Place of care in the last three years of life for Medicare beneficiaries.

BACKGROUND: Most older adults prefer aging in place; however, patients with advanced illness often need institutional care. Understanding place of care trajectory patterns may inform patient-centered care planning and health policy decisions. The purpose of this study was to characterize place of care trajectories during the last three years of life. METHODS: Linked administrative, claims, and assessment data were analyzed for a 10% random sample cohort of US Medicare beneficiaries who died in 2018, aged fifty or older, and continuously enrolled in Medicare during their last five years of life. A group-based trajectory modeling approach was used to classify beneficiaries based on the proportion of days of institutional care (hospital inpatient or skilled nursing facility) and skilled home care (home health care and home hospice) used in each quarter of the last three years of life. Associations between group membership and sociodemographic and clinical predictors were evaluated. RESULTS: The analytic cohort included 199,828 Medicare beneficiaries. Nine place of care trajectory groups were identified, which were categorized into three clusters: home, skilled home care, and institutional care. Over half (59%) of the beneficiaries were in the home cluster, spending their last three years mostly at home, with skilled home care and institutional care use concentrated in the final quarter of life. One-quarter (27%) of beneficiaries were in the skilled home care cluster, with heavy use of skilled home health care and home hospice; the remaining 14% were in the institutional cluster, with heavy use of nursing home and inpatient care. Factors associated with both the skilled home care and institutional care clusters were female sex, Black race, a diagnosis of dementia, and Medicaid insurance. Extended use of skilled home care was more prevalent in southern states, and extended institutional care was more prevalent in midwestern states. CONCLUSIONS: This study identified distinct patterns of place of care trajectories that varied in the timing and duration of institutional and skilled home care use during the last three years of life. Clinical, socioregional, and health policy factors influenced where patients received care. Our findings can help to inform personal and societal care planning.

Comparison of concurrent chemoradiotherapy with radiotherapy alone for locally advanced esophageal squamous cell cancer in elderly patients: A randomized, multicenter, phase II clinical trial.

This randomized, multicenter, phase II clinical trial was performed to compare the safety and efficacy of concurrent chemoradiotherapy using S-1 (CCRT) with radiotherapy alone (RT) for elderly patients with locally advanced esophageal squamous cell carcinoma (ESCC). All eligible patients were randomly assigned to the CCRT group or the RT group at a 1:1 ratio. The CCRT group received 50.4 Gy radiotherapy concurrent with S-1 and the RT group received 59.4 Gy radiotherapy alone. The primary endpoints were toxicity and the overall response rate (ORR), and the secondary endpoints were overall survival (OS) and progression-free survival (PFS). In total, 157 elderly patients with ESCC were recruited from December 2016 to March 2020. By June 2021, the median follow-up duration had reached 38 months. No grade 5 toxicities occurred in either group and the overall rate of severe toxicities (≥grade 3) was higher in the CCRT group (19.2% vs 7.6%; P = .037), particularly neutropenia (7.7% vs 1.3%; P = .06). The CCRT group presented a significantly higher ORR (83.3% vs 68.4%; P = .009) and prolonged PFS (25.7 vs 13.9 months; P = .026) than the RT group. The median OS was 27.3 months in the CCRT group and 19.1 months in the RT group (P = .59). For patients older than 70 years with locally advanced ESCC, concurrent chemoradiotherapy with S-1 had tolerable adverse effects and improved ORR and PFS compared to radiotherapy alone.

Identifying quality of life outcome patterns to inform treatment choices in ischemic cardiomyopathy.

