0% compared to 3.3% among those without MS. Adjusted survival models indicated that adults with MS had a substantially high risk for early-onset ADRD diagnosis (among 45-64 years old: unmatched hazard ratio (HR): 4.25 (95% CI: 3.40 -5.32), matched HR: 4.49 (95% CI:2.62-7.69); among 65+ years old: unmatched HR: 1.39 (95% CI: 1.22, 1.58), matched HR: 1.26 (1.04, 1.54)).Individuals with MS had a greater incidence of and risk for early- and late-onset ADRD diagnosis compared to those without MS. It is not clear whether this greater risk is due to an accelerated dementia risk or at least partially due to clinical misdiagnosis. Advancements in the development of clinical and imaging biomarkers should be more commonly used in clinical settings to facilitate future research on this topic.
View details for DOI 10.1016/j.msard.2021.103351
View details for Web of Science ID 000791949600028
View details for PubMedID 35158460
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Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries
JAMA NETWORK OPEN
2021; 4 (11): e2134980
Abstract
Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs).To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals.This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021.The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization.The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs.The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.
View details for DOI 10.1001/jamanetworkopen.2021.34980
View details for Web of Science ID 000720504700003
View details for PubMedID 34797370
View details for PubMedCentralID PMC8605483
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Annual Wellness Visits for Persons With Physical Disabilities Before and After ACA Implementation
ANNALS OF FAMILY MEDICINE
2021; 19 (6): 484-491
Abstract
Persons with disabilities often experience uncoordinated health care, with repeated out-of-pocket copays. One purpose of the Patient Protection and Affordable Care Act (ACA) was to create zero copays for preventive health care including an annual wellness visit (AWV). The purpose of this study was to document the use of AWVs by persons with physical disabilities during the ACA rollout.An administrative claims database, including both Medicare Advantage (MA) and commercial (COM) payers from 2008 to 2016, was used to identify unique wellness visits for adults with physical disabilities. We used interrupted time series analysis to compare AWV use by insurance type, sex, disability type, and race over time.The proportion of zero copays provided a timeline of ACA implementation categorized as pre-ACA, ACA-implementation, and post-ACA periods. By 2016, AWV use maximized at 47.6% (95% CI, 44.7%-50.8%) among COM-insured White women with congenital disabilities. By 2016, the lowest AWV use reached one-half the maximum, at 21.6% (95% CI, 18.4%-25.2%) among COM-insured Hispanic men with acquired disabilities. MA-insured Black and Hispanic men with acquired disabilities reached similarly low levels of AWV use.The ACA mandated zero copays, thereby allowing persons with physical disabilities the option for preventive health care without cost. Insurance type and sex significantly influenced AWV use, followed by disability type and race. Gaps in AWV use were exposed by insurance type, sex, disability, and race for persons with disabilities. Gaps in AWV use were also exposed between the general population and persons with disabilities.Annals "Online First" article.
View details for DOI 10.1370/afm.2712
View details for Web of Science ID 000739110700005
View details for PubMedID 34518196
View details for PubMedCentralID PMC8575518
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Hysterectomy Complications Relative to HbA<sub>1c</sub> Levels: Identifying a Threshold for Surgical Planning
JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY
2021; 28 (10): 1735-+
Abstract
To evaluate whether diabetes diagnosis and level of diabetes control as reflected by higher preoperative glycosylated hemoglobin (HbA1c) levels are associated with increased complication rates after hysterectomy and to identify a threshold of preoperative HbA1c level past which we should consider delaying surgery owing to increased risk of complications.Retrospective cohort study.Hospitals in the Michigan Surgical Quality Collaborative between June 4, 2012, and October 17, 2017.Women with and without a diabetes diagnosis.Hysterectomy.Data on demographics, preoperative HbA1c values, surgical approach, composite postoperative complications, readmissions, emergency department visits, and reoperations were abstracted. The risk of a postoperative complication when diabetes was stratified by preoperative HbA1c level was evaluated in a sensitivity analysis, and independent associations were identified in a mixed, multivariate logistic regression model. We identified 41 286 hysterectomies performed at 70 hospitals to be included for analysis. The sensitivity analysis identified 4 groups of risk for postoperative complications: group 1: no diabetes diagnosis and no HbA1c value; group 2: no diabetes diagnosis, with HbA1c levels between 4% and 6.5%; group 3: diabetes diagnosis and no HbA1c value or HbA1c levels <9%; and group 4: diabetes diagnosis with HbA1c levels ≥9%. In the adjusted model, there were significant 32% and 34% increased odds of postoperative complications for groups 2 and 3, respectively, compared with group 1. There were more than 2-fold increased odds of complications for women with diabetes and a preoperative HbA1c level ≥9% (group 4) compared with the women in group 1. Diabetes diagnosis with preoperative HbA1c levels ≥9% had increased odds of complications compared with diabetes diagnosis with preoperative HbA1c levels <9%. Patients with well-controlled diabetes seemed to have increased odds of complications with laparoscopic surgery.Diabetes diagnosis and measurement of preoperative HbA1c levels provide risk stratification for postoperative complications after hysterectomy, with the highest observed effect among patients with diabetes with a preoperative HbA1c level ≥9%.
View details for DOI 10.1016/j.jmig.2021.02.010
View details for Web of Science ID 000709740800017
View details for PubMedID 33617984
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Pain phenotypes among adults living with cerebral palsy and spina bifida
PAIN
2021; 162 (10): 2532-2538
Abstract
Chronic pain is the most commonly reported physical symptomology of cerebral palsy (CP) and spina bifida (SB) throughout the lifespan, and yet, pain is perhaps the least understood comorbidity in these populations. The objective of this study was to compare the prevalence and types of pain diagnosed among adults living with and without CP or SB. In this retrospective cohort study, we analyzed data from a nationwide commercial insurance claims database. Beneficiaries were included if they had an International Classification of Diseases, Ninth revision, Clinical Modification diagnosis code for CP or SB (n = 22,648). Adults without CP or SB were also included as controls (n = 931,623). Pain phenotypes (nociceptive, nociplastic, and neuropathic pain) and pain multimorbidity (≥2 conditions) were compared. We found that adults living with CP or SB had a higher prevalence of any pain disorders (55.9% vs 35.2%), nociceptive pain (44.0% vs 26.7%), nociplastic pain (26.1% vs 11.9%), neuropathic pain (9.6% vs 5.6%), and pain multimorbidity (21.1% vs 8.4%), as compared to adults without CP or SB, and differences were to a clinically meaningful extent. Adjusted odds ratios of nociceptive pain (odds ratio [OR]: 2.20; 95% confidence interval [CI]: 2.15-2.24), nociplastic pain (OR: 2.47; 95% CI: 2.41-2.53), neuropathic pain (OR: 2.71; 95% CI: 2.54-2.89), and other pain (OR: 3.92; 95% CI: 3.67-4.19) were significantly higher for adults living with CP or SB. In conclusion, adults with CP or SB have a significantly higher prevalence and odds of common peripheral, central, and neuropathic pain disorders and pain multimorbidity, as compared to adults without CP or SB.
View details for DOI 10.1097/j.pain.0000000000002240
View details for Web of Science ID 000711760800009
View details for PubMedID 34534178
View details for PubMedCentralID PMC9665000
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Psychological, Cardiometabolic, and Musculoskeletal Morbidity and Multimorbidity Among Adults With Cerebral Palsy and Spina Bifida <i>A Retrospective Cross-sectional Study</i>
AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION
2021; 100 (10): 940-945
Abstract
Individuals living with cerebral palsy or spina bifida are at heightened risk for a number of chronic health conditions, such as secondary comorbidities, that may develop or be influenced by the disability, the presence of impairment, and/or the process of aging. However, very little is known about the prevalence and/or risk of developing secondary comorbidities among individuals living with cerebral palsy or spina bifida throughout adulthood. The objective of this study was to compare the prevalence of psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity among adults with and without cerebral palsy or spina bifida.Privately insured beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for cerebral palsy or spina bifida (n = 29,841). Adults without cerebral palsy or spina bifida were also included (n = 5,384,849). Prevalence estimates of common psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity (≥2 conditions) were compared.Adults living with cerebral palsy or spina bifida had a higher prevalence of all psychological disorders and psychological multimorbidity (14.6% vs. 5.4%), all cardiometabolic disorders and cardiometabolic multimorbidity (22.4% vs. 15.0%), and all musculoskeletal disorders and musculoskeletal multimorbidity (12.2% vs. 5.4%), as compared with adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent.Adults with cerebral palsy or spina bifida have a significantly higher prevalence of common psychological, cardiometabolic, and musculoskeletal morbidity and multimorbidity, as compared with adults without cerebral palsy or spina bifida. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of disease onset/progression in these higher risk populations.Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.Upon completion of this article, the reader should be able to: (1) List the main categories of morbidity that present with higher risk in adults with cerebral palsy and spina bifida; (2) Discuss the potential impact of multimorbidity on 'early aging' in adults living with cerebral palsy and spina bifida; and (3) Describe challenges that adults with cerebral palsy and spina bifida have in obtaining appropriate health care to address prevention and treatment of multimorbidity.Advanced.The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
View details for DOI 10.1097/PHM.0000000000001787
View details for Web of Science ID 000696338000011
View details for PubMedID 34001837
View details for PubMedCentralID PMC9642813
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Risk of early- and late-onset Alzheimer disease and related dementia in adults with cerebral palsy
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY
2022; 64 (3): 372-378
Abstract
To examine the risk of Alzheimer disease and related dementia (ADRD) among adults with cerebral palsy (CP).Using administrative insurance claims data for 2007 to 2017 in the USA, we identified adults (45y or older) with a diagnosis of CP (n=5176). Adults without a diagnosis of CP were included as a typically developing comparison group (n=1 119 131). Using age, sex, ethnicity, other demographic variables, and a set of chronic morbidities, we propensity-matched individuals with and without CP (n=5038). Cox survival models were used to estimate ADRD risk within a 3-year follow up.The unadjusted incidence of ADRD was 9 and 2.4 times higher among cohorts of adults 45 to 64 years (1.8%) and 65 years and older (4.8%) with CP than the respective unmatched individuals without CP (0.2% and 2.0% among 45-64y and 65y or older respectively). Fully adjusted survival models indicated that adults with CP had a greater hazard for ADRD (among 45-64y: unmatched hazard ratio 7.48 [95% confidence interval {CI} 6.05-9.25], matched hazard ratio 4.73 [95% CI 2.72-8.29]; among 65y or older: unmatched hazard ratio 2.21 [95% CI 1.95-2.51], matched hazard ratio 1.73 [1.39-2.15]).Clinical guidelines for early screening of cognitive function among individuals with CP need updating, and preventative and/or therapeutic services should be used to reduce the risk of ADRD.
View details for DOI 10.1111/dmcn.15044
View details for Web of Science ID 000695473200001
View details for PubMedID 34496036
View details for PubMedCentralID PMC10424101
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Cardiovascular and metabolic morbidity following spinal cord injury
SPINE JOURNAL
2021; 21 (9): 1520-1527
Abstract
Individuals living with a spinal cord injury (SCI) are at heightened risk for a number of chronic health conditions such as secondary comorbidities that may develop or be influenced by the injury, the presence of impairment, and/or the process of aging.The objective of this study was to compare the incidence of and adjusted hazards for cardiovascular and metabolic (cardiometabolic) morbidities among adults following SCI compared to adults without SCIs.Longitudinal cohort from a nationwide insurance claims database.Privately-insured beneficiaries were included if they had an ICD-9-CM diagnostic code for traumatic SCI (n=9,081). Adults without SCI were also included (n=1,474,232).Incidence estimates of common cardiometabolic morbidities were compared at 4-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident cardiometabolic morbidities.Adults living with traumatic SCIs had a higher 5-year incidence of any cardiometabolic morbidities (56.2% vs. 36.4%) as compared to adults without SCI, and differences were to a clinically meaningful extent. Survival models demonstrated that adults with SCI had a greater hazard for any cardiometabolic morbidity (Hazard Ratio [HR]: 1.67; 95%CI: 1.58, 1.76) and all cardiometabolic disorders; this ranged from HR: 1.45 (1.32, 1.59) for non-alcoholic fatty liver disease to HR: 3.55 (3.36, 3.76) for heart failure.Adults with SCIs have a significantly higher incidence of and risk for common cardiometabolic morbidities, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of cardiometabolic disease onset/progression in this vulnerable population.
View details for DOI 10.1016/j.spinee.2021.05.014
View details for Web of Science ID 000704897200013
View details for PubMedID 34023517
View details for PubMedCentralID PMC9645293
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Letter to the Editor: Traumatic Spinal Cord Injury and Risk of Early and Late Onset Alzheimer's Disease and related Dementia: Large Longitudinal Study
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2021; 102 (7): 1431-1432
View details for DOI 10.1016/j.apmr.2021.03.003
View details for Web of Science ID 000683144700022
View details for PubMedID 33745890
View details for PubMedCentralID PMC10437009
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Traumatic Spinal Cord Injury and Risk of Early and Late Onset Alzheimer's Disease and Related Dementia: Large Longitudinal Study
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2021; 102 (6): 1147-1154
Abstract
Traumatic spinal cord injury (TSCI) is a life altering event most often causing permanent physical disability. Little is known about the risk of developing Alzheimer disease and related dementia (ADRD) among middle-aged and older adults living with TSCI. Time to diagnosis of and adjusted hazard for ADRD was assessed.Cohort study.Using 2007-2017 claims data from the Optum Clinformatics Data Mart, we identified adults (45+) with diagnosis of TSCI (n=7019). Adults without TSCI diagnosis were included as comparators (n=916,516). Using age, sex, race/ethnicity, cardiometabolic, psychological, and musculoskeletal chronic conditions, US Census division, and socioeconomic variables, we propensity score matched persons with and without TSCI (n=6083). Incidence estimates of ADRD were compared at 4 years of enrollment. Survival models were used to quantify unadjusted, fully adjusted, and propensity-matched unadjusted and adjusted hazard ratios (HRs) for incident ADRD.Adults with and without TSCI (N=6083).Not applicable.Diagnosis of ADRD.Both middle-aged and older adults with TSCI had higher incident ADRD compared to those without TSCI (0.5% vs 0.2% and 11.7% vs 3.3% among 45-64 and 65+ y old unmatched cohorts, respectively) (0.5% vs 0.3% and 10.6% vs 6.2% among 45-64 and 65+ y old matched cohorts, respectively). Fully adjusted survival models indicated that adults with TSCI had a greater hazard for ADRD (among 45-64y old: unmatched HR: 3.19 [95% confidence interval, 95% CI, 2.30-4.44], matched HR: 1.93 [95% CI, 1.06-3.51]; among 65+ years old: unmatched HR: 1.90 [95% CI, 1.77-2.04], matched HR: 1.77 [1.55-2.02]).Adults with TSCI are at a heightened risk for ADRD. Improved clinical screening and early interventions aiming to preserve cognitive function are of paramount importance for this patient cohort.
View details for DOI 10.1016/j.apmr.2020.12.019
View details for Web of Science ID 000657477200012
View details for PubMedID 33508336
View details for PubMedCentralID PMC10536758
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Continuous quality improvement in statistical code: avoiding errors and improving transparency
BMJ QUALITY & SAFETY
2021; 30 (3): 240-244
View details for DOI 10.1136/bmjqs-2020-012387
View details for Web of Science ID 000624061800011
View details for PubMedID 33023935
View details for PubMedCentralID PMC7897229
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Psychological morbidity among adults with cerebral palsy and spina bifida
PSYCHOLOGICAL MEDICINE
2021; 51 (4): 694-701
View details for DOI 10.1017/S0033291720001981
View details for Web of Science ID 000635684800018
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Psychological morbidity among adults with cerebral palsy and spina bifida.
Psychological medicine
2021; 51 (4): 694-701
Abstract
Very little is known about the risk of developing psychological morbidities among adults living with cerebral palsy (CP) or spina bifida (SB). The objective of this study was to compare the incidence of and adjusted hazards for psychological morbidities among adults with and without CP or SB.Privately insured beneficiaries were included if they had an International Classification of Diseases, Ninth revision, Clinical Modification diagnostic code for CP or SB (n = 15 302). Adults without CP or SB were also included (n = 1 935 480). Incidence estimates of common psychological morbidities were compared at 4-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident psychological morbidities.Adults living with CP or SB had a higher 4-year incidence of any psychological morbidity (38.8% v. 24.2%) as compared to adults without CP or SB, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with CP or SB had a greater hazard for any psychological morbidity [hazard ratio (HR): 1.60; 95% CI 1.55-1.65], and all but one psychological disorder (alcohol-related disorders), and ranged from HR: 1.32 (1.23, 1.42) for substance disorders, to HR: 4.12 (3.24, 5.25) for impulse control disorders.Adults with CP or SB have a significantly higher incidence of and risk for common psychological morbidities, as compared to adults without CP or SB. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce the risk of disease onset/progression in these higher-risk populations.
View details for DOI 10.1017/S0033291720001981
View details for PubMedID 32713401
View details for PubMedCentralID PMC9650963
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Variation in pre-hospital outcomes after out-of-hospital cardiac arrest in Michigan
RESUSCITATION
2021; 158: 201-207
Abstract
Care by emergency medical service (EMS) agencies is critical for optimizing prehospital outcomes following out-of-hospital cardiac arrest (OHCA). We explored whether substantial differences exist in prehospital outcomes across EMS agencies in Michigan-specifically focusing on rates of sustained return of spontaneous circulation (ROSC) upon emergency department (ED) arrival.Using data from Michigan Cardiac Arrest Registry to Enhance Survival (MI-CARES) for years 2014-2017, we calculated rates of sustained ROSC upon ED arrival across EMS agencies in Michigan. We used hierarchical logistic regression models that accounted for patient, arrest-, community-, and response-level characteristics to determine adjusted rates of sustained ROSC among EMS agencies.A total of 103 EMS agencies and 20,897 OHCA cases were included. Average age of the cohort was 62.5 years (SD = 19.6), 39.7% were female, and 17.9% had an initial shockable rhythm due to ventricular fibrillation or pulseless ventricular tachycardia. The adjusted rate of sustained ROSC upon ED arrival across all EMS agencies was 23.8% with notable variation across EMS agencies (interquartile range [IQR], 20.5-29.2%). The top five EMS agencies had mean adjusted rates of sustained ROSC upon ED arrival of 42.7% (95% CI: 34.6-51.1%) while the bottom five had mean adjusted rates of 9.8% (95% CI: 7.6-12.7%).Substantial variation in sustained ROSC upon ED arrival exists across EMS agencies in Michigan after adjusting for patient-, arrest, community-, and response-level features. Such differences suggest opportunities to identify and improve best practices in EMS agencies to advance OHCA care.
View details for DOI 10.1016/j.resuscitation.2020.11.034
View details for Web of Science ID 000608110100029
View details for PubMedID 33307157
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EXAMINING THE RISK OF POTENTIALLY PREVENTABLE HOSPITALIZATION IN ADULTS WITH CONGENITAL AND ACQUIRED DISABILITIES
OXFORD UNIV PRESS. 2021: 575
View details for Web of Science ID 000842009902655
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RACIAL-ETHNIC DISPARITIES IN ACCESS TO PREVENTIVE SERVICES AMONG PRIVATELY INSURED ADULTS WITH DISABILITIES
OXFORD UNIV PRESS. 2021: 546
View details for Web of Science ID 000842009902547
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Impact of a National Private Health Insurer's Prior Authorization Policy on Utilization of Vaginal Hysterectomy
FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY
2021; 27 (1): 46-50
Abstract
On April 6, 2015, the largest private health insurer in the United States implemented a policy requiring prior authorization for all hysterectomies except those done as outpatient vaginal. The purpose of this policy was to increase utilization of vaginal hysterectomy; however, it is unknown whether this policy had its intended effect. We sought to analyze trends in hysterectomy routes before and after implementation of the prior authorization policy to see if utilization of vaginal hysterectomy increased.This was a retrospective study using the Optum Clinformatics Data Mart national claims database of women enrolled in a single national private health insurer who underwent hysterectomy for any indication between January 1, 2010, and June 30, 2016. Per-quarter utilization of hysterectomy routes (abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal) was compared between the prepolicy and postpolicy periods using interrupted time series analyses.Data for 305,139 hysterectomies were available-248,821 in the prepolicy period and 56,318 in the postperiod. Outpatient vaginal hysterectomy had the greatest increase in utilization of all routes and types; the average utilization per quarter in the prepolicy period was -0.61%, and this increased to 0.21% in the postpolicy period (P < 0.0001). Outpatient laparoscopic hysterectomy had the greatest decrease in utilization, with an average decrease of -1.50% per quarter.The prior authorization policy was associated with a short-term increase in utilization of vaginal hysterectomy.
View details for DOI 10.1097/SPV.0000000000000729
View details for Web of Science ID 000616080200018
View details for PubMedID 31335478
View details for PubMedCentralID PMC6800593
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NEIGHBORHOOD ENVIRONMENT AND CARDIOMETABOLIC DISEASE IN INDIVIDUALS AGING WITH PHYSICAL DISABILITY
OXFORD UNIV PRESS. 2021: 474-475
View details for Web of Science ID 000842009902289
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Musculoskeletal morbidity following spinal cord injury: A longitudinal cohort study of privately-insured beneficiaries
BONE
2021; 142: 115700
Abstract
People living with spinal cord injuries (SCIs) experience motor, sensory and autonomic impairments that cause musculoskeletal disorders following the injury and that progress throughout lifetime. The range and severity of issues are largely dependent on level and completeness of the injury and preserved function.High risk of developing musculoskeletal morbidities among individuals after sustaining a traumatic SCI is well known in the clinical setting, however, there is a severe lack of evidence in literature. The objective of this study was to compare the incidence of and adjusted hazards for musculoskeletal morbidities among adults with and without SCIs.Privately-insured beneficiaries were included if they had an ICD-9-CM diagnostic code for SCI (n = 9081). Adults without SCI were also included (n = 1,474,232). Incidence estimates of common musculoskeletal morbidities (e.g., osteoporosis, sarcopenia, osteoarthritis, fractures, etc.) were compared at 5-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident musculoskeletal morbidities.Adults living with traumatic SCIs had a higher incidence of any musculoskeletal morbidities (82.4% vs. 47.5%) as compared to adults without SCI, and differences were to a clinically meaningful extent. Survival models demonstrated that adults with SCI had a greater fully-adjusted hazard for any musculoskeletal morbidity (Hazard Ratio [HR]: 2.41; 95%CI: 2.30, 2.52), and all musculoskeletal disorders, and ranged from HR: 1.26 (1.14, 1.39) for rheumatoid arthritis to HR: 7.02 (6.58, 7.49) for pathologic fracture.Adults with SCIs have a significantly higher incidence of and risk for common musculoskeletal morbidities, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of musculoskeletal disease onset/progression in this higher risk population.
View details for DOI 10.1016/j.bone.2020.115700
View details for Web of Science ID 000601336400014
View details for PubMedID 33091639
View details for PubMedCentralID PMC9671069
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RISK OF ALZHEIMER'S DISEASE AND RELATED DEMENTIA AMONG ADULTS WITH CONGENITAL AND ACQUIRED DISABILITIES
OXFORD UNIV PRESS. 2021: 226-227
View details for Web of Science ID 000842009901132
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Development of a new comorbidity index for adults with cerebral palsy and comparative assessment with common comorbidity indices
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY
2021; 63 (3): 313-319
Abstract
To develop a new comorbidity index for adults with cerebral palsy (CP), the Whitney Comorbidity Index (WCI), which includes relevant comorbidities for this population and better predicts mortality than the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI).Data from the Optum Clinformatics Data Mart was used for this retrospective cohort study. Diagnosis codes were used to identify adults aged 18 years or older with CP (n=1511 females, n=1511 males; mean [SD; range] age=48y [19y 2mo; 18-89y]) and all comorbidities in the year 2014. The WCI was developed based on the comorbidities of the CCI and ECI and other relevant comorbidities associated with 2-year mortality using Cox regression and competing risk analysis. The WCI was examined as unweighted (WCIunw ) and weighted (WCIw ). The model fit and discrimination (C-statistic) of each index was assessed using Cox regression.Twenty-seven comorbidities were included in the WCI; seven new comorbidities that were not part of the CCI or ECI were added. The WCIunw and WCIw showed a better model fit and discrimination for 1- and 2-year mortality compared to the CCI and ECI. The WCIunw and WCIw were strong predictors for 1- and 2-year mortality (C-statistic [95% confidence interval] ranging from 0.81 [0.76-0.85] to 0.88 [0.82-0.94]).The new WCI, designed to include clinically relevant comorbidities, provides a better model fit and discrimination of mortality for adults with CP.Common comorbidity indices exclude relevant comorbidities for adults with cerebral palsy (CP). A new comorbidity index for adults with CP was created by harmonizing clinical theory and data-driven methods. The Whitney Comorbidity Index better predicted 1- and 2-year mortality than other commonly used comorbidity indices.
View details for DOI 10.1111/dmcn.14759
View details for Web of Science ID 000595091300001
View details for PubMedID 33289071
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Cardiometabolic Morbidity in Adults With Cerebral Palsy and Spina Bifida
AMERICAN JOURNAL OF MEDICINE
2020; 133 (12): E695-E705
Abstract
The purpose of this study was to compare the incidence of, and adjusted hazards for, cardiometabolic morbidities among adults with and without cerebral palsy or spina bifida.Privately insured beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code for cerebral palsy or spina bifida (n = 15,302). Adults without cerebral palsy or spina bifida were also included (n = 1,935,480). Incidence estimates of common cardiometabolic morbidities were compared at 4 years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios (HRs) for incident cardiometabolic morbidities.Adults living with cerebral palsy or spina bifida had a higher 4-year incidence of any cardiometabolic morbidity (41.5% vs 30.6%) as compared to adults without cerebral palsy or spina bifida, and differences were to a clinically meaningful extent. Fully adjusted survival models demonstrated that adults with cerebral palsy or spina bifida had a greater hazard for any cardiometabolic morbidity (HR: 1.52; 95% confidence interval [CI]: 1.47, 1.57), and all but 1 cardiometabolic disorder (nonalcoholic fatty liver disease) and ranged from HR: 1.20 (1.15, 1.25) for hypercholesterolemia to HR: 1.86 (1.74, 1.98) for heart failure.Adults with cerebral palsy or spina bifida have a significantly higher incidence of, and risk for, common cardiometabolic morbidities, as compared to adults without cerebral palsy or spina bifida. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of cardiometabolic disease onset and progression in these higher-risk populations.
View details for DOI 10.1016/j.amjmed.2020.05.032
View details for Web of Science ID 000594461000007
View details for PubMedID 32687812
View details for PubMedCentralID PMC9645295
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Potentially Preventable Hospitalizations Among Older Adults: 2010-2014
ANNALS OF FAMILY MEDICINE
2020; 18 (6): 511-519
Abstract
We undertook a study to examine national trends in potentially preventable hospitalizations-those for ambulatory care-sensitive conditions that could have been avoided if patients had timely access to primary care-across 3,200 counties and various subpopulations of older adults in the United States.We used 2010-2014 Medicare claims data to examine trends in potentially preventable hospitalizations among beneficiaries aged 65 years and older and developed heat maps to examine county-level variation. We used a generalized estimating equation and adjusted the model for demographics, comorbidities, dual eligibility (Medicare and Medicaid), ZIP code-level income, and county-level number of primary care physicians and hospitals.Across the 3,200 study counties, potentially preventable hospitalizations decreased in 327 counties, increased in 123 counties, and did not change in the rest. At the population level, the adjusted rate of potentially preventable hospitalizations declined by 3.45 percentage points from 19.42% (95% CI, 18.4%-20.5%) in 2010 to 15.97% (95% CI, 15.3%-16.6%) in 2014; it declined by 2.93, 2.87, and 3.33 percentage points among White, Black, and Hispanic patients to 14.96% (95% CI, 14.67%-15.24%), 17.92% (95% CI, 17.27%-18.58%), and 17.10% (95% CI, 16.25%-18.0%), respectively. Similarly, the rate for dually eligible patients fell by 3.71 percentage points from 21.62% (95% CI, 20.5%-22.8%) in 2010 to 17.91% (95% CI, 17.2%-18.7%) in 2014. (P <.001 for all).During 2010-2014, rates of potentially preventable hospitalization did not change in the majority of counties. At the population level, although the rate declined among all subpopulations, dually eligible patients and Black and Hispanic patients continued to have substantially higher rates compared with non-dually eligible and White patients, respectively.
View details for DOI 10.1370/afm.2605
View details for Web of Science ID 000590265700007
View details for PubMedID 33168679
View details for PubMedCentralID PMC7708283
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Advanced CKD Among Adults With Cerebral Palsy: Incidence and Risk Factors
KIDNEY MEDICINE
2020; 2 (5): 569-+
Abstract
Recent evidence suggests that adults with cerebral palsy have an elevated risk for developing advanced chronic kidney disease (CKD). To develop effective interventions, the objective was to identify whether demographics and preexisting medical conditions are risk factors for advanced CKD among adults with cerebral palsy.Retrospective cohort study.Data were from the Optum Clinformatics Data Mart. Adults 18 years or older with cerebral palsy and without advanced CKD (CKD stage 4 or later) were identified from 2013 and subsequently followed up from January 1, 2014, to the development of advanced CKD, death, loss to follow-up, or end of the study period (December 31, 2017), whichever came first. Diagnostic, procedure, and diagnosis-related group codes were used to identify cerebral palsy, incident cases of advanced CKD, comorbid intellectual disability, and 10 preexisting medical conditions.Demographic variables and 10 preexisting medical conditions: CKD stages 1-3, hypertension, diabetes, heart and cerebrovascular disease, non-CKD urologic conditions, bowel conditions, respiratory disease, skeletal fragility, arthritis, and dysphagia.Incidence of advanced CKD.Crude incidence rate (IR) of advanced CKD and IR ratios with 95% CIs were estimated. Cox proportional hazards regression models that were adjusted for demographics, intellectual disability, and preexisting medical conditions were used to evaluate the adjusted independent effect of predictor variables.237 of the 8,011 adults with cerebral palsy developed advanced CKD during follow-up (IR, 10.16/1,000 person years; 95% CI, 8.87-11.46). In the crude analysis, all preexisting medical conditions were associated with an elevated IR and IR ratio of advanced CKD. In the fully adjusted Cox proportional hazards regression model, the HR was elevated for older age, CKD stages 1-3 (HR, 3.32; 95% CI, 2.39-4.61), diabetes (HR, 2.69; 95% CI, 2.03-3.57), hypertension (HR, 1.54; 95% CI, .10-2.16), heart and cerebrovascular disease (HR, 1.53; 95% CI, 1.12-2.07), and non-CKD urologic conditions (HR, 1.39; 95% CI, 1.05-1.84).Private insurance database, short follow-up period, and lack of laboratory values, such as albuminuria/proteinuria.Advanced CKD was common among adults with cerebral palsy and its development was associated with both traditional and nontraditional urologic risk factors.
View details for DOI 10.1016/j.xkme.2020.05.012
View details for Web of Science ID 000659991500013
View details for PubMedID 33094275
View details for PubMedCentralID PMC7568081
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Availability of Statistical Code From Studies Using Medicare Data in General Medical Journals
JAMA INTERNAL MEDICINE
2020; 180 (6): 905-907
Abstract
This study assesses the availability of statistical code from research articles using Medicare data published in leading general medical journals.
View details for DOI 10.1001/jamainternmed.2020.0671
View details for Web of Science ID 000540431200022
View details for PubMedID 32282018
View details for PubMedCentralID PMC7154950
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Psychological Morbidity and Chronic Disease Among Adults With Traumatic Spinal Cord Injuries: A Longitudinal Cohort Study of Privately Insured Bene ficiaries
MAYO CLINIC PROCEEDINGS
2020; 95 (5): 920-928
Abstract
To compare the longitudinal incidence of psychological morbidities and multimorbidity and estimates of chronic diseases among adults with spinal cord injuries (SCIs) as compared with adults without SCIs.Privately insured beneficiaries who had medical coverage at any time between January 1, 2001, and December 31, 2017 were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for a traumatic SCI (n=6,847).Adults with SCIs (n=6847) had a higher incidence of adjustment reaction (7.2% [n=493] vs 5.0% [n=42,862]), anxiety disorders (19.3% [n=1,322] vs 14.1% [n=120,872]), depressive disorders (29.3% [n=2,006] vs 9.3% [n=79,724]), alcohol dependence (2.4% [n=164] vs 1.0% [n=8,573]), drug dependence (2.3% [n=158] vs 0.8% [n=6,858]), psychogenic pain (1.0% [n=69] vs 0.2% [n=1,715]), dementia (6.5% [n=445] vs 1.5% [n=12,859]), insomnia (10.9% [n=746] vs 7.2% [n=61,722]), and psychological multimorbidity (37.4% [n=2,561] vs 23.9% [n=204,882]) as compared with adults without SCIs (n=857,245). The adjusted hazard ratios (HRs) of each psychological outcome were significantly higher for individuals with SCI and ranged from 1.18 (95% CI, 1.08-1.29) for anxiety disorders to 3.32 (95% CI, 1.93-5.71) for psychogenic pain. Adults with SCIs also had a significantly higher prevalence of all chronic diseases and chronic disease multimorbidity (51.1% vs 14.1%), except human immunodeficiency virus infection/AIDS. After propensity matching for age, education, race, sex, and chronic diseases (n=5884 matched pairs), there was still a significantly higher incidence of most psychological disorders and psychological multimorbidity among adults with SCIs.Adults with traumatic SCIs experienced an increased incidence of psychological morbidities and multimorbidity as compared with adults without SCIs. Clinical efforts are needed to improve mental health screening and targeted interventions to reduce the risk for psychological disease onset in the traumatic SCI population.
View details for DOI 10.1016/j.mayocp.2019.11.029
View details for Web of Science ID 000540247200016
View details for PubMedID 32299672
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Disparities in the Use of Guideline-Based Pharmacotherapy Exist for Atherosclerotic Cardiovascular Disease and Heart Failure Patients Who Have Intellectual/Developmental Disabilities in a Commercially Insured Database
ANNALS OF PHARMACOTHERAPY
2020; 54 (10): 958-966
Abstract
Patients who have intellectual/developmental disabilities (IDDs) develop atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) at rates similar to or higher than the general population. They also face disparities accessing and using health care services.To determine if disparities exist in the use of guideline-based pharmacotherapy (GBP) for ASCVD or HF for adults with IDD.Using the 2014 Clinformatics Data Mart Database, adults with ASCVD or HF were divided into IDD or non-IDD groups. Patients with contraindications for GBP medications were excluded. Use of GBP between IDD and non-IDD groups was examined. Subgroup analysis included comparisons between IDD groups.For HF, 1011 patients with IDD and 236,638 non-IDD patients were identified. For ASCVD, 2190 IDD and 790,343 non-IDD patients were identified. We found that 47.9%, 35.8%, and 13.1% of IDD and 58.7%, 48.4%, and 18.9% of non-IDD patients had pharmacy claims for statins (P < 0.001), β-blockers (P < 0.001), or antiplatelet therapy (P < 0.001), respectively. For HF, 46.8% and 50.3% of IDD and 59.8% and 55.4% of non-IDD patients had pharmacy claims for β-blockers (P < 0.001) and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs; P = 0.003), respectively. In all but one multivariate regression models patients with IDD were less likely to use GBP than patients in the non-IDD group. Subgroup analysis revealed that patients who had Down syndrome had lower GBP use in 4 of the 5 measures.Disparities exist in the use of GBP for patients with IDD with ASCVD or HF. Patients who have an IDD should be examined by clinicians to ensure appropriate access to and use of GBP.