BACKGROUND: The Surgical Treatment for Ischemic Heart Failure (STICH) trial found that routine use of coronary artery bypass surgery (CABG) improved mean quality of life (QoL) scores relative to guideline-directed medical therapy (GDMT) in patients with ischemic cardiomyopathy. However, mean differences in QoL scores do not provide what patients want to know when facing a high-risk/high-benefit treatment choice. METHODS: We analyzed Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary scores in CABG and GDMT patients over 36 months using a combination of statistical methods to group QoL data into clinically relevant outcome patterns (phenotype trajectories) and to then identify the main baseline predictors of each phenotype. QoL outcome phenotypes were developed using mixture models to define the dominant phenotype trajectories present in STICH QoL data. Logistic regression models were used to predict each patient's probability of achieving each outcome pattern with each treatment. RESULTS: In STICH, 592 patients underwent CABG and 607 were managed with GDMT. Our analyses identified 3 phenotype trajectory patterns in both treatment groups. Two of the 3 trajectories showed improving patterns, and were classified as "good QoL trajectories," seen in 498 (84.1%) CABG and 449 (73.9%) GDMT patients. Defining a consequential CABG-GDMT treatment difference as a >10% higher absolute predicted probability of belonging to good QoL trajectories, 277 (23.5%) patients were more likely to have good outcome with CABG while 45 (3.8%) patients were more likely to have a good outcome with GDMT. For 644 (54.7%) patients, CABG and GDMT probabilities of a good outcome were within 5% of each other. CONCLUSIONS: The pattern of QoL outcomes after CABG compared with GDMT in STICH followed 3 main phenotypic trajectories, which could be predicted based on individual baseline features. Patient-specific predictions about expected QoL outcomes with different treatment choices provide an intuitive framework for personalizing patient decision making.

Risk factors of esophageal fistula induced by re-radiotherapy for recurrent esophageal cancer with local primary site.

PURPOSE: The purpose of the present study was to investigate risk factors for esophageal fistula (EF) in patients with recurrent esophageal cancer receiving re-radiotherapy with or without chemotherapy. METHODS: We reviewed retrospectively the clinical characters and dosimetric parameters of 96 patients with recurrent esophageal cancer treated with re-radiotherapy in Cancer Hospital Affiliated to Shandong First Medical University between August 2014 and January 2021.Univariate and multivariate logistic regression analyses were provided to determine the risk factors of EF induced by re-radiotherapy. RESULTS: The median time interval between two radiotherapy was 23.35 months (range, 4.30 to 238.10 months). EF occurred in 19 patients (19.79%). In univariate analysis, age, T stage, the biologically equivalent dose in the re-radiotherapy, total biologically equivalent dose, hyperfractionated radiotherapy, ulcerative esophageal cancer, the length of tumor and the maximum thickness of tumor had a correlation with the prevalence of EF. In addition, age (HR = 0.170, 95%CI 0.030-0.951, p = 0.044), T stage (HR = 8.369, 95%CI 1.729-40.522, p = 0.008), ulcerative esophageal cancer (HR = 5.810, 95%CI 1.316-25.650, p = 0.020) and the maximum thickness of tumor (HR = 1.314, 95%CI 1.098-1.572, p = 0.003) were risk factors of EF in multivariate logistic regression analysis. CONCLUSIONS: The incidence of EF was significantly increased in patients with recurrent esophageal cancer who underwent re-radiotherapy. This study revealed that age, T stage, ulcerative esophageal cancer and the maximum thickness of the tumor were risk factors associated with EF. In clinical work, patients with risk factors for EF ought to be highly concerned and individualized treatment plans should be taken to reduce the occurrence of EF.

Clinical and EEG factors associated with antiseizure medication resistance in idiopathic generalized epilepsy.