View details for DOI 10.1177/1060028020916842
View details for Web of Science ID 000535215200001
View details for PubMedID 32336108
View details for PubMedCentralID PMC8009695
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Use of electronic medical records in development and validation of risk prediction models of hospital readmission: systematic review
BMJ-BRITISH MEDICAL JOURNAL
2020; 369: m958
Abstract
To provide focused evaluation of predictive modeling of electronic medical record (EMR) data to predict 30 day hospital readmission.Systematic review.Ovid Medline, Ovid Embase, CINAHL, Web of Science, and Scopus from January 2015 to January 2019.All studies of predictive models for 28 day or 30 day hospital readmission that used EMR data.Characteristics of included studies, methods of prediction, predictive features, and performance of predictive models.Of 4442 citations reviewed, 41 studies met the inclusion criteria. Seventeen models predicted risk of readmission for all patients and 24 developed predictions for patient specific populations, with 13 of those being developed for patients with heart conditions. Except for two studies from the UK and Israel, all were from the US. The total sample size for each model ranged between 349 and 1 195 640. Twenty five models used a split sample validation technique. Seventeen of 41 studies reported C statistics of 0.75 or greater. Fifteen models used calibration techniques to further refine the model. Using EMR data enabled final predictive models to use a wide variety of clinical measures such as laboratory results and vital signs; however, use of socioeconomic features or functional status was rare. Using natural language processing, three models were able to extract relevant psychosocial features, which substantially improved their predictions. Twenty six studies used logistic or Cox regression models, and the rest used machine learning methods. No statistically significant difference (difference 0.03, 95% confidence interval -0.0 to 0.07) was found between average C statistics of models developed using regression methods (0.71, 0.68 to 0.73) and machine learning (0.74, 0.71 to 0.77).On average, prediction models using EMR data have better predictive performance than those using administrative data. However, this improvement remains modest. Most of the studies examined lacked inclusion of socioeconomic features, failed to calibrate the models, neglected to conduct rigorous diagnostic testing, and did not discuss clinical impact.
View details for DOI 10.1136/bmj.m958
View details for Web of Science ID 000527704900002
View details for PubMedID 32269037
View details for PubMedCentralID PMC7249246
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Patterns of glucocorticoid prescribing and provider-level variation in a commercially insured incident rheumatoid arthritis population: A retrospective cohort study
SEMINARS IN ARTHRITIS AND RHEUMATISM
2020; 50 (2): 228-236
Abstract
Glucocorticoids are common in RA management despite an unfavorable, exposure-dependent risk profile impacted by patient and provider-level factors. Existing work describing glucocorticoid use in RA is not generalizable and does not adequately examine provider factors. We aim to describe how providers prescribe glucocorticoids to commercially insured, newly diagnosed RA patients in the United States.This was a retrospective cohort study which used the national Optum© administrative database. We identified 9221 adults ages 18-65 with RA diagnosed 2010-2014. We assessed glucocorticoid dispensing 3 months pre-diagnosis through 12months post-diagnosis ("study period"), cumulatively stratified by calendar quarter and prescriber specialty (rheumatologist, primary care, other). We examined prescribing variation among individual rheumatologists by dividing quarterly distribution of per-patient dose and days' supply into quartiles.6717 (72.8%) patients filled ≥1 glucocorticoid prescription during the study period. 2890 (31.3%) patients received ≥3 months' supply, with median (IQR) daily dose 10 (6.6) mg/day and days' supply 189 (143) days. 52.6% of patients received glucocorticoids 1-3 months post-diagnosis; 29.2% received glucocorticoids 10-12 months post-diagnosis. Among glucocorticoid users post-diagnosis, quarterly median daily dose and days' supply were consistently ≥10 mg/day and ≥30 days, respectively. Rheumatologists prescribed most glucocorticoids, with median per-quarter daily dose and days' supply 10 mg/day and 43-60 days. Individual rheumatologists' prescribing varied widely across all quarters.Among commercially insured incident RA patients, receipt of ≥10 mg/day prednisone equivalent for months is common, typically prescribed by rheumatologists, and persists a year post-diagnosis in 29.2% of patients. Glucocorticoid prescribing varies widely across rheumatologists. Further work is warranted to identify provider factors explaining variation in glucocorticoid prescribing, and assess how these affect health outcomes.
View details for DOI 10.1016/j.semarthrit.2019.09.002
View details for Web of Science ID 000523512800007
View details for PubMedID 31522762
View details for PubMedCentralID PMC7060094
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Factors Associated With Potentially Missed Diagnosis of Appendicitis in the Emergency Department
JAMA NETWORK OPEN
2020; 3 (3): e200612
Abstract
Appendicitis may be missed during initial emergency department (ED) presentation.To compare patients with a potentially missed diagnosis of appendicitis (ie, patients with symptoms associated with appendicitis, including abdominal pain, constipation, nausea and/or vomiting, fever, and diarrhea diagnosed within 1-30 days after initial ED presentation) with patients diagnosed with appendicitis on the same day of ED presentation to identify factors associated with potentially missed appendicitis.In this cohort study, a retrospective analysis of commercially insured claims data was conducted from January 1 to December 15, 2019. Patients who presented to the ED with undifferentiated symptoms associated with appendicitis between January 1, 2010, and December 31, 2017, were identified using the Clinformatics Data Mart administrative database (Optum Insights). The study sample comprised eligible adults (aged ≥18 years) and children (aged <18 years) who had previous ED visits within 30 days of an appendicitis diagnosis.Potentially missed diagnosis of appendicitis. Adjusted odds ratios (AORs) for abdominal pain and its combinations with other symptoms associated with appendicitis were compared between patients with a same-day diagnosis of appendicitis and patients with a potentially missed diagnosis of appendicitis.Of 187 461 patients with a diagnosis of appendicitis, a total of 123 711 (66%; 101 375 adults [81.9%] and 22 336 children [18.1%]) were eligible for analysis. Among adults, 51 923 (51.2%) were women, with a mean (SD) age of 44.3 (18.2) years; among children, 9631 (43.1%) were girls, with a mean (SD) age of 12.2 (18.2) years. The frequency of potentially missed appendicitis was 6060 of 101 375 adults (6.0%) and 973 of 22 336 children (4.4%). Patients with isolated abdominal pain (adults, AOR, 0.65; 95% CI, 0.62-0.69; P < .001; children, AOR, 0.79; 95% CI, 0.69-0.90; P < .001) or with abdominal pain and nausea and/or vomiting (adults, AOR, 0.90; 95% CI, 0.84-0.97; P = .003; children, AOR, 0.84; 95% CI, 0.71-0.98; P = .03) were less likely to have missed appendicitis. Patients with abdominal pain and constipation (adults, AOR, 1.51; 95% CI, 1.31-1.75; P < .001; children, AOR, 2.43; 95% CI, 1.86-3.17; P < .001) were more likely to have missed appendicitis. Stratified by the presence of undifferentiated symptoms, women (abdominal pain, AOR, 1.68; 95% CI, 1.58-1.78; nausea and/or vomiting, AOR, 1.68; 95% CI, 1.52-1.85; fever, AOR, 1.32; 95% CI, 1.10-1.59; diarrhea, AOR, 1.19; 95% CI, 1.01-1.40; and constipation, AOR, 1.50; 95% CI, 1.24-1.82) and girls (abdominal pain, AOR, 1.64; 95% CI, 1.43-1.88; nausea and/or vomiting, AOR, 1.74; 95% CI, 1.42-2.13; fever, AOR, 1.55; 95% CI, 1.14-2.11; diarrhea, AOR, 1.80; 95% CI, 1.19-2.74; and constipation, AOR, 1.25; 95% CI, 0.88-1.78) as well as patients with a comorbidity index of 2 or greater (adults, abdominal pain, AOR, 3.33; 95% CI, 3.09-3.60; nausea and/or vomiting, AOR, 3.66; 95% CI, 3.23-4.14; fever, AOR, 5.00; 95% CI, 3.79-6.60; diarrhea, AOR, 4.27; 95% CI, 3.39-5.38; and constipation, AOR, 4.17; 95% CI, 3.08-5.65; children, abdominal pain, AOR, 2.42; 95% CI, 1.93-3.05; nausea and/or vomiting, AOR, 2.55; 95% CI, 1.89-3.45; fever, AOR, 4.12; 95% CI, 2.71-6.25; diarrhea, AOR, 2.17; 95% CI, 1.18-3.97; and constipation, AOR, 2.19; 95% CI, 1.30-3.70) were more likely to have missed appendicitis. Adult patients who received computed tomographic scans at the initial ED visit (abdominal pain, AOR, 0.58; 95% CI, 0.52-0.65; nausea and/or vomiting, AOR, 0.63; 95% CI, 0.52-0.75; fever, AOR, 0.41; 95% CI, 0.29-0.58; diarrhea, AOR, 0.83; 95% CI, 0.58-1.20; and constipation, AOR, 0.60; 95% CI, 0.39-0.94) were less likely to have missed appendicitis.Regardless of age, a missed diagnosis of appendicitis was more likely to occur in women, patients with comorbidities, and patients who experienced abdominal pain accompanied by constipation. Population-based estimates of the rates of potentially missed appendicitis reveal opportunities for improvement and identify factors that may mitigate the risk of a missed diagnosis.
View details for DOI 10.1001/jamanetworkopen.2020.0612
View details for Web of Science ID 000563927500002
View details for PubMedID 32150270
View details for PubMedCentralID PMC7063499
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Early-Onset Noncommunicable Disease and Multimorbidity Among Adults With Pediatric-Onset Disabilities
MAYO CLINIC PROCEEDINGS
2020; 95 (2): 274-282
Abstract
To determine the prevalence of major noncommunicable diseases among young adults with pediatric-onset disabilities (PoDs) compared with young adults without PoDs.Data were obtained from the Optum Clinformatics Data Mart, a de-identified nationwide claims database of beneficiaries from a single private payer in the United States. Beneficiaries were included if they were 18 to 40 years old and had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for a PoD known to originate in childhood. Diagnostic codes were used to identify high-burden noncommunicable diseases: ischemic heart disease, cerebrovascular disease, hypertensive and other cardiovascular disease, type 2 diabetes, malignant cancer, osteoporosis, mood affective disorders, chronic obstructive pulmonary disease, chronic kidney disease, and liver disease. The prevalence of noncommunicable diseases and multimorbidity (≥2 diseases) was compared between adults with (N=47,077) and without (N=2,180,250) PoDs, before and after adjusting for sociodemographic characteristics. This study was conducted between July 1, 2018, and February 1, 2019.Adults with PoDs had higher prevalences and adjusted odds of all noncommunicable diseases (odds ratio, 2.1-9.0; all P<.05) and multimorbidity (odds ratio, 3.8; 95% CI, 3.7-3.9) compared with adults without PoDs. After stratifying by the type of PoD (eg, musculoskeletal, circulatory), all PoD categories had higher prevalence of all noncommunicable diseases and multimorbidity compared with young adults without PoDs, except for ischemic heart disease and cerebrovascular disease among adults with PoDs of the genital organs.Young adults with PoDs have an early onset of several noncommunicable diseases that represent major contributors to the global and national burden of disease and mortality.
View details for DOI 10.1016/j.mayocp.2019.07.010
View details for Web of Science ID 000511835100015
View details for PubMedID 31810527
View details for PubMedCentralID PMC9674030
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Philosophy and Pandemic in the Postdigital Era: Foucault, Agamben, Zizek.
Postdigital science and education
2020; 2 (3): 556-561
View details for DOI 10.1007/s42438-020-00117-4
View details for PubMedID 40477051
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Maternal care matters: An analysis of hospital Cesarean delivery rates in Michigan
MOSBY-ELSEVIER. 2020: S237-S238
View details for DOI 10.1016/j.ajog.2019.11.372
View details for Web of Science ID 000504997300355
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Elevated fracture risk for adults with neurodevelopmental disabilities
BONE
2020; 130: 115080
Abstract
Fracture is a high-burden condition that accelerates unhealthful aging and represents a considerable economic burden. Adults with neurodevelopmental disabilities (NDDs) may be susceptible for fracture at younger ages compared to adults without NDDs; and yet, very little is known about the burden of fracture for these underserved populations. The purpose of this study was to determine the sex-stratified prevalence of all-cause fracture among adults with NDDs, as compared to adults without NDDs, and if comorbidity of NDDs is associated with greater risk of fracture.Data from 2016 were extracted from Optum Clinformatics® Data Mart (private insurance) and a random 20% sample from Medicare fee-for-service (public insurance). ICD-10-CM diagnosis codes were used to identify adults with NDDs, including intellectual disabilities, autism spectrum disorders, and cerebral palsy. Age-standardized prevalence of any fracture and fracture by anatomical location was compared between adults with and without NDDs, and then for adults with 1 NDD vs. 2 and 3 NDDs.Adults with intellectual disabilities (n=69,456), autism spectrum disorders (n=21,844), and cerebral palsy (n=29,255) had a higher prevalence of any fracture compared to adults without NDDs (n=8.7 million). For women, it was 8.3%, 8.1%, and 8.5% vs. 3.5%, respectively. For men, it was 6.6%, 5.9%, and 6.7% vs. 3.0%, respectively. Women with NDDs had a higher prevalence of fracture of the head/neck, thoracic, lumbar/pelvis, upper extremities, and lower extremities compared to women without NDDs. A similar pattern was observed for men, except for no difference for lumbar/pelvis for all NDDs and thoracic for autism spectrum disorders. For women and men, increasing comorbidity of NDDs was associated with a higher prevalence of any fracture: 1 NDD (women, 7.7%; men, 5.7%); 2 NDDs (women, 9.4%; men, 7.2%); all 3 NDDs (women, 11.3%; men, 13.7%).Study findings suggest that adults with NDDs have an elevated prevalence of fracture compared to adults without NDDs, with the fracture risk being higher with greater numbers of comorbid NDD conditions for most anatomical locations. Our study findings indicate a need for earlier screening and preventive services for musculoskeletal frailty for adults with NDDs.
View details for DOI 10.1016/j.bone.2019.115080
View details for Web of Science ID 000503321100016
View details for PubMedID 31655219
View details for PubMedCentralID PMC8065344
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Adverse Medication Events Related to Hospitalization in the United States: A Comparison Between Adults With Intellectual and Developmental Disabilities and Those Without
AJIDD-AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
2020; 125 (1): 37-48
Abstract
This study examined the proportion of hospitalizations associated with adverse medication events (AMEs) for adults with intellectual and developmental disabilities (IDD) and adults from the general population in the United States using the 2013 National Inpatient Sample (NIS) dataset of the Healthcare Cost and Utilization Project (HCUP). Adults with IDD had greater odds of having a hospitalization associated with an AME than the general adult population. Unadjusted odds ratios (95% CI) for hospitalization due to any medication for IDD was 2.47 (2.31-2.65). In the multivariate logistic regression model, IDD was significantly associated, with an odds ratio of 1.28 (1.19-1.38). Adults who have IDD are at greater risk of having a hospital admission due to an AME.
View details for DOI 10.1352/1944-7558-125.1.37
View details for Web of Science ID 000504826000003
View details for PubMedID 31877264
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Hospital Variation in Readmissions and Visits to the Emergency Department Following Ileostomy Surgery
JOURNAL OF GASTROINTESTINAL SURGERY
2020; 24 (11): 2602-2612
Abstract
Ileostomy surgery is associated with a high readmission rate, and care pathways to prevent readmissions have been proposed. However, the extent to which readmission rates have improved is unknown. This study examined rates of readmission and emergency department visits ("return to hospital," or RTH) across hospitals in Michigan.This was a retrospective cohort study of patients undergoing colorectal surgery with ileostomy formation from July 2012 to August 2017 in twenty Michigan Surgical Quality Collaborative (MSQC) hospitals. Primary outcome was RTH within 30 days of surgery. Multivariable logistic regression was used to identify risk factors for RTH. RTH rates over time were calculated, and hospitals' risk-adjusted rates were estimated using a multivariable model. Hospitals were divided into quartiles by risk-adjusted RTH rates, and RTH rates were compared between quartiles.Of 982 patients, 28.5% experienced RTH. Rates of RTH did not decrease over time. Adjusted hospital RTH rates ranged from 9.4 to 43.3%. The risk-adjusted rate in the best-performing hospital quartile was 17.5% vs. 37.3% in the worst-performing quartile (p < 0.001). Hospitals that were outliers for ileostomy RTH were not outliers for colorectal resection RTH in general.Rates of RTH following ileostomy surgery are high and vary between hospitals. This suggests inconsistent or ineffective use of pathways to prevent these events and potential for improvement. There is clear opportunity to standardize care to prevent RTH after ileostomy surgery.
View details for DOI 10.1007/s11605-019-04407-6
View details for Web of Science ID 000498141800001
View details for PubMedID 31754986
View details for PubMedCentralID PMC7239750
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Nation-Wide Use of Periprocedural Bridging Anticoagulation in Patients With Atrial Fibrillation
AMERICAN JOURNAL OF CARDIOLOGY
2019; 124 (10): 1549-1553
Abstract
The randomized, controlled BRIDGE trial established a lack of efficacy for use of bridging anticoagulation in warfarin-treated patients who underwent surgical procedures. A large nation-wide insurance claims database was used to perform a retrospective interrupted time series cohort study of adult patients with atrial fibrillation treated with warfarin who underwent surgical procedures. Patients were assessed for the use of low-molecular-weight heparin (LMWH) use as a periprocedural bridging anticoagulant between July 2015 and November 2017. The interrupted time series regression model was used to estimate the reduction in use of bridging LMWH following the publication of the BRIDGE trial in July 2015. The cohort consisted of 9,278 warfarin-treated patients with atrial fibrillation. Use of bridging LMWH declined by an estimated 6.7% (95% confidence interval [CI] 2.1% to 11.3%) to 13.0% following publication of the BRIDGE trial. The decline in bridging LMWH use was numerically larger for patients with a moderate- or high risk of stroke (8.9% decline, 95% CI 0.4% to 17.4%) than for patients at low risk for stroke (6.2% decline, 95% CI 0.7% to 11.5%). Significant predictors of bridging LMWH use include younger age and no co-morbid diabetes. In conclusion, this nation-wide, claims-based study identified a significant reduction in the use of bridging LMWH following the publication of the BRIDGE trial for warfarin-treated patients with AF.
View details for DOI 10.1016/j.amjcard.2019.08.020
View details for Web of Science ID 000499765300008
View details for PubMedID 31543215
View details for PubMedCentralID PMC6825891
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Can Hearing Aids Delay Time to Diagnosis of Dementia, Depression, or Falls in Older Adults?
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY
2019; 67 (11): 2362-2369
Abstract
To examine the association between hearing aids (HAs) and time to diagnosis of Alzheimer disease (AD) or dementia, anxiety or depression, and injurious falls among adults, aged 66 years and older, within 3 years of hearing loss (HL) diagnosis.Retrospective cohort study.We used 2008 to 2016 national longitudinal claims data (based on office visit, inpatient, or outpatient healthcare encounters) from a large private payer. We used Kaplan-Meier curves to examine unadjusted disease-free survival and crude and adjusted Cox regression models to examine associations between HAs and time to diagnosis of three age-related/HL-associated conditions within 3 years of HL diagnosis. All models were adjusted for age, sex, race/ethnicity, census divisions, and prior diagnosis of cardiovascular conditions, hypertension, hypercholesterolemia, obesity, and diabetes.The participants included 114 862 adults, aged 66 years and older, diagnosed with HL.Diagnosis of (1) AD or dementia; (2) depression or anxiety; and (3) injurious falls.Use of HAs.Large sex and racial/ethnic differences exist in HA use. Approximately 11.3% of women vs 13.3% of men used HAs (95% confidence interval [CI] difference = -0.024 to -0.016). Approximately 13.6% of whites (95% CI = 0.13-0.14) vs 9.8% of blacks (95% CI = 0.09-0.11) and 6.5% of Hispanics (95% CI = 0.06-0.07) used HAs. The risk-adjusted hazard ratios of being diagnosed with AD/dementia, anxiety/depression, and injurious falls within 3 years after HL diagnosis, for those who used HAs vs those who did not, were 0.82 (95% CI = 0.76-0.89), 0.89 (95% CI = 0.86-0.93), and 0.87 (95% CI = 0.80-0.95), respectively.Use of HAs is associated with delayed diagnosis of AD, dementia, depression, anxiety, and injurious falls among older adults with HL. Although we have shown an association between use of HAs and reduced risk of physical and mental decline, randomized trials are needed to determine whether, and to what extent, the relationship is causal. J Am Geriatr Soc 67:2362-2369, 2019.
View details for DOI 10.1111/jgs.16109
View details for Web of Science ID 000496755300022
View details for PubMedID 31486068
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Psychological morbidity and chronic disease among adults with nontraumatic spinal cord injuries: a cohort study of privately insured beneficiaries
SPINE JOURNAL
2019; 19 (10): 1680-1686
Abstract
Individuals living with a spinal cord injury (SCI) are at heightened risk for a number of chronic health conditions such as secondary comorbidities that may develop or be influenced by the injury, the presence of impairment, and/or the process of aging. However, very little is known about the development of secondary comorbidities among individuals living with nontraumatic SCIs (NTSCIs).The objective of this study was to compare the prevalence of psychological morbidities and chronic diseases among adults with and without NTSCIs.Cross-sectional cohort from a nationwide insurance claims database.Privately insured beneficiaries were included if they had an ICD-9-CM diagnostic code for a NTSCI and accompanying diagnosis of paraplegia, tetraplegia, quadriplegia, or unspecified paralysis (n=10,006). Adults without SCIs were also included (n=779,545). Prevalence estimates of common psychological morbidities, chronic diseases, and multimorbidity (≥2 conditions) were compared.Adults with NTSCIs had a higher prevalence of adjustment reaction (11.4% vs 5.1%), anxiety disorders (23.7% vs 14.5%), depressive disorders (31.6% vs 9.6%), drug dependence (3.4% vs 0.8%), episodic mood disorders (15.9% vs 5.4%), central pain syndrome (1% vs 0%), psychogenic pain (1.9% vs 0.2%), dementia (5.2% vs 1.5%), and psychological multimorbidity (29.3% vs 11.6%), as compared to adults without SCIs. The adjusted odds of psychological multimorbidity were 1.86 (95% confidence interval: 1.76-2.00). Adults with NTSCIs also had a significantly higher prevalence of all chronic diseases and chronic disease multimorbidity (73.5% vs 18%), except HIV/AIDS. After propensity matching for age, education, race, sex, and the chronic diseases (n=7,419 matched pairs), there was still a higher prevalence of adjustment reaction (9.2% vs 5.4%), depressive symptoms (23.5% vs 16.0%), central pain syndrome (1% vs 0%), psychogenic pain (1.5% vs 0.3%), and psychological multimorbidity (20.2% vs 17.4%) among adults with NTSCIs.Adults with NTSCIs have a significantly increased prevalence of psychological morbidities, chronic disease, and multimorbidity, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of disease onset/progression in this higher risk population.
View details for DOI 10.1016/j.spinee.2019.05.591
View details for Web of Science ID 000487825300012
View details for PubMedID 31153961
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Patient Characteristics Associated with Long Term Glucocorticoid Use in a Commercially Insured Incident RA Cohort
WILEY. 2019
View details for Web of Science ID 000507466904152
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Prevalence of Mental Health Disorders Among Adults With Cerebral Palsy A Cross-sectional Analysis
ANNALS OF INTERNAL MEDICINE
2019; 171 (5): 328-+
Abstract
Persons with cerebral palsy (CP) have an increased risk for secondary chronic conditions during childhood, including mental health disorders. However, little is known about how these disorders affect adults with CP.To determine the prevalence of mental health disorders among adults with CP compared with those without CP.Cross-sectional.2016 Optum Clinformatics Data Mart.8.7 million adults (including 7348 adults with CP).Other neurodevelopmental comorbid conditions (intellectual disabilities, autism spectrum disorders, epilepsy) and 37 mental health disorders (as 6 categories) were identified on the basis of diagnosis codes. Direct age-standardized prevalence of the mental health disorder categories was estimated by sex for adults with CP alone, adults with CP and neurodevelopmental disorders, and adults without CP.Men with CP alone had higher age-standardized prevalence than men without CP for schizophrenic disorders (2.8% [95% CI, 2.2% to 3.4%] vs. 0.7%), mood affective disorders (19.5% [CI, 18.0% to 21.0%] vs. 8.1%), anxiety disorders (19.5% [CI, 18.0% to 21.0%] vs. 11.1%), disorders of adult personality and behavior (1.2% [CI, 0.8% to 1.6%] vs. 0.3%), and alcohol- and opioid-related disorders (4.7% [CI, 3.9% to 5.5%] vs. 3.0%). The same pattern was observed for women. Compared with adults with CP alone, those with CP and neurodevelopmental disorders had similar or higher age-standardized prevalence of the 6 mental health disorder categories, except for the lower prevalence of alcohol- and opioid-related disorders in men.Single claims code was used to define the cohort of interest. Information on the severity of CP was not available.Compared with adults without CP, those with CP have an elevated prevalence of mental health disorders, some of which may be more pronounced in patients with comorbid neurodevelopmental disorders.National Institute on Disability, Independent Living, and Rehabilitation Research.
View details for DOI 10.7326/M18-3420
View details for Web of Science ID 000484610900005
View details for PubMedID 31382276
View details for PubMedCentralID PMC9704040
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Economic burden of paediatric-onset disabilities among young and middle-aged adults in the USA: a cohort study of privately insured beneficiaries
BMJ OPEN
2019; 9 (9): e030490
Abstract
Individuals with paediatric-onset disabilities (PoDs) have complex healthcare needs and are susceptible to adverse health outcomes, which may impose a higher strain on healthcare resources. The burden of healthcare resource utilisation and costs attributed to the population of adults with PoDs is not clearly established. The objective here was to compare healthcare resource utilisation and costs between adults with versus without PoDs.Cohort.Data were from the 2016 Optum Clinformatics Data Mart, a de-identified nationwide claims database of beneficiaries from a single private payer in the USA.International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes were used to identify beneficiaries with PoDs that were between 18 and 64 years of age.Annual all-cause healthcare resource utilisation and total healthcare costs were compared between adults with and without PoDs before and after adjusting for sociodemographics and several costly non-communicable diseases.Adults with PoDs (n=121 446) had greater annual mean counts of service utilisation for all service types (eg, inpatient, outpatient, emergency visits) compared with adults without PoDs (n=5 415 475) before and after adjustments (all p<0.001). Adults with PoDs had greater unadjusted total standardised reimbursement costs (US$26 702 vs US$8464; mean difference=US$18 238; cost ratio (CR)=3.16; 95% CI=3.13 to 3.18) and total patient out-of-pocket costs (US$2226 vs US$1157; mean difference=US$1069; CR=1.88; 95%CI=1.86 to 1.89). After adjustments, total standardised reimbursement costs were 2.32 times higher (95% CI=2.30 to 2.34) and total patient out-of-pocket costs were 1.65 times higher (95% CI=1.64 to 1.66) compared with adults without PoDs.Adults with PoDs had greater healthcare utilisation and costs, even after accounting for costly diseases. Future research is needed to identify the cost drivers for adults with PoDs.
View details for DOI 10.1136/bmjopen-2019-030490
View details for Web of Science ID 000497787600286
View details for PubMedID 31481565
View details for PubMedCentralID PMC6731834
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Can Insurance Companies Save Money by Covering Hearing Aids?
WILEY. 2019: S595
View details for Web of Science ID 000482910500003
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Hospital contribution to variation in rates of vaginal birth after cesarean
JOURNAL OF PERINATOLOGY
2019; 39 (7): 904-910
Abstract
To determine the influence of delivery hospital on the rate of vaginal birth after cesarean (VBAC).This retrospective cohort study used claims data from Blue Cross and Blue Shield of Michigan. Women with a prior cesarean and a singleton livebirth between 2012 and 2016 were included. We calculated the hospital-specific risk-standardized VBAC rates and median odds ratio as a measure of variation.Hospital-level adjusted rates varied nearly tenfold (3.7%-35.5%). Compared to the lowest volume hospitals (1st quartile), the likelihood of VBAC increased for those in the 2nd (adjusted OR 2.75 [95% CI 1.23-6.17]), 3rd (adjusted OR 3.73 [95% CI 1.59-8.75]), and 4th quartiles (adjusted OR 2.9 [95% CI 1.11-7.72]). The median OR suggested significant variation by hospital after adjustment.The delivery hospital itself explains a large amount of the variation in rates of VBAC after adjustment for patient and hospital characteristics.
View details for DOI 10.1038/s41372-019-0373-2
View details for Web of Science ID 000472630200002
View details for PubMedID 30952949
View details for PubMedCentralID PMC6592715
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Breast Screening Utilization and Cost Sharing Among Employed Insured Women After the Affordable Care Act
JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY
2019; 16 (6): 788-796
Abstract
To assess changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised US Preventive Services Task Force (USPSTF) guidelines. To compare mammography cost sharing between women aged 40 to 49 and those 50 to 74.We used patient-level analytic files between 2004 and 2014 from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minnesota). We included women 40 to 74 years without a history of breast cancer or mastectomy. We conducted an interrupted time series analyses assessing cost sharing and utilization trends before and after the ACA implementation and USPSTF revised guidelines.We identified 1,763,959 commercially insured women aged 40 to 74 years. Between 2004 and 2014, the proportion of women with zero cost share for screening mammography increased from 81.9% in 2004 to 98.2% in 2014, reaching 93.1% with the 2010 ACA implementation. The adjusted median cost share remained $0 over time. Initially at 36.0% in 2004, screening utilization peaked at 42.2% in 2009 with the USPSTF guidelines change, dropping to 40.0% in 2014. Comparing women aged 40 to 49, 50 to 64, and 65 to 74, the proportion exposed to cost sharing declined over time in all groups.A substantial majority of commercially insured women had first-dollar coverage for mammography before the ACA. After ACA, nearly all women had access to zero cost-share mammography. The lack of an increase in mammography use post-ACA can be partially attributed to a USPSTF guideline change, the high proportion of women without cost sharing before the ACA, and the relatively low levels of cost sharing before the policy implementation.
View details for DOI 10.1016/j.jacr.2019.01.028
View details for Web of Science ID 000470799800004
View details for PubMedID 30833168
View details for PubMedCentralID PMC7384237
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Location, Location, Location: Hospital Level Predictors of Length of Stay Following Cesarean Section
LIPPINCOTT WILLIAMS & WILKINS. 2019: 156S
View details for DOI 10.1097/01.AOG.0000559327.57779.c9
View details for Web of Science ID 000473810000531
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Impact of Cesarean Delivery Rate Calculation Method on Hospital Ranking
LIPPINCOTT WILLIAMS & WILKINS. 2019: 163S
View details for Web of Science ID 000473810000556
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Documenting pessary offer prior to hysterectomy for management of pelvic organ prolapse
INTERNATIONAL UROGYNECOLOGY JOURNAL
2019; 30 (5): 753-759
Abstract
To (1) determine the proportion of hysterectomy cases with documentation of pessary counseling prior to prolapse surgery and (2) identify variables associated with women offered a pessary.The Michigan Surgical Quality Collaborative (MSQC) is a hysterectomy improvement initiative. Hysterectomies from 2013 to 2015 in which prolapse was the principal diagnosis were included. "Pessary offer" was defined as documentation showing the patient declined, could not tolerate, or failed a pessary trial. Bivariate analyses were used to compare demographics, medical history, surgical route, concomitant procedures (colpopexy or colporrhaphy), and intra- and postoperative complications between women with and without pessary offer. Hierarchical logistic regression was used to determine factors independently associated with pessary offer. Risk-adjusted pessary offer rates by hospital were calculated.The adjusted rate of pessary offer was 25.2%, ranging from 3 to 76% per hospital. Bivariate comparisons showed differences between women with and without pessary offer in age, tobacco use, prior pelvic surgery, insurance status, surgical approach, secondary indication for surgery, concomitant prolapse procedure, teaching hospital status and hospital bed size. In logistic regression, odds of pessary offer increased with age > 55 years (OR 1.45, 95% CI 1.12-1.88, p = 0.006), Medicare insurance (OR 1.65, 95% CI 1.30-2.10, p < 0.0001), and a concomitant procedure (OR 1.5, 95% CI 1.16-1.93, p = 0.002). Postoperative urinary tract infections were more common in patients offered a pessary (6.4% vs. 2.5%, p < 0.0001), but other complications were similar.Overall, only one-quarter of hysterectomies for prolapse in MSQC hospitals had documentation of pessary counseling-suggesting an opportunity to improve documentation, counseling regarding pessary use, or both.
View details for DOI 10.1007/s00192-018-3696-1
View details for Web of Science ID 000466445100012
View details for PubMedID 29934768
View details for PubMedCentralID PMC6470058
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Impact of the Image Gently® Campaign on Computerized Tomography Use for Evaluation of Pediatric Nephrolithiasis
JOURNAL OF UROLOGY
2019; 201 (5): 996-1004
Abstract
The Image Gently® campaign was launched by several radiological societies in 2007 to promote safe imaging in children. A goal of the campaign was to reduce ionizing radiation exposure in children. Given the recurrent nature of kidney stones, affected children are at risk for unnecessary ionizing radiation exposure from computerized tomography. We sought to determine whether the Image Gently campaign led to a decrease in the use of computerized tomography for evaluating children with nephrolithiasis. We hypothesized that the campaign was the primary cause of a reduction in the use of computerized tomography.We analyzed medical claims data from 2001 to 2015 identifying children with nephrolithiasis covered by the same commercial insurance provider. Using a difference in differences design, we estimated changes in computerized tomography use after the campaign started among patients less than 18 years old compared to a control group age 18 years or older with nephrolithiasis.We identified 12,734 children and 787,720 adults diagnosed with nephrolithiasis. Before 2007 quarterly rates of computerized tomography use during a stone episode (per 1,000 patients) were increasing at a parallel rate in children and adults (5.1 in children vs 7.2 in adults, p = 0.123). After the Image Gently campaign started the use of computerized tomography decreased in both groups but at a slightly higher rate in adults (difference in differences 2.96, 95% CI 0.00 to 5.91, p = 0.050).Although there has been a reduction in the use of computerized tomography among children with nephrolithiasis, given a similar trend seen in adults this change cannot be primarily attributed to the Image Gently campaign.