OBJECTIVE: We sought to determine which combination of clinical and electroencephalography (EEG) characteristics differentiate between an antiseizure medication (ASM)-resistant vs ASM-responsive outcome for patients with idiopathic generalized epilepsy (IGE). METHODS: This was a case-control study of ASM-resistant cases and ASM-responsive controls with IGE treated at five epilepsy centers in the United States and Australia between 2002 and 2018. We recorded clinical characteristics and findings from the first available EEG study for each patient. We then compared characteristics of cases vs controls using multivariable logistic regression to develop a predictive model of ASM-resistant IGE. RESULTS: We identified 118 ASM-resistant cases and 114 ASM-responsive controls with IGE. First, we confirmed our recent finding that catamenial epilepsy is associated with ASM-resistant IGE (odds ratio [OR] 3.53, 95% confidence interval [CI] 1.32-10.41, for all study subjects) after covariate adjustment. Other independent factors seen with ASM resistance include certain seizure-type combinations (absence, myoclonic, and generalized tonic-clonic seizures [OR 7.06, 95% CI 2.55-20.96]; absence and generalized tonic-clonic seizures [OR 4.45, 95% CI 1.84-11.34]), as well as EEG markers of increased generalized spike-wave discharges (GSWs) in sleep (OR 3.43, 95% CI 1.12-11.36 for frequent and OR 7.21, 95% CI 1.50-54.07 for abundant discharges in sleep) and the presence of generalized polyspike trains (GPTs; OR 5.49, 95% CI 1.27-38.69). The discriminative ability of our final multivariable model, as measured by area under the receiver-operating characteristic curve, was 0.80. SIGNIFICANCE: Multiple clinical and EEG characteristics independently predict ASM resistance in IGE. To improve understanding of a patient's prognosis, clinicians could consider asking about specific seizure-type combinations and track whether they experience catamenial epilepsy. Obtaining prolonged EEG studies to record the burden of GSWs in sleep and assessing for the presence of GPTs may provide additional predictive value.

Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey.

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

Endometrial Sampling for Preoperative Diagnosis of Uterine Leiomyosarcoma.

STUDY OBJECTIVES: To examine the effectiveness of endometrial sampling for preoperative detection of uterine leiomyosarcoma in women undergoing hysterectomy, identify factors associated with missed diagnosis, and compare the outcomes of patients who had a preoperative diagnosis with those of patients who had a missed diagnosis. DESIGN: Retrospective cohort study using linked data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry from 2003 to 2015. SETTING: Inpatient and outpatient encounters at civilian hospitals and ambulatory surgery centers in New York State. PATIENTS: Women with uterine leiomyosarcoma who underwent a hysterectomy and a preoperative endometrial sampling within 90 days before the hysterectomy. INTERVENTIONS: Endometrial sampling. MEASUREMENTS AND MAIN RESULTS: A total of 79 patients with uterine leiomyosarcoma met the sample eligibility criteria. Of these patients, 46 (58.2%) were diagnosed preoperatively, and 33 (41.8%) were diagnosed postoperatively. Patients in the 2 groups did not differ significantly in age, race/ethnicity, bleeding symptoms, or comorbidities assessed. In multivariable regression analysis, women who had endometrial sampling performed with hysteroscopy (compared with women who had endeometrial sampling performed without hysteroscopy) had a higher likelihood of preoperative diagnosis (adjusted risk ratio [aRR] 3.03; 95% confidence interval [CI], 1.43-6.42). Patients with localized stage (vs distant stage) or tumor size >11 cm (vs <8 cm) were less likely to be diagnosed preoperatively (aRR 0.50; 95% CI, 0.28-0.89, and aRR 0.54; 95% CI, 0.30-0.99, respectively). Supracervical hysterectomy was not performed in any of the patients whose leiomyosarcoma was diagnosed preoperatively compared with 21.2% of the patients who were diagnosed postoperatively (p = .002). CONCLUSION: Endometrial sampling detected leiomyosarcoma preoperatively in 58.2% of the patients. The use of hysteroscopy with endometrial sampling improved preoperative detection of leiomyosarcoma by threefold. Patients with a missed diagnosis had a higher risk of undergoing suboptimal surgical management at the time of their index surgery.

Psychometric Evaluation of the Patient-Nurse Trust Scale among Sexual and Gender Minorities.

PURPOSE: To assess the psychometric properties of a newly developed instrument patient-nurse trust scale (PNTS) among sexual and gender minorities (SGM). DESIGN: Secondary data analysis. METHODS: Reliability and construct validity of the PNTS were assessed. FINDINGS: The PNTS showed high internal consistency (Cronbach's alpha= 0.96). It also demonstrated a good fit to the data and confirmed construct validity. CONCLUSIONS: PNTS is a reliable and valid instrument to measure trust in the nurse-patient relationship with SGM youth. CLINICAL EVIDENCE: PNTS is a valid and reliable tool that quantifies patient-nurse trust relationship and can predict patient satisfaction, health behaviors and health outcomes.