View details for DOI 10.1097/JU.0000000000000030
View details for Web of Science ID 000475849900100
View details for PubMedID 30694933
View details for PubMedCentralID PMC7075491
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Breast Screening Utilization and Cost Sharing Among Employed Insured Women Following the Affordable Care Act: Impact of Race and Income
JOURNAL OF WOMENS HEALTH
2019; 28 (11): 1529-1537
Abstract
Introduction: We assessed changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised U.S. Preventive Services Task Force (USPSTF) recommendations by race and income. Methods: We used Optum™© Clinformatics™® Data Mart deidentified patient-level analytic files between 2004 and 2014. We first visually inspected trends for screening mammography utilization and cost-sharing elimination over time by race and income. We then specifically calculated the slopes and compared trends before and after 2009 and 2010 to assess the impact of ACA implementation and USPSTF recommendation revisions on screening mammography cost-sharing elimination and utilization. All analyses were conducted in 2018. Results: A total of 1,763,959 commercially insured women, ages 40-74, were included. Comparing trends for cost-sharing elimination before and after the 2010 ACA implementation, a statistically significant but small upward trend was found among all races and income levels with no racial or income disparities evident. However, screening utilization plateaued or showed a significant decline after the 2009 USPSTF recommendation revision in all income and racial groups except for African Americans in whom screening rates continued to increase after 2009. Conclusions: Impact of ACA cost-sharing elimination did not differ among various racial and income groups. Among our population of employer-based insured women, the racial gap in screening mammography use appeared to have closed and potentially reversed among African American women. Continued monitoring of screening utilization as health care policies and recommendations evolve is required, as these changes may affect race- and income-based disparities.
View details for DOI 10.1089/jwh.2018.7403
View details for Web of Science ID 000464564800001
View details for PubMedID 30985249
View details for PubMedCentralID PMC6862944
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Importance of Estimated Blood Loss in Resource Utilization and Complications of Hysterectomy for Benign Indications
LIPPINCOTT WILLIAMS & WILKINS. 2019: 650-657
Abstract
To identify the variation in estimated blood loss at the time of hysterectomy for benign indications and to analyze how blood loss is associated with measures of resource utilization and complications.We conducted a retrospective cohort study and analyzed hysterectomy for benign indications at hospitals in the Michigan Surgical Quality Collaborative between January 1, 2013, and May 30, 2015. A sensitivity analysis was performed to identify how estimated blood loss was associated with measures of utilization (transfusion, readmission, reoperation, and length of stay) and postoperative complications. A hierarchical logistic regression model was used to identify patient level factors independently associated with estimated blood loss greater than 400 mL and to calculate a risk- and reliability-adjusted rate for each hospital.There were 18,033 hysterectomies for benign indications from 61 hospitals included for analysis. The median estimated blood loss was 100 mL, and the 90th percentile estimated blood loss was 400 mL. A sensitivity analysis demonstrated increased risks of transfusion, readmission, reoperation, length of stay, and major postoperative complications with estimated blood loss greater than 400 mL. The proportion of hysterectomies at hospitals in the collaborative with estimated blood loss greater than 400 mL ranged from 3.5% to 16.9% after risk and reliability adjustments. The risk factors with the highest adjusted odds for estimated blood loss greater than 400 mL included abdominal surgery compared with laparoscopic hysterectomy (adjusted odds ratio [aOR] 2.8, CI 2.3-3.5), surgical time longer than 3 hours (aOR 3.9, CI 3.3-4.5), and specimen weight greater than 250 g compared with less than 100 g (aOR 4.8, CI 3.9-5.8). Adhesive disease, low surgeon volume, being younger than 40 years of age, having a body mass index greater than 35, and the need for a preoperative transfusion were also statistically significantly associated with estimated blood loss greater than 400 mL.There is fivefold variation in the hospital rate of hysterectomies with an estimated blood loss greater than 400 mL (90th percentile)-a threshold associated with significantly higher rates of health care utilization and complications. Avoidance of abdominal hysterectomy when possible may reduce intraoperative blood loss and associated sequelae.
View details for DOI 10.1097/AOG.0000000000003182
View details for Web of Science ID 000480712000015
View details for PubMedID 30870284
View details for PubMedCentralID PMC6485959
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Age-related trends in cardiometabolic disease among adults with cerebral palsy
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY
2019; 61 (4): 484-+
Abstract
To examine the longitudinal trends of cardiometabolic diseases in a large sample of adults with cerebral palsy (CP).The Optum Clinformatics Data Mart is a de-identified nationwide claims database of beneficiaries from a single private payer. Beneficiaries were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification code for a diagnosis of CP. Adults with at least 3 years of continuous enrollment on a single plan between 2002 and 2009 were included in the final analyses (n=2659). We examined the longitudinal trends of incident diabetes mellitus, hypercholesterolemia, hypertension, cardiac dysrhythmias, and atherosclerosis, stratified by age categories: 18 to 39 years, 40 to 59 years, and 60 years and over. Kaplan-Meier product-limit survival curves were compared across age categories for each of the cardiometabolic outcomes, and a Cox proportional hazards regression was run to determine adjusted hazard ratios.The cumulative incidence of each of the cardiometabolic diseases ranged from 6.0% for atherosclerosis to 34.4% for hypercholesterolemia at 3 years and over. Risk-adjusted Cox proportional hazard models revealed that age was a robust predictor of survival for each outcome, with higher hazard ratio ranges in middle age (hazard ratio 1.41-2.72) and older adults (hazard ratio 2.20-5.93) compared with young adults.Adults with CP have high rates of cardiometabolic diseases; and disease-free survival shortens significantly with higher ages.Adults with cerebral palsy have high rates of cardiometabolic diseases. Disease-free survival of all cardiometabolic diseases shortens significantly with higher ages. The highest rates were for hypercholesterolemia and hypertension.
View details for DOI 10.1111/dmcn.13777
View details for Web of Science ID 000460344300019
View details for PubMedID 29704244
View details for PubMedCentralID PMC6204119
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Academic Hospitals Discharge Fewer Patients to Postacute Care Facilities After Colorectal Resection
DISEASES OF THE COLON & RECTUM
2019; 62 (4): 483-490
Abstract
Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home.We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection.This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns.Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals.Patients undergoing colon and rectal resections were included.The main outcome measure was hospital use patterns of nonhome discharge.Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045).This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size.This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.
View details for DOI 10.1097/DCR.0000000000001308
View details for Web of Science ID 000469490500020
View details for PubMedID 30844972
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Preoperatively predicting non-home discharge after surgery for gynecologic malignancy
ACADEMIC PRESS INC ELSEVIER SCIENCE. 2019: 293-297
Abstract
Returning home after surgery is a desirable patient-centered outcome associated with decreased costs compared to non-home discharge. Our objective was to develop a preoperative risk-scoring model predicting non-home discharge after surgery for gynecologic malignancy.Women who underwent surgery involving hysterectomy for gynecologic malignancy from 2013 to 2015 were identified from the Michigan Surgical Quality Collaborative database. Patients were divided by discharge destination, and a multivariable logistic regression model was developed to create a nomogram to assign case-specific risk scores. The model was validated using the National Surgical Quality Improvement Program (NSQIP) database.Non-home discharge occurred in 3.1% of 2134 women. The proportion of non-home discharges did not differ by cancer diagnosis (uterine 3.5%, ovarian 2.5%, and cervical 1.6%, p = 0.2). Skilled nursing facilities were the most common non-home destination (68.2%). Among patients with comorbidities (hypertension, diabetes, coronary artery disease, chronic obstructive pulmonary disease /dyspnea, arrhythmia, and history of deep vein thrombosis/pulmonary embolism), non-home discharge was more common in women with 1 (adjusted OR [aOR] 3.4; p = 0.03) or ≥2 of these comorbidities (aOR 5.1; p = 0.003) compared to none. Non-home discharge was more common after laparotomy (aOR 6.7; p < 0.0001) than laparoscopy, and in those aged ≥70 years (aOR 3.4; p < 0.0001) with American Society of Anesthesiologists class ≥ 3 (aOR 4.5; p = 0.0004) and dependent functional status (aOR 8.7; p < 0.0001). The model C-statistic was 0.89. When the model was applied to 4248 eligible patients from the NSQIP dataset, the C-statistic was 0.84 (95% CI: 0.79-0.89).Non-home discharge after surgery for gynecologic malignancy was predicted with high accuracy in this retrospective analysis.
View details for DOI 10.1016/j.ygyno.2018.11.029
View details for Web of Science ID 000459089600012
View details for PubMedID 30497792
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Prevalence of high-burden medical conditions and health care resource utilization and costs among adults with cerebral palsy
CLINICAL EPIDEMIOLOGY
2019; 11: 469-480
Abstract
Purpose: Individuals with cerebral palsy (CP) are susceptible to early development of high-burden medical conditions, which may place a considerable strain on health care resources. However, little is known about the prevalence of high-burden medical conditions or health care resource utilization among adults with CP. The purpose of this study was to determine the prevalence of high-burden medical conditions and health care resource utilization and costs among adults with CP, as compared to adults without CP. Patients and methods: Cross-sectional data from the 2016 Optum Clinformatics® Data Mart, a de-identified nationwide claims database of beneficiaries from a single private payer in the US. ICD-10-CM diagnosis codes were used to identify all medical conditions among beneficiaries with and without CP who were between 18 and 64 years of age. Medical and outpatient pharmacy claims were used to identify annual all-cause health care resource utilization and health care costs as standardized reimbursement and patient out-of-pocket costs. Results: Adults with CP (n=5,555) had higher prevalence and odds of all medical conditions compared to adults without CP (OR=1.3-5.8; all P<0.05), except cancer (OR=1.1; 95% CI=0.9-1.3). Adults with CP had greater annual mean counts of all health care service types (eg, inpatient, emergency department) compared to adults without CP (all P<0.01). Adults with CP had higher unadjusted standardized reimbursement (mean difference=$16,288; cost ratio [CR]=3.0; 95% CI=2.9-3.1) and patient out-of-pocket (mean difference=$778; CR=1.7; 95% CI=1.6-1.7) costs compared to adults without CP. After adjusting for all prevalent medical conditions, adults with CP still had higher standardized reimbursement (CR=2.5; 95% CI=2.5-2.6) and patient out-of-pocket (CR=1.8; 95% CI=1.7-1.8) costs. Conclusion: Adults with CP have a higher prevalence of high-burden medical conditions, health care resource utilization, and health care costs compared to adults without CP. Study findings suggest the need for earlier screening strategies and preventive medical services to quell the disease and economic burden attributable to adults with CP.
View details for DOI 10.2147/CLEP.S205839
View details for Web of Science ID 000472767500001
View details for PubMedID 31417318
View details for PubMedCentralID PMC6592066
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Savings with expanding use of the levonorgestrel intrauterine device and fewer benign hysterectomies
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2019; 220 (1): 116-U296
View details for DOI 10.1016/j.ajog.2018.10.015
View details for Web of Science ID 000454239900033
View details for PubMedID 30321528
View details for PubMedCentralID PMC6487885
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Acute Care Surgery Model and Outcomes in Emergency General Surgery
ELSEVIER SCIENCE INC. 2019: 21-+
Abstract
Annually, more than 2 million patients are admitted with emergency general surgery (EGS) conditions. Emergency general surgery cases comprise 11% of all general surgery operations, yet account for 47% of mortalities and 28% of complications. Using the statewide general surgery Michigan Surgical Quality Collaborative (MSQC) data, we previously confirmed that wide variations in EGS outcomes were unrelated to case volume/complexity. We assessed whether patient care model (PCM) affected EGS outcomes.There were 34 hospitals that provided data for PCM, resources, surgeon practice patterns, and comprehensive MSQC patient data from January 1, 2008 to December 31, 2016 (general surgery cases = 126,494; EGS cases = 39,023). Risk and reliability adjusted outcomes were determined using hierarchical multivariable logistic regression analysis with multiple clinical covariates and PCM.The general surgery service (GSS) model was more common (73%) than acute care surgery (ACS, 27%). Emergency general surgery 30-day mortality was 4.1% (intestinal resections 11.6%). The ACS model was associated with a reduction of 31% in mortality (odds ratio [OR] 0.69; 95% CI 0.52-0.92] for EGS cases, related to decreased mortality in the intestinal resection cohort (8.5% ACS vs 12% GSS, p < 0.0001). Morbidity in EGS was 17.4% (9.7% elective); highest (40%) in intestinal resection, and PCM did not affect morbidity. We identified specific variables for an optimal EGS risk adjustment model.This is the first multi-institutional study to identify that an ACS model is associated with a significant 31% mortality reduction in EGS using prospectively collected, clinically obtained, research-quality collaborative data. We identified that new risk adjustment models are necessary for EGS outcomes evaluations.
View details for DOI 10.1016/j.jamcollsurg.2018.07.664
View details for Web of Science ID 000453923600003
View details for PubMedID 30359826
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Length of Catheter Use After Hysterectomy as a Risk Factor for Urinary Tract Infection
FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY
2018; 24 (6): 430-434
Abstract
The aims of this study were to determine the effect of length of postoperative catheterization on risk of urinary tract infection (UTI) and to identify risk factors for postoperative UTI.This was a retrospective case-control study. Demographic and perioperative data, including duration of indwelling catheter use and postoperative occurrence of UTI within 30 days of surgery, were analyzed for hysterectomies using the Michigan Surgical Quality Collaborative database. Catheter exposure was categorized as low-no catheter placed/catheter removed the day of surgery, intermediate-catheter removed postoperative day 1, high-catheter removal on postoperative day 2 or later, or highest-patient discharged home with catheter. A multivariable logistic regression model was developed to identify factors associated with UTI. An interaction term was included in the final model.Overall, UTI prevalence was 2.3% and increased with duration of catheter exposure (low: 1.3% vs intermediate: 2.1% vs high: 4.1% vs highest: 6.5%, P < 0.0001). High (odds ratio [OR] = 2.54 [1.51-4.27]) and highest (OR = 3.39 [1.86-6.17]) catheter exposure, operative time (OR = 1.15 [1.03-1.29]), and dependent functional status (OR = 4.62 [1.90-11.20]) were independently associated with UTI. Women who had a vaginal hysterectomy with sling/pelvic organ prolapse repair were more likely to have a UTI than those who had a vaginal hysterectomy alone (OR = 2.58 [1.10-6.07]) and more likely to have a UTI than women having an abdominal or laparoscopic hysterectomy with a sling/pelvic organ prolapse repair (OR = 2.13 [1.12-4.04]).Length of catheterization and operative time are modifiable risk factors for UTI after hysterectomy. An interaction between vaginal hysterectomy and concomitant pelvic reconstruction increases the odds of UTI.
View details for DOI 10.1097/SPV.0000000000000486
View details for Web of Science ID 000449402700012
View details for PubMedID 28914703
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Definition development and prevalence of new persistent opioid use following hysterectomy
MOSBY-ELSEVIER. 2018: 486.e1-486.e7
Abstract
Opioids used for postoperative pain control after surgery have been associated with an increased risk of chronic opioid use. Hysterectomy is the most common major gynecological procedure in the United States; however, we lack a data-driven definition of new persistent opioid use specific to hysterectomy.The objectives of the study were as follows: (1) determine a data-driven definition of new persistent opioid use among opioid naïve women undergoing hysterectomy and (2) determine the prevalence of and risk factors for new persistent opioid use.We used data from Optum Clinformatics that include both medical and pharmacy data from a single national private health insurer. Hysterectomies performed from Jan. 1, 2011, to Dec. 31, 2014, were identified using current procedural terminology and International Classification of Diseases, ninth revision, codes. Inclusion criteria included the following: age ≤63 years at hysterectomy, no opioid fills for 8 months preceding (excluding the 30 days immediately prior), and no additional surgical procedures within 6 months after hysterectomy. The perioperative period was defined as 30 days prior to 14 days after hysterectomy. Number of opioid prescription fills, days supplied, and total oral morphine equivalents were analyzed to determine the distribution of opioid use in the perioperative and postoperative periods. We obtained demographics including age, race, educational level, and division of the country according to the US Census Bureau and used International Classification of Diseases, ninth revision, diagnosis codes to identify hysterectomy indications, surgical route, chronic pain disorders, depression/anxiety, and substance abuse. Bivariate analyses were used to compare persistent with nonpersistent opioid users. A hierarchical logistic regression model controlling for regional variation was used to determine factors associated with new persistent opioid use following hysterectomy.A total of 24,331 women were included in the analysis. New persistent opioid use was defined as follows: ≥2 opioid fills within 6 months of hysterectomy with ≥1 fill every 3 months and either total oral morphine equivalent ≥1150 or days supplied ≥39. Based on this definition, the prevalence of new persistent opioid use was 0.5% (n = 122). Median perioperative oral morphine equivalents prescribed to those who became new persistent users was 437.5 mg (interquartile range, 200-750) compared with 225 mg (interquartile range, 150-300) for nonpersistent users (P < .0001). Factors independently associated with new persistent opioid use included the following: increasing age (adjusted odds ratio, 1.04, 95% confidence interval, 1.01-1.06, P = .006), African-American race (reference: white, adjusted odds ratio, 1.61 95% confidence interval, 1.02-2.55, P = .04), gynecological malignancy (adjusted odds ratio, 7.61, 95% confidence interval, 3.35-17.27, P < .0001), abdominal route (adjusted odds ratio, 3.61, 95% confidence interval, 2.03-6.43, P < .0001), depression/anxiety (adjusted odds ratio, 2.62, 95% confidence interval, 1.71-4.02, P < .0001), and preoperative opioid fill (adjusted odds ratio, 2.76, 95% confidence interval, 1.87-4.07, P < .0001). The C-statistic for this model is 0.74.Based on our definition, the prevalence of new persistent opioid use among opioid-naïve women undergoing hysterectomy is low; however, 2 potentially modifiable risk factors are preoperative opioid prescription and abdominal route of surgery.
View details for DOI 10.1016/j.ajog.2018.06.010
View details for Web of Science ID 000448396200020
View details for PubMedID 29928864
View details for PubMedCentralID PMC6392025
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Impact of State-Specific Health Care Reform on Utilization of Bariatric Surgery
ELSEVIER SCIENCE INC. 2018: E30-E31
View details for DOI 10.1016/j.jamcollsurg.2018.08.079
View details for Web of Science ID 000447772500066
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Acute Care Surgery Model Associated with Decreased Mortality in Emergency General Surgery
ELSEVIER SCIENCE INC. 2018: E20
View details for DOI 10.1016/j.jamcollsurg.2018.08.048
View details for Web of Science ID 000447772500040
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Patterns of Glucocorticoid Use and Provider-Level Variation in a Commercially Insured Incident Rheumatoid Arthritis Population
WILEY. 2018
View details for Web of Science ID 000447268903092
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Evaluation of the Methods Used by Medicare's Hospital-Acquired Condition Reduction Program to Identify Outlier Hospitals for Surgical Site Infection
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2018; 227 (3): 346-356
Abstract
The Hospital Acquired Condition Reduction Program (HACRP) is a national pay-for-performance program that includes a measure of surgical site infection (SSI) after hysterectomy and colectomy. This study compares the HACRP SSI measure with other published methods.This was a retrospective cohort study from the Michigan Surgical Quality Collaborative (MSQC). The outcome was 30-day, adjusted deep and organ space SSI ("complex SSI"). Observed-to-expected ratios of complex SSI for each hospital were calculated using HACRP, National Healthcare Safety Network (NHSN), and MSQC methodologies. C-statistics were compared between models. Hospital rankings were compared, and ladder plots show changes in hospitals' HACRP scores that derive from each algorithm.Complex SSI occurred in 1.1% (190 of 16,672) of hysterectomies and 4.8% (n = 514 of 10,725) of colectomies. The HACRP risk-adjustment model for hysterectomy had a C-statistic of 0.55, significantly lower than NHSN (0.61, p = 0.0461) or MSQC models (0.77, p < 0.0001). For colectomy, C-statistics were 0.57, 0.66 (p < 0.0001) and 0.73 (p < 0.0001), respectively. For both operations, there were 5 high-outlier hospitals using HACRP, but fewer (4 or 3) using the other methods. Most hospitals in the bottom quartile were not statistical outliers, but would be flagged under HACRP. More than 50% of hospitals changed ranking position between models, which would result in different scores under HACRP.This study showed that the HACRP SSI measure unfairly places hospitals at risk for financial penalties that are not statistical outliers. Policy makers need to weigh the burden of data collection and the accuracy needed to identify hospitals for financial reward or penalty.
View details for DOI 10.1016/j.jamcollsurg.2018.06.003
View details for Web of Science ID 000442517200005
View details for PubMedID 29936061
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Intrauterine Device Insertion Before and After Mandated Health Care Coverage <i>The Importance of Baseline Costs</i>
OBSTETRICS AND GYNECOLOGY
2018; 131 (5): 843-849
Abstract
To evaluate changes in out-of-pocket cost for intrauterine device (IUD) placement before and after mandated coverage of contraceptive services and to examine how changes in out-of-pocket cost influence IUD insertion as a function of baseline cost.We conducted a cross-sectional pre-post analysis at the plan level using a large deidentified medical claims database to analyze our primary outcome, new IUD insertions among women enrolled in employer-sponsored health plans in 2009 and 2014, and our secondary outcome, out-of-pocket cost. Patient costs and utilization were aggregated by plan and year to conduct a plan-specific analysis. Plans were classified by mean out-of-pocket cost level: no out-of-pocket cost, low out-of-pocket cost (less than the 75th percentile), and high out-of-pocket cost (75th percentile or greater). A generalized estimating equation was used to evaluate average plan utilization of IUD services in 2009 and 2014 as a function of plan cost category and year.Overall, average plan utilization of IUD services demonstrated a significant increase between 2009 (12.5%, 95% CI 11.6-13.4%) and 2014 (13.8%, 95% CI 13.0-14.7%; P<.001). When plans were grouped by out-of-pocket cost level, significant differences in plan utilization over time were observed. Plans that went from high out-of-pocket cost in 2009 to no out-of-pocket cost in 2014 saw a higher average increase in the rate of plan IUD insertions over time (2.4%, 95% CI 0.04-4.5%) compared with plans with no out-of-pocket cost in both 2009 and 2014 (-1.0%, 95% CI -3.3 to 1.4%, P=.02). Among all women in all plans, the 75th percentile of out-of-pocket cost in 2009 was $368; this number dropped to $0 in 2014.Women in plans with the greatest reduction in out-of-pocket cost after mandated coverage of contraception had the greatest gains in IUD insertion. This suggests that baseline cost should be considered in evaluations of this policy and others that eliminate patient out-of-pocket cost.
View details for DOI 10.1097/AOG.0000000000002567
View details for Web of Science ID 000441350600016
View details for PubMedID 29630013
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Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2018; 218 (4): 425.e1-425.e18
Abstract
Laparotomy followed by inpatient hospitalization has traditionally been the most common surgical care for hysterectomy. The financial implications of the increased use of laparoscopy and outpatient hysterectomy are unknown.The objective of the study was to quantify the increasing use of laparoscopy and outpatient hysterectomy and to describe the financial implications among women with commercially based insurance in the United States.Hysterectomies between 2010 and 2013 were identified in the Health Care Cost Institute, a national data set with inpatient and outpatient private insurance claims for more than 25 million women. Surgical approach was categorized with procedure codes as abdominal, laparoscopic, laparoscopic assisted vaginal, or vaginal. Payments were adjusted to 2013 US dollars to account for change because of inflation.Between 2010 and 2013, there were 386,226 women who underwent hysterectomy. The rate of utilization decreased 12.4%, from 39.9 to 35.0 hysterectomies per 10,000 women. The largest absolute decreases were observed among women younger than 55 years and among those with uterine fibroids, abnormal uterine bleeding, and endometriosis. The proportion of laparoscopic hysterectomies increased from 26.1% to 43.4%, with concomitant decreases in abdominal (38.6% to 28.3%), laparoscopic assisted vaginal (20.2 to 16.7%), and vaginal (15.1% to 11.5%) hysterectomies. There was also a shift from inpatient to outpatient surgery. In 2010, the inpatient and outpatient rates of hysterectomy were 26.6 and 13.3 per 10,000 women, respectively. By 2013, the rates were 15.4 and 19.6 per 10,000 women. In each year of analysis, the average reimbursement for outpatient procedures was 44-46% less than for similar inpatient procedures. Offsetting the lower utilization of hysterectomy and lower reimbursement for outpatient surgery were increases in average inpatient and outpatient hysterectomy reimbursement of 19.4% and 19.8%, respectively. Total payments for hysterectomy decreased 6.3%, from $823.4 million to $771.3 million.Between 2010 and 2013, laparoscopy emerged as the most common surgical approach for hysterectomy, and outpatient hysterectomy became more common than inpatient among women with commercially based insurance. While average reimbursement per case increased, overall payments for hysterectomy are decreasing because of decreased utilization and dramatic differences in how hysterectomy is performed.
View details for DOI 10.1016/j.ajog.2017.12.218
View details for Web of Science ID 000428406300009
View details for PubMedID 29288067
View details for PubMedCentralID PMC5931386
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Rate of Pelvic Organ Prolapse Surgery-Among Privately Insured Women in the United States, 2010-2013
OBSTETRICS AND GYNECOLOGY
2018; 131 (3): 484-492
Abstract
To analyze utilization of, and payments for, pelvic organ prolapse procedures after the 2011 U.S. Food and Drug Administration (FDA) communication regarding transvaginal mesh.This is a retrospective cohort study examining private claims from three insurance providers for inpatient and outpatient prolapse procedures from 2010 to 2013 in the Health Care Cost Institute. Primary outcomes were the change in utilization of prolapse procedures, with and without mesh, before and after the July 2011 FDA communication. Secondary outcomes were the changes in payments and reimbursements for these procedures. Utilization rates and payments were compared using generalized linear models and interrupted time-series analysis.Utilization of prolapse procedures decreased from 12.3 to 9.7 per 10,000 woman-years (P=.027) with a decrease of 30.7% (3.9 in 2010 to 2.7 in 2013, P=.05) in number of mesh procedures and 16.6% (8.4 in 2010 to 7.0 in 2013, P=.011) for nonmesh procedures. Quarterly utilization of mesh procedures was increasing before the FDA communication and then significantly declined after its release (slope=0.024 vs -0.025, P=.002). Nonmesh procedures, however, were already slightly decreasing before July 2011 and continued to decline at a more rapid pace after that time, although not significantly (slope=-0.004 vs -0.022, P=.47). Inpatient utilization decreased 52.2% (P=.002), whereas outpatient utilization increased 18.5% (P=.132). Payments for individual inpatient procedures, with and without mesh, increased by 12.0% ($8,315 in 2010 to $9,315 in 2013, P=.001) and 15.6% ($7,826 in 2010 to $9,048 in 2013, P=.005), respectively, whereas those for outpatient procedures increased by 41% ($4,961 in 2010 to $6,981 in 2013, P=.006) and 30% ($3,955 in 2010 to $5,149 in 2013, P=.004), respectively.Use of prolapse surgery declined during the study period. After the 2011 FDA communication regarding transvaginal mesh, there was a significant decrease in the utilization of procedures with mesh but not for those without mesh. A shift toward outpatient surgeries was observed, and payments for both individual inpatient and outpatient cases increased.
View details for DOI 10.1097/AOG.0000000000002485
View details for Web of Science ID 000428994700014
View details for PubMedID 29420405
View details for PubMedCentralID PMC5823748
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Assessing maternal and neonatal risks associated with prolonged induction of labor
MOSBY-ELSEVIER. 2018: S117-S118
View details for DOI 10.1016/j.ajog.2017.10.048
View details for Web of Science ID 000422946900172
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Hospital contribution to variation in rates of vaginal birth after cesarean: A Michigan Value Collaborative study
MOSBY-ELSEVIER. 2018: S351-S352
View details for DOI 10.1016/j.ajog.2017.11.115
View details for Web of Science ID 000423616600086
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The Use of Opportunistic Salpingectomy at the Time of Benign Hysterectomy
JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY
2018; 25 (1): 53-61
Abstract
To delineate the use of opportunistic salpingectomy over the study period, to examine factors associated with its use, and to evaluate whether salpingectomy was associated with perioperative complications.A retrospective cross-sectional study (Canadian Task Force classification II-2).The Michigan Surgical Quality Collaborative.Women undergoing ovarian-conserving hysterectomy for benign indications from January 2013 through April 2015.The primary outcome was the performance of opportunistic salpingectomy with ovarian preservation during benign hysterectomy. The change in the rate of salpingectomy was examined at 4-month intervals to assess a period effect over the study period. Multivariate logistic regression was performed to evaluate independent effects of patient, operative, and period factors. Perioperative outcomes were compared using propensity score matching.There were 10 676 (55.9%) ovarian-conserving hysterectomies among 19 090 benign hysterectomies in the Michigan Surgical Quality Collaborative in the study period. The rate of opportunistic salpingectomy was 45.8% (n = 4890). Rates of opportunistic salpingectomy increased over the study period from 27.5% to 61.6% (p < .001), demonstrating a strong period effect in the consecutive 4-month period analysis. Salpingectomy was more likely with the laparoscopic approach (odds ratio = 3.48; 95% confidence interval, 3.15-3.85) and among women younger than 60 years of age (odds ratio = 1.60; 95% CI, 1.34-1.92). There was substantial variation in salpingectomy across hospital sites, ranging from 3.6% to 79.9%. Salpingectomy was associated with a 12-minute increase in operative time (p < .001), but there were no differences in the estimated blood loss or perioperative complications.The rates of salpingectomy increased significantly over the study period. The laparoscopic approach and younger age are associated with an increased probability of salpingectomy. Salpingectomy is not associated with increased blood loss or perioperative complications.
View details for DOI 10.1016/j.jmig.2017.07.004
View details for Web of Science ID 000422778600019
View details for PubMedID 28712794
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Risk Factors for Emergency Department Visits After Hysterectomy for Benign Disease EDITORIAL COMMENT
OBSTETRICAL & GYNECOLOGICAL SURVEY
2017; 72 (11): 648-650
View details for DOI 10.1097/01.ogx.0000525610.54627.93
View details for Web of Science ID 000416005500011
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Risk Factors for Emergency Department Visits After Hysterectomy for Benign Disease
OBSTETRICS AND GYNECOLOGY
2017; 130 (2): 296-304
Abstract
To identify the incidence, indications, and risk factors for emergency department visits that do not result in readmission within 30 days of hysterectomy for benign disease.We conducted a secondary data analysis of hysterectomies for benign disease using the Michigan Surgical Quality Collaborative, a statewide group of hospitals that voluntarily reports perioperative outcomes. Hysterectomies for benign disease were abstracted from January 1, 2013, to July 2, 2014. We examined the incidence of emergency department visits within 30 days after hysterectomy for benign disease and constructed a multivariable logistic regression model to identify risk factors for these visits. We focused on emergency department visits that did not result in readmission because they are more likely to represent avoidable encounters.Among the 10,274 women who underwent hysterectomy for benign disease during the study period, 932 (9.1%) presented to the emergency department and were not readmitted to the hospital. Based on a multivariable regression model, risk factors for emergency department visits after hysterectomy for benign disease were younger age, higher parity, Medicaid or self-pay insurance, prior venous thromboembolism, chronic obstructive pulmonary disease, preoperative surgical indication of chronic pelvic pain, and postoperative day 1 pain scores greater than 4 on a 0-10 numeric rating scale. The most common primary emergency department International Classification of Diseases, 9th Revision diagnoses were for pain (29.5% [n=275]), gastrointestinal (12.8% [n=118]), and genitourinary (10.7% [n=99]) complaints.Approximately 1 in 11 women present to the emergency department, but do not result in readmission within 30 days of hysterectomy for benign disease. Emergency department visits might be avoided with expanded perioperative education and improved communication pathways for high-risk patients.
View details for DOI 10.1097/AOG.0000000000002146
View details for Web of Science ID 000406240500013
View details for PubMedID 28697116
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Ligament shortening compared to vaginal colpopexy at the time of hysterectomy for pelvic organ prolapse
INTERNATIONAL UROGYNECOLOGY JOURNAL
2017; 28 (6): 899-905
Abstract
The performance of a colpopexy at the time of hysterectomy for pelvic organ prolapse is a potential indicator of surgical quality. However, vaginal colpopexy has not been directly compared with the classic technique of ligament shortening and reattachment. We sought to test the null hypothesis that there is no difference in prolapse recurrence between the techniques.We performed a retrospective chart review of 330 vaginal hysterectomies performed for prolapse, comparing symptomatic and/or anatomic recurrence rates between patients having a vaginal colpopexy (uterosacral ligament suspension or sacrospinous ligament suspension) and those having ligament shortening and reattachment. Clinically relevant variables significantly associated with recurrence in a univariate analysis were used to create a multivariable logistic regression model to predict recurrence.With a mean follow-up of 20 months, there was no significant difference between symptomatic and/or anatomic recurrence rates: 19.4 % of patients (41 of 211) having colpopexy vs. 11.8 % of patients (14 of 119) having ligament shortening (p = 0.07). Baseline prolapse stage was higher in patients having colpopexy (median 3, IQR 2 - 5) than in those having ligament shortening (median 2, IQR 1 - 3; p ≤ 0.0001). In the multivariable logistic regression analysis, the procedure performed was not associated with recurrence (OR 1.57, 95 % CI 0.79 - 3.12). A baseline prolapse of 4 cm or greater was associated with recurrence (OR 2.63, 95 % CI 1.32 - 5.22), as was the time since hysterectomy (OR 1.02 per month, 95 % CI 1.01 - 1.04).When compared with vaginal colpopexy, selective use of the ligament shortening technique at the time of vaginal hysterectomy was associated with similar rates of prolapse recurrence. Preoperative prolapse size was the factor most strongly associated with recurrence.