Timing of Antiretroviral Therapy Initiation and Risk of Cancer Among Persons Living With Human Immunodeficiency Virus.

BACKGROUND: Persons living with human immunodeficiency virus (HIV; PLWH) experience a high burden of cancer. It remains unknown which cancer types are reduced in PLWH with earlier initiation of antiretroviral therapy (ART). METHODS: We evaluated AIDS-free, ART-naive PLWH during 1996-2014 from 22 cohorts participating in the North American AIDS Cohort Collaboration on Research and Design. PLWH were followed from first observed CD4 of 350-500 cells/µL (baseline) until incident cancer, death, lost-to-follow-up, or December 2014. Outcomes included 6 cancer groups and 5 individual cancers that were confirmed by chart review or cancer registry linkage. We evaluated the effect of earlier (in the first 6 months after baseline) versus deferred ART initiation on cancer risk. Marginal structural models were used with inverse probability weighting to account for time-dependent confounding and informative right-censoring, with weights informed by subject's age, sex, cohort, baseline year, race/ethnicity, HIV transmission risk, smoking, viral hepatitis, CD4, and AIDS diagnoses. RESULTS: Protective results for earlier ART were found for any cancer (adjusted hazard ratio [HR] 0.57; 95% confidence interval [CI], .37-.86), AIDS-defining cancers (HR 0.23; 95% CI, .11-.49), any virus-related cancer (HR 0.30; 95% CI, .16-.54), Kaposi sarcoma (HR 0.25; 95% CI, .10-.61), and non-Hodgkin lymphoma (HR 0.22; 95% CI, .06-.73). By 15 years, there was also an observed reduced risk with earlier ART for virus-related NADCs (0.6% vs 2.3%; adjusted risk difference -1.6; 95% CI, -2.8, -.5). CONCLUSIONS: Earlier ART initiation has potential to reduce the burden of virus-related cancers in PLWH but not non-AIDS-defining cancers (NADCs) without known or suspected viral etiology.

Hospital variation in responses to safety warnings about power morcellation in hysterectomy.

BACKGROUND: Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes. OBJECTIVE: This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy. STUDY DESIGN: This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions. RESULTS: Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72). CONCLUSION: Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.

Latent class mediator for multiple indicators of mediation.

This paper demonstrates the utility of latent classes in evaluating the effect of an intervention on an outcome through multiple indicators of mediation. These indicators are observed intermediate variables that identify an underlying latent class mediator, with each class representing a different mediating pathway. The use of a latent class mediator allows us to avoid modeling the complex interactions between the multiple indicators and ensures the decomposition of the total mediating effects into additive effects from individual mediating pathways, a desirable feature for evaluating multiple indicators of mediation. This method is suitable when the goal is to estimate the total mediating effects that can be decomposed into the additive effects of distinct mediating pathways. Each indicator may be involved in multiple mediation pathways and at the same time multiple indicators may contribute to a single mediating pathway. The relative importance of each pathway may vary across subjects. We applied this method to the analysis of the first 6 months of data from a 2-year clustered randomized trial for adults in their first episode of schizophrenia. Four indicators of mediation are considered: individual resiliency training; family psychoeducation; supported education and employment; and a structural assessment for medication. The improvement in symptoms was found to be mediated by the latent class mediator derived from these four service indicators. Simulation studies were conducted to assess the performance of the proposed model and showed that the simultaneous estimation through the maximum likelihood yielded little bias when the entropy of the indicators was high.

Association of Immunosuppression and Human Immunodeficiency Virus (HIV) Viremia With Anal Cancer Risk in Persons Living With HIV in the United States and Canada.