View details for DOI 10.1007/s00192-016-3201-7
View details for Web of Science ID 000401787900015
View details for PubMedID 27858132
View details for PubMedCentralID PMC5435546
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Trends in Chlamydia Screening Provision During Outpatient Visits for Young Women in the United States
LIPPINCOTT WILLIAMS & WILKINS. 2017: 58S-59S
View details for DOI 10.1097/01.AOG.0000514817.10959.43
View details for Web of Science ID 000402705800206
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Are Perioperative Bundles Associated With Reduced Postoperative Morbidity in Women Undergoing Benign Hysterectomy? Retrospective Cohort Analysis of 16,286 Cases in Michigan
OBSTETRICAL & GYNECOLOGICAL SURVEY
2017; 72 (5): 273-274
View details for DOI 10.1097/OGX.0000000000000437
View details for Web of Science ID 000401941500009
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Are perioperative bundles associated with reduced postoperative morbidity in women undergoing benign hysterectomy? Retrospective cohort analysis of 16,286 cases in Michigan
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2017; 216 (5): 502.e1-502.e11
Abstract
Healthcare teams that frequently follow a bundle of evidence-based processes provide care with lower rates of morbidity. Few process bundles to improve surgical outcomes in hysterectomy have been identified.The purpose of this study was to investigate whether a bundle of 4 perioperative care processes is associated with fewer postoperative complications and readmissions for hysterectomies in the Michigan Surgical Quality Collaborative.A bundle of perioperative care process goals was developed retrospectively with 30-day peri- and postoperative outcome data from the Hysterectomy Initiative in Michigan Surgical Quality Collaborative. All benign hysterectomies that had been performed between January 2013 and January 2015 were included. Based on evidence of lower complication rates after benign hysterectomy, the following processes were considered to be the "bundle": use of guideline-appropriate preoperative antibiotics, a minimally invasive surgical approach, operative duration <120 minutes, and avoidance of intraoperative hemostatic agent use. Each process was considered present or absent, and the number of processes was summed for a bundle score that ranged from 0-4. Cases with a score of zero were excluded. Outcomes measured were rates of complications (any and major) and hospital readmissions, all within 30 days of surgery. Postoperative events that were considered a "major complication" included acute renal failure, cardiac arrest that required cardiopulmonary resuscitation, central line infection, cerebral vascular accident, death, deep vein thrombosis, intestinal obstruction, myocardial infarction, pelvic abscess, pulmonary embolism, rectovaginal fistula, sepsis, surgical site infection (deep and organ-space), unplanned intubation, ureteral obstruction, and ureterovaginal and vesicovaginal fistula. The outcome "any complication" included all those events already described in addition to blood transfusion within 72 hours of surgery, urinary tract infection, and superficial surgical site infection. Outcomes were adjusted for patient demographics, surgical factors, and hospital-level clustering effects.There were 16,286 benign hysterectomies available for analysis. Among all hysterectomies that were reviewed, 33.6% met criteria for all bundle processes; however, there was wide variation in the rate among the 56 hospitals in the study sample with 9.1% of cases at the lowest quartile and 60.4% at the highest quartile of hospitals that met criteria for all bundle processes. Overall, the rate of any complication was 6.8% and of any major complication was 2.3%. The rate of hospital readmissions was 3.6%. After adjustment for confounders, in cases in which all bundle criterion were met compared with cases in which all bundle criterion were not met, the rate of any complications increased from 4.3-7.8% (P<.001); major complications increased from 1.7-2.6% (P<.001), and readmissions increased from 2.6-4.1% (P<.001). After adjustment for confounders, hospitals with greater rates of meeting all 4 criteria were associated significantly with lower hospital-level rates of postoperative complications (P<.001) and readmissions (P<.001).This multiinstitutional evaluation reveals that reduced morbidity and readmission are associated with rates of bundle compliance. The proposed bundle is a surgical goal, which is not possible in every case, and there is significant variation in the proportion of cases meeting all 4 bundle processes in Michigan hospitals. Implementation of evidence-based process bundles at a healthcare system level are worthy of prospective study to determine whether improvements in patient outcomes are possible.
View details for DOI 10.1016/j.ajog.2016.12.173
View details for Web of Science ID 000402492100014
View details for PubMedID 28082214
View details for PubMedCentralID PMC5420470
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Risk Factors and Outcomes for Conversion to Laparotomy of Laparoscopic Hysterectomy in Benign Gynecology Reply
OBSTETRICS AND GYNECOLOGY
2017; 129 (4): 752
View details for DOI 10.1097/AOG.0000000000001959
View details for Web of Science ID 000398166800039
View details for PubMedID 28333801
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Comparison of Robotic and Other Minimally-Invasive Routes of Hysterectomy for Benign Indications
OBSTETRICAL & GYNECOLOGICAL SURVEY
2017; 72 (3): 158-159
View details for DOI 10.1097/01.ogx.0000512477.25144.00
View details for Web of Science ID 000395944100009
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Hydroxychloroquine as Empiric Treatment for Recurrent Pregnancy Loss.
SAGE PUBLICATIONS INC. 2017: 294A
View details for Web of Science ID 000399043900778
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A retrospective cohort study of hemostatic agent use during hysterectomy and risk of post-operative complications
INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS
2017; 136 (2): 232-237
Abstract
To determine if the use of intraoperative hemostatic agents was a risk factor for post-operative adverse events within 30 days of patients undergoing hysterectomy.A population-based retrospective cohort study included data from patients undergoing hysterectomy for any indication between January 1, 2013, and December 31, 2014, at 52 hospitals in Michigan, USA. Any individuals with missing covariate data were excluded, and multivariable logistic regression and propensity score-matching were used to estimate the rate of post-operative adverse events associated with intra-operative hemostatic agents independent of demographic and surgical factors.There were 17 960 surgical procedures included in the analysis, with 4659 (25.9%) that included the use of hemostatic agents. Hemostatic agent use was associated with an increase in predicted hospital re-admissions (P=0.007). Among all hysterectomy approaches, and after adjusting for demographic and surgical factors, hemostatic agent use during robotic-assisted laparoscopic hysterectomy was associated with an increased predicted rate of blood transfusions (P=0.019), an increased predicted rate of pelvic abscess diagnoses (P=0.001), an increased predicted rate of hospital re-admission (P=0.001), and an increased predicted rate of re-operation (P=0.021).Hemostatic agents should be used carefully owing to associations with increased post-operative re-admissions and re-operations when used during hysterectomy.
View details for DOI 10.1002/ijgo.12037
View details for Web of Science ID 000397098600019
View details for PubMedID 28099744
View details for PubMedCentralID PMC5245183
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Correlates of Resource Empowerment among Parents of Children with Overweight or Obesit
CHILDHOOD OBESITY
2017; 13 (1): 63-71
Abstract
Few studies have examined correlates of resource empowerment among parents of children with overweight or obesity.We studied baseline data of 721 parent-child pairs participating in the Connect for Health randomized trial being conducted at six pediatric practices in Massachusetts. Parents completed the child weight management subscale (n = 5 items; 4-point response scale) of the Parent Resource Empowerment Scale; items were averaged to create a summary empowerment score. We used linear regression to examine the independent effects of child (age, sex, and race/ethnicity), parent/household characteristics (age, education, annual household income, BMI category, perceived stress, and their ratings of their healthcare quality), and neighborhood median household income, on parental resource empowerment.Mean (SD) child age was 7.7 years (2.9) and mean (SD) BMI z-score was 1.9 (0.5); 34% of children were white, 32% black, 22% Hispanic, 5% Asian, and 6% multiracial/other. The mean parental empowerment score was 2.95 (SD = 0.56; range = 1-4). In adjusted models, parents of older children [β -0.03 (95% CI: -0.04, -0.01)], Hispanic children [-0.14 (-0.26, -0.03)], those with annual household income less than $20,000 [-0.16 (-0.29, -0.02)], those with BMI ≥30.0 kg/m2 [-0.17 (-0.28, -0.07)], and those who reported receiving lower quality of obesity-related care [-0.05 (-0.07, -0.03)] felt less empowered about resources to support their child's healthy body weight.Parental resource empowerment is influenced by parent and child characteristics as well as the quality of their obesity-related care. These findings could help inform equitable, family-centered approaches to improve parental resource empowerment.
View details for DOI 10.1089/chi.2016.0136
View details for Web of Science ID 000394505400008
View details for PubMedID 27875076
View details for PubMedCentralID PMC5278806
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Anastomotic leak after colorectal resection: A population-based study of risk factors and hospital variation.
Surgery
2017
Abstract
Anastomotic leak is a major source of morbidity in colorectal operations and has become an area of interest in performance metrics. It is unclear whether anastomotic leak is associated primarily with surgeons' technical performance or explained better by patient characteristics and institutional factors. We sought to establish if anastomotic leak could serve as a valid quality metric in colorectal operations by evaluating provider variation after adjusting for patient factors.We performed a retrospective cohort study of colorectal resection patients in the Michigan Surgical Quality Collaborative. Clinically relevant patient and operative factors were tested for association with anastomotic leak. Hierarchical logistic regression was used to derive risk-adjusted rates of anastomotic leak.Of 9,192 colorectal resections, 244 (2.7%) had a documented anastomotic leak. The incidence of anastomotic leak was 3.0% for patients with pelvic anastomoses and 2.5% for those with intra-abdominal anastomoses. Multivariable analysis showed that a greater operative duration, male sex, body mass index >30 kg/m(2), tobacco use, chronic immunosuppressive medications, thrombocytosis (platelet count >400 × 10(9)/L), and urgent/emergency operations were independently associated with anastomotic leak (C-statistic = 0.75). After accounting for patient and procedural risk factors, 5 hospitals had a significantly greater incidence of postoperative anastomotic leak.This population-based study shows that risk factors for anastomotic leak include male sex, obesity, tobacco use, immunosuppression, thrombocytosis, greater operative duration, and urgent/emergency operation; models including these factors predict most of the variation in anastomotic leak rates. This study suggests that anastomotic leak can serve as a valid metric that can identify opportunities for quality improvement.
View details for DOI 10.1016/j.surg.2016.12.033
View details for PubMedID 28238345
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Insurance Type and Major Complications After Hysterectomy
FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY
2017; 23 (1): 39-43
Abstract
The aim of this study was to investigate the relationship between primary insurance type and major complications after hysterectomy.A retrospective analysis was performed on women with Medicaid, Medicare, and private insurance who underwent hysterectomy from January 1, 2012, to July 1, 2014, and were included in the Michigan Surgical Quality Collaborative. Major complications within 30 days of surgery included the following: deep/organ space surgical site infection, deep venous and pulmonary thromboembolism, myocardial infarction or stroke, pneumonia or sepsis, blood transfusion, readmission, and death. Multivariable logistic regression was used to identify factors associated with major complications and characteristics associated with the Medicaid and Medicare groups.A total of 1577 women had Medicaid, 2103 had Medicare, and 11,611 had private insurance. The Medicaid and Medicare groups had a similar rate of major complications, nearly double that of the private insurance group (6.85% vs 7.85% vs 3.79%; P < .001). Compared with private insurance, women with Medicaid and Medicare had increased odds of major complications (Medicaid: odds ratio [OR], 1.60; 95% confidence interval [CI], 1.26-2.04; P < .001; Medicare: OR, 1.34; 95% CI, 1.04-1.73; P = .03). Women with Medicaid were more likely to be nonwhite, have a higher body mass index (BMI), report tobacco use in the last year and undergo an abdominal hysterectomy. Those with Medicare were more likely to be white, to have gynecologic cancer, and to be functionally dependent. Both groups had increased odds of American Society of Anesthesiology class 3 or higher and decreased odds of undergoing hysterectomy at large hospitals (≥500 beds).Women with Medicaid and Medicare insurance have increased odds of major complications after hysterectomy. Abdominal hysterectomy, BMI, and smoking are potentially modifiable risk factors for women with Medicaid.
View details for DOI 10.1097/SPV.0000000000000325
View details for Web of Science ID 000391867000011
View details for PubMedID 27682744
View details for PubMedCentralID PMC5161579
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Risk Factors and Outcomes for Conversion to Laparotomy of Laparoscopic Hysterectomy in Benign Gynecology
OBSTETRICS AND GYNECOLOGY
2016; 128 (6): 1295-1305
Abstract
To estimate the incidence and factors for conversion to laparotomy in women scheduled for laparoscopic hysterectomy for benign gynecologic indications and to examine the effect of conversion on patient outcomes.A retrospective cohort study of a Michigan multicenter prospective database was abstracted from January 1, 2013, through July 2, 2014. Participants were collected from an all-payer quality and safety database maintained by the Michigan Surgical Quality Collaborative. Women with a preoperative indication of cancer or obstetric indications were excluded. A logistic regression model was used to calculate odds of conversion using patient preoperative and intraoperative attributes.During the study period, 6,992 women underwent an attempted laparoscopic hysterectomy with 3.93% (n=275) converted to laparotomy. After adjusting for socioeconomic differences, hysterectomy indication, and intraoperative factors, there were decreased odds of conversion to laparotomy with use of robotic-assisted laparoscopy compared with traditional laparoscopy (adjusted odds ratio [OR] 0.14, 95% confidence interval [CI] 0.07-0.25) with a predicted risk of conversion of 0.8% compared with 5.4% (P<.001). High-volume surgeons were less likely to convert to laparotomy compared with low- and medium-volume surgeons (adjusted OR 0.66, 95% CI 0.47-0.92) with a predicted risk of conversion of 1.4% compared with 2.25% (P=.015). Conversion was associated with moderate or severe adhesive disease and increasing specimen weight. Conversion was associated with increased rates of surgical site infection, blood transfusion, severe sepsis, and reoperation.This analysis demonstrates that conversion to laparotomy is associated with increased odds of postoperative morbidity, and robotic assistance and surgeon volume are strongly associated with decreased odds of conversion.
View details for DOI 10.1097/AOG.0000000000001743
View details for Web of Science ID 000389645200011
View details for PubMedID 27824755
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A Favorability Score for Vaginal Hysterectomy in a Statewide Collaborative
JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY
2016; 23 (7): 1146-1151
Abstract
STUDY OBJECTIVE: Because it is associated with fewer complications and more rapid recovery, the vaginal approach is preferred for benign hysterectomy. Patient characteristics that traditionally favor a vaginal approach include adequate vaginal access, small uterine size, and low suspicion for extrauterine disease. However, the low proportion of hysterectomies performed vaginally in the United States suggests that these data are not routinely applied in clinical practice. We sought to analyze the association of parity, prior pelvic surgery, and uterine weight with the use of the vaginal, laparoscopic, robotic, and abdominal approaches to hysterectomy.A retrospective cohort study (Canadian Task Force classification II-2).The Michigan Surgical Quality Collaborative is a statewide organization of 52 academic and community hospitals in Michigan funded by Blue Cross and Blue Shield of Michigan/Blue Care Network, including patients from all insurance payers.Five thousand six hundred eight women undergoing hysterectomy for benign gynecologic conditions from January 1, 2013, through December 8, 2013, and included in the Michigan Surgical Quality Collaborative.To assess potential for vaginal hysterectomy, a favorability score of 0, 1, 2, or 3 was calculated by summing 1 point each for parity ≥1, no prior pelvic surgery, and uterine weight <250 g. Frequencies of surgical approaches to hysterectomy were compared using chi-square tests across favorability scores.The use of robotic hysterectomy was most frequent (41.9%, n = 2349/5608) followed by abdominal (19.7%, n = 1103/5608), laparoscopic (14.4%, n = 809/5608), vaginal (13.5%, n = 758/5608), and laparoscopic-assisted vaginal (10.5%, n = 589/5608) hysterectomy. With favorability scores of 0, 1, 2, and 3, vaginal hysterectomy was performed in 0.6% (n = 1/167), 5% (n = 66/1324), 13.7% (n = 415/3036), and 25.5% (n = 276/1081) of cases and abdominal hysterectomy in 41.9% (n = 70/167), 30.8% (n = 408/1324), 17.5% (n = 531/3036), and 8.7% (n = 94/1081), respectively. There was little variation in the rates of laparoscopic hysterectomy (13.3%-16.8%, p = .429) and robotic hysterectomy (39.5%-42.4%, p = .518) across favorability scores.In a population of women undergoing hysterectomy in the state of Michigan, the use of vaginal and abdominal hysterectomy varied with respect to parity, prior pelvic surgery, and uterine weight, but there was little variation in the use of laparoscopic and robotic approaches. The favorability score could potentially be used as a quality improvement tool to evaluate practice patterns with respect to the use of various surgical approaches to hysterectomy.
View details for DOI 10.1016/j.jmig.2016.08.821
View details for Web of Science ID 000387638700019
View details for PubMedID 27565997
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Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2016; 215 (5): 650.e1-650.e8
Abstract
Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade.We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications.A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data.In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3 ± 198.9 mL, P < .001), longer surgical time (2.3 ± 1.0 vs 2.0 ± 1.0 hours, P < .001), larger specimen weights (178.9 ± 186.3 vs 160.5 ± 190 g, P = .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P < .001). Overall, the rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P = .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = .01) and blood transfusion (0.8% [11] vs 1.9% [25], P = .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429).Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.
View details for DOI 10.1016/j.ajog.2016.06.027
View details for Web of Science ID 000389513700039
View details for PubMedID 27343568
View details for PubMedCentralID PMC5086293
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Prevalence of Endometriosis During Abdominal or Laparoscopic Hysterectomy for Chronic Pelvic Pain EDITORIAL COMMENT
OBSTETRICAL & GYNECOLOGICAL SURVEY
2016; 71 (10): 589-591
View details for DOI 10.1097/01.ogx.0000499755.80840.50
View details for Web of Science ID 000386764500010
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The Decision to Incision Curriculum: Teaching Preoperative Skills and Achieving Level 1 Milestones
ELSEVIER SCIENCE INC. 2016: 735-740
Abstract
To evaluate the effectiveness of a preoperative skills curriculum, and to assess and document competence in associated Obstetrics and Gynecology Level 1 Milestones.The Decision to Incision curriculum was developed by a team of medical educators with the goal of teaching and evaluating 5 skills pertinent to Milestone 1: Preoperative consent, patient positioning, Foley catheter placement, surgical scrub, and preoperative time-out. Competence, overall skill performance, and knowledge were assessed by evaluator rating using checklists before and after the educational intervention. Differences between preintervention and postintervention skills performance and competence were assessed using Wilcoxon rank test and Fisher exact test, respectively.Clinical Simulation Center at an academic medical center.Overall, 29 fourth year medical students matriculating into Obstetrics and Gynecology residencies.The proportion of participants meeting Milestone competence significantly increased in all 5 skills, with competence achieved in 95.6% (95% CI: 92.1-99.0) of posttest skills assessments. Median overall performance also significantly improved for all 5 skills, with 83.6% (95% CI: 77.3-89.9) earning scores of 4 out of 5 or greater on the posttest. For knowledge testing, the proportion of correct responses significantly increased for both topics evaluated, from 45.2% to 99.7% (p < 0.0001) for positioning and from 32.8% to 83.1% (p < 0.0001) for time-out.The decision to incision curriculum significantly improved preoperative skills, including skills that may be required on day 1 of residency. This curriculum also facilitated achievement and documentation of competence in multiple Milestones.
View details for Web of Science ID 000378300900027
View details for PubMedID 27137663
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Prevalence of Endometriosis During Abdominal or Laparoscopic Hysterectomy for Chronic Pelvic Pain
OBSTETRICS AND GYNECOLOGY
2016; 127 (6): 1045-1053
Abstract
To estimate the prevalence of surgically confirmed endometriosis in women undergoing laparoscopic or abdominal hysterectomy, including those with and without preoperative indications of chronic pelvic pain or endometriosis, and to describe characteristics and operative findings associated with surgically confirmed endometriosis in women undergoing hysterectomy for chronic pelvic pain.A retrospective cohort study was performed with 9,622 women who underwent laparoscopic or abdominal hysterectomy for benign indications in the Michigan Surgical Quality Collaborative from January 1, 2013, to July 2, 2014. The prevalence of surgically confirmed endometriosis, determined by review of the operative report and surgical pathology, was calculated for the entire cohort and for subgroups of women with and without chronic pelvic pain or endometriosis. Multivariate logistic regression models were used to identify characteristics associated with surgically confirmed endometriosis at the time of hysterectomy among women with chronic pelvic pain.Of the 9,622 hysterectomies available for analysis during the study period, 15.2% (n=1,465) had endometriosis at the time of hysterectomy. Among the 3,768 women with a preoperative indication of chronic pelvic pain, fewer than one in four had endometriosis (806/3,768 [21.4%]). Even among those with preoperative indication of endometriosis, many women did not actually have endometriosis at the time of hysterectomy (527/1,232 [42.8%]). The rate of unexpected endometriosis in women without a preoperative indication of chronic pelvic pain or endometriosis was 8.0% (434/5,457). Among women with a preoperative indication of chronic pelvic pain (n=3,786), multivariate analysis showed endometriosis was more common in women of younger age, white race, lower body mass index, and those who failed another treatment previously. Among those with pelvic pain, oophorectomy was more commonly performed in women with surgically confirmed endometriosis than those without (47.4% compared with 33.3%, P<.001).Fewer than 25% of women undergoing laparoscopic or abdominal hysterectomy for chronic pelvic pain have endometriosis at the time of surgery.
View details for DOI 10.1097/AOG.0000000000001422
View details for Web of Science ID 000376939500011
View details for PubMedID 27159755
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Prophylactic Antibiotic Choice and Risk of Surgical Site Infection After Hysterectomy
OBSTETRICS AND GYNECOLOGY
2016; 127 (2): 321-329
Abstract
To evaluate associations between prophylactic preoperative antibiotic choice and surgical site infection rates after hysterectomy.A retrospective cohort study was performed of patients in the Michigan Surgical Quality Collaborative undergoing hysterectomy from July 2012 to February 2015. The primary outcome was a composite outcome of any surgical site infection (superficial surgical site infections or combined deep organ space surgical site infections). Preoperative antibiotics were categorized based on the recommendations set forth by the American College of Obstetricians and Gynecologists and the Surgical Care Improvement Project. Patients receiving a recommended antibiotic regimen were categorized into those receiving β-lactam antibiotics and those receiving alternatives to β-lactam antibiotics. Patients receiving nonrecommended antibiotics were categorized into those receiving overtreatment (excluded from further analysis) and those receiving nonstandard antibiotics. Multivariable logistic regression models were developed to estimate the independent effect of antibiotic choice. Propensity score matching analysis was performed to validate the results.The study included 21,358 hysterectomies. The overall rate of any surgical site infection was 2.06% (n=441). Unadjusted rates of "any surgical site infection" were 1.8%, 3.1%, and 3.7% for β-lactam, β-lactam alternatives, and nonstandard groups, respectively. After adjusting for patient and operative factors within clusters of hospitals, compared with the β-lactam antibiotics (reference group), the risk of "any surgical site infection" was higher for the group receiving β-lactam alternatives (odds ratio [OR] 1.7, confidence interval [CI] 1.27-2.07) or the nonstandard antibiotics (OR 2.0, CI 1.31-3.1).Compared with women receiving β-lactam antibiotic regimens, there is a higher risk of surgical site infection after hysterectomy among those receiving a recommended β-lactam alternative or nonstandard regimen.
View details for DOI 10.1097/AOG.0000000000001245
View details for Web of Science ID 000369256900001
View details for PubMedID 26942361
View details for PubMedCentralID PMC4780348
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Surgical site infection following hysterectomy: adjusted rankings in a regional collaborative
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2016; 214 (2): 259.e1-259.e8
Abstract
Surgical site infection after abdominal hysterectomy (defined as open and laparoscopic) will be a metric used to rank and penalize hospitals in the Hospital Acquired Condition Reduction program. Hospitals whose Hospital Acquired Condition Reduction score places them in the bottom quartile will lose 1% of reimbursement from the Centers of Medicaid and Medicare Services.The objectives of this analysis were to develop a risk adjustment model for surgical site infection after hysterectomy, to calculate adjusted surgical site infection rates, to rank hospitals by the predicted to expected (P/E) ratio, and to compare the number of outlier hospitals with the number in the bottom quartile.This was a retrospective analysis of hysterectomies from the Michigan Surgical Quality Collaborative performed between July 1, 2012, and July 1, 2014. Superficial, deep, and organ space surgical site infections were categorized according to Centers for Disease Control and Prevention criteria. Deep and organ space surgical site infections were considered 1 group for this analysis because these spaces are contiguous after hysterectomy. Hospital rankings focused on deep/organ space events because the Hospital Acquired Condition Reduction program will rank and penalize based on them, not superficial surgical site infection. Hierarchical multivariable logistic regression, which takes into account hospital effects, was used to identify risk factors for all surgical site infections and deep/organ space surgical site infections. Predicted to expected ratios for deep surgical site infection were calculated for each hospital and used to determine hospital rankings. Outliers were defined as those hospitals who predicted to expected confidence intervals crossed the reference line of 1. The number of outlier hospitals was compared with the number in the bottom quartile.The overall surgical site infection rate following hysterectomy was 2.1% (351 of 16,548). Deep/organ space surgical site infection accounted for 1.0% (n = 167 of 16,548). Deep surgical site infection was associated independently with younger age, longer surgical times, gynecological cancer, and open hysterectomy. There was a marginal association with blood transfusion. After risk adjustment of rates and ranking by the predicted to expected ratio, there was a change in quartile rank for 42.8% of hospitals (21 of 49). Two hospitals were identified as outliers. However, if the bottom quartile was identified, as called for by the Hospital Acquired Condition Reduction program, 10 additional hospitals would be targeted for a penalty. Hospitals with < 300 beds were most likely to see their quartile rank worsen, whereas those > 500 beds were most likely to see their quartile rank improve (P = .01).After adjusting for patient-related factors and site variation, more than 40% of hospitals will change quartile rank with respect to deep surgical site infection. Identifying a quartile of hospitals that are statistically different from others was not feasible in our collaborative because only 2 of 12 hospitals were outliers. These findings suggest that under the Hospital Acquired Condition Reduction program, many hospitals will be unjustly penalized.
View details for DOI 10.1016/j.ajog.2015.10.002
View details for Web of Science ID 000369518200014
View details for PubMedID 26475423
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Rates of colpopexy and colporrhaphy at the time of hysterectomy for prolapse
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2016; 214 (2): 262.e1-262.e7
Abstract
It has been shown that addressing apical support at the time of hysterectomy for pelvic organ prolapse (POP) reduces recurrence and reoperation rates. In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP. Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure and hysterectomy alone is often utilized for treatment of prolapse.The objectives of this study were to: (1) determine rates of concomitant procedures for POP in hysterectomies performed with POP as an indication, (2) identify factors associated with performance of a colpopexy at the time of hysterectomy for POP, and (3) identify the influence of surgical complexity on perioperative complication rates.This is a retrospective cohort study of hysterectomies performed for POP from Jan. 1, 2013, through May 7, 2014, in a statewide surgical quality database. Patients were stratified based on procedures performed: hysterectomy alone, hysterectomy with colporrhaphy and without apical suspension, and hysterectomy with colpopexy with or without colporrhaphy. Demographics, medical history and intraoperative care, and perioperative care were compared between the groups. Multivariable logistic regression models were created to identify factors independently associated with use of colpopexy and factors associated with increased rates of postoperative complications.POP was an indication in 1557 hysterectomies. Most hysterectomies were vaginal (59.6%), followed by laparoscopic or robotic (34.1%), and abdominal (6.2%). Hysterectomy alone was performed in 43.1% (95% confidence interval [CI], 40.6-45.6) of cases, 32.8% (95% CI, 30.4-35.1) had a colporrhaphy without colpopexy, and 24.1% (95% CI, 22-26.3) had a colpopexy with or without colporrhaphy. Use of colpopexy was independently associated with patient age >40 years, POP as the only indication for surgery (odd ratio [OR], 1.6; 95% CI, 1.185-2.230), laparoscopic surgery (OR, 3.2; 95% CI, 2.860-5.153), and a surgeon specializing in urogynecology (OR, 8.2; 95% CI, 5.156-12.923). The overall perioperative complication rate was 6.6%, with the majority being considered minor. Complications were more likely when the procedure was performed with an abdominal approach (OR, 2.3; 95% CI, 1.088-4.686), with the use of a colpopexy procedure (OR, 3.1; 95% CI, 1.840-5.194), and by a surgeon specializing in urogynecology (OR, 2.2; 95% CI, 1.144-4.315).Colpopexy and colporrhaphy may be underutilized and are potential targets for quality improvement. Performance of additional procedures at the time of hysterectomy increased the rate of perioperative complications. Long-term consequences of these surgical practices deserve additional study.
View details for DOI 10.1016/j.ajog.2015.08.053
View details for Web of Science ID 000369518200016
View details for PubMedID 26366666
View details for PubMedCentralID PMC4744488
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Practice patterns and postoperative complications before and after US Food and Drug Administration safety communication on power morcellation
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY
2016; 214 (1): 98.e1-98.e13
Abstract
In April 2014, the US Food and Drug Administration (FDA) published its first safety communication discouraging "the use of laparoscopic power morcellation during hysterectomy or myomectomy for the treatment of women with uterine fibroids." Due to the concern of worsening outcomes for patients with occult uterine malignancy, specifically uterine leiomyosarcoma, the FDA recommended a significant change to existing surgical planning, patient consent, and surgical technique in the United States.We sought to report temporal trends in surgical approach to hysterectomy and postoperative complications before and after the April 17, 2014, FDA safety communication concerning the use of power morcellation during myomectomy or hysterectomy.A retrospective cohort study was performed with patients undergoing hysterectomy for benign indications in the Michigan Surgical Quality Collaborative from Jan. 1, 2013, through Dec. 31, 2014. The rates of abdominal, laparoscopic, and vaginal hysterectomy, as well as the rates of major postoperative complications and 30-day hospital readmissions and reoperations, were compared before and after April 17, 2014, the date of the original FDA safety communication. Major postoperative complications included blood transfusions, vaginal cuff infection, vaginal cuff dehiscence, ureteral obstruction, vesicovaginal fistula, deep and organ space surgical site infection, acute renal failure, respiratory failure, sepsis, pulmonary embolism, deep vein thrombosis requiring therapy, cerebral vascular accident, cardiac arrest, and death. We calculated the median episode cost related to hysterectomy readmissions using Michigan Value Collaborative data. Analyses were performed using robust multivariable multinomial and logistic regression models.There were 18,299 hysterectomies available for analysis during the study period. In all, 2753 cases were excluded due to an indication for cancer, cervical dysplasia, or endometrial hyperplasia, and 174 cases were excluded due to missing covariate data. Compared to the 15 months preceding the FDA safety communication, in the 8 months afterward, utilization of laparoscopic hysterectomies decreased by 4.1% (P = .005) and both abdominal and vaginal hysterectomies increased (1.7%, P = .112 and 2.4%, P = .012, respectively). Major surgical complications not including blood transfusions significantly increased after the date of the FDA safety communication, from 2.2-2.8% (P = .015), and the rate of hospital readmission within 30 days also increased from 3.4-4.2% (P = .025). The rate of all major surgical complications or hospital reoperations did not change significantly after the date of the FDA communication (P = .177 and P = .593, respectively). The median risk-adjusted total episode cost for readmissions was $5847 (interquartile range $5478-10,389).Following the April 2014 FDA safety communication regarding power morcellation, utilization of minimally invasive hysterectomy decreased, and major surgical, nontransfusion complications and 30-day hospital readmissions increased.
View details for DOI 10.1016/j.ajog.2015.08.047
View details for Web of Science ID 000367093000014
View details for PubMedID 26314519
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Analysis of High-, Intermediate-, and Low-Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse
FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY
2016; 22 (1): 43-50
Abstract
To determine if surgeon volume is associated with differences in the use of apical colpopexy and cystoscopy and in the rate of intraoperative complications during hysterectomy for prolapse.We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008, and December 31, 2011. Low (≤10 cases)-, intermediate (11-49 cases)-, and high (≥50 cases)-volume surgeon groups for the 4-year period were established a priori. Rates of concomitant colpopexy, cystoscopy, and intraoperative complications were determined by chart review for 15% of the cases. Multivariate logistic regression models adjusted for site and other clinical and patient variables were used to estimate associations between surgeon case volume and the use of apical colpopexy and cystoscopy and the rate of intraoperative complications.Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Six hundred thirty-eight patients were selected for chart review. The rates among high-, intermediate-, and low-volume surgeons for performing colpopexy were 85.2% versus 77.8% versus 61.1% (P < 0.001) and for cystoscopy were 96.8% versus 78.3% versus 74.7% (P < 0.001), respectively. Rates of intraoperative complications among the 3 groups were 4.4%, 11.6%, and 6.3% (P = 0.011), respectively. With adjustment, high-volume surgeons were more likely to do a colpopexy than low-volume surgeons (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.1); however, the likelihood of colpopexy did not differ between high- and intermediate-volume surgeons (OR, 1.9; 95% CI, 0.84-4.3) or between intermediate- and low-volume surgeons (OR, 0.99; 95% CI, 0.50-2.0). High-volume surgeons were more likely than intermediate-volume (OR, 4.4; 95% CI, 1.7-11.0) and low-volume (OR, 4.5; 95% CI, 2.6-8.0) surgeons to do a cystoscopy. High-volume (OR, 0.42; 95% CI, 0.30-0.61) and low-volume (OR, 0.32; 95% CI, 0.15-0.66) surgeons were less likely than intermediate-volume surgeons to have intraoperative complications. The difference between high- and low-volume surgeons was not statistically significant (OR, 0.77; 95% CI, 0.5-1.2).Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. The finding that intermediate-volume surgeons have the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and avoidance of injury.
View details for DOI 10.1097/SPV.0000000000000214
View details for Web of Science ID 000367554400010
View details for PubMedID 26516812
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Risk Factors for Venous Thromboembolism After Hysterectomy
OBSTETRICS AND GYNECOLOGY
2015; 125 (5): 1139-1144
Abstract
To assess the prevalence of and risk factors for venous thromboembolism after hysterectomy.This is a retrospective analysis of data from a voluntary, statewide surgical quality improvement collaborative. Demographics and perioperative data were obtained for hysterectomies performed from January 1, 2008, to April 4, 2014. Postoperative venous thromboembolism was defined as a deep vein thrombosis, pulmonary embolism, or both diagnosed within 30 days of hysterectomy. Significant variables related to postoperative venous thromboembolism were identified using bivariate analyses, and then logistic mixed modeling was used to develop a final model for venous thromboembolism.The rate of postoperative venous thromboembolism was 0.5% (110/20,496). Women who had a postoperative venous thromboembolism more frequently had a body mass index 35 or greater (40.0% compared with 25.2%, odds ratio [OR] 1.96, 95% confidence interval [CI] 1.08-3.56, P=.03), abdominal hysterectomy (referent nonabdominal hysterectomy; 61.8% compared with 29.9%, OR 2.67, 95% CI 1.46-4.86, P=.001), and gynecologic cancer as the indication for surgery (16.4% compared with 9.6%, OR 2.49, 95% CI 1.22-5.07, P=.01). Increasing surgical time (hours; referent 1 hour; OR 1.55, 95% CI 1.31-1.84, P<.001) was also an associated factor. In bivariate analyses, women with, compared with without, venous thromboembolism more frequently received both preoperative and postoperative heparin (31.9% compared with 15.2%, P<.001 and 55.9% compared with 33.5%, P<.001, respectively), but this did not remain significant in the final model.Body mass index 35 or greater, abdominal hysterectomy, increasing surgical time, and cancer as the indication for surgery are risk factors for venous thromboembolism after hysterectomy.III.
View details for DOI 10.1097/AOG.0000000000000822
View details for Web of Science ID 000354965200020
View details for PubMedID 25932841
View details for PubMedCentralID PMC4418022