BACKGROUND: People living with human immunodeficiency virus (HIV; PLWH) have a markedly elevated anal cancer risk, largely due to loss of immunoregulatory control of oncogenic human papillomavirus infection. To better understand anal cancer development and prevention, we determined whether recent, past, cumulative, or nadir/peak CD4+ T-cell count (CD4) and/or HIV-1 RNA level (HIV RNA) best predict anal cancer risk. METHODS: We studied 102 777 PLWH during 1996-2014 from 21 cohorts participating in the North American AIDS Cohort Collaboration on Research and Design. Using demographics-adjusted, cohort-stratified Cox models, we assessed associations between anal cancer risk and various time-updated CD4 and HIV RNA measures, including cumulative and nadir/peak measures during prespecified moving time windows. We compared models using the Akaike information criterion. RESULTS: Cumulative and nadir/peak CD4 or HIV RNA measures from approximately 8.5 to 4.5 years in the past were generally better predictors for anal cancer risk than their corresponding more recent measures. However, the best model included CD4 nadir (ie, the lowest CD4) from approximately 8.5 years to 6 months in the past (hazard ratio [HR] for <50 vs ≥500 cells/µL, 13.4; 95% confidence interval [CI], 3.5-51.0) and proportion of time CD4 <200 cells/µL from approximately 8.5 to 4.5 years in the past (a cumulative measure; HR for 100% vs 0%, 3.1; 95% CI, 1.5-6.6). CONCLUSIONS: Our results are consistent with anal cancer promotion by severe, prolonged HIV-induced immunosuppression. Nadir and cumulative CD4 may represent useful markers for identifying PLWH at higher anal cancer risk.

Validity of Race and Ethnicity Codes in Medicare Administrative Data Compared With Gold-standard Self-reported Race Collected During Routine Home Health Care Visits.

BACKGROUND: Misclassification of Medicare beneficiaries' race/ethnicity in administrative data sources is frequently overlooked and a limitation in health disparities research. OBJECTIVE: To compare the validity of 2 race/ethnicity variables found in Medicare administrative data [enrollment database (EDB) and Research Triangle Institute (RTI) race] against a gold-standard source also available in the Medicare data warehouse: the self-reported race/ethnicity variable on the home health Outcome and Assessment Information Set (OASIS). SUBJECTS: Medicare beneficiaries over the age of 18 who received home health care in 2015 (N=4,243,090). MEASURES: Percent agreement, sensitivity, specificity, positive predictive value, and Cohen κ coefficient. RESULTS: The EDB and RTI race variable have high validity for black race and low validity for American Indian/Alaskan Native race. Although the RTI race variable has better validity than the EDB race variable for other races, κ values suggest room for future improvements in classification of whites (0.90), Hispanics (0.87), Asian/Pacific Islanders (0.77), and American Indian/Alaskan Natives (0.44). DISCUSSION: The status quo of using "good-enough for government" race/ethnicity variables contained in Medicare administrative data for minority health disparities research can be improved through the use of self-reported race/ethnicity data, available in the Medicare data warehouse. Health services and policy researchers should critically examine the source of race/ethnicity variables used in minority health and health disparities research. Future work to improve the accuracy of Medicare beneficiaries' race/ethnicity data should incorporate and augment the self-reported race/ethnicity data contained in assessment and survey data, available within the Medicare data warehouse.

Prevalence, characteristics, and risk factors of occult uterine cancer in presumed benign hysterectomy.

BACKGROUND: Occult uterine cancer at the time of benign hysterectomy poses unique challenges in patient care. There is large variability and uncertainty in estimated risk of occult uterine cancer in the literature and prior research often did not differentiate/include all subtypes. OBJECTIVES: To thoroughly examine the prevalence of occult uterine cancer in a large population-based sample of women undergoing hysterectomy for presumed benign indications and to identify associated risk factors. STUDY DESIGN: Using the New York Statewide Planning and Research Cooperative System database, we identified 229,536 adult women who underwent an inpatient or outpatient hysterectomy for benign indications during the period October 1, 2003 to December 31, 2013 at civilian hospitals and ambulatory surgery centers throughout the state. Diagnosis of corpus uteri cancer within 28 days after the index hysterectomy was determined using linked state cancer registry data. We estimated the prevalence of occult uterine cancer (overall and by subtype) and developed and validated risk prediction models using a random split sample approach. RESULTS: Overall, 0.96% (95% confidence interval: 0.92-1.00%) of the women had occult uterine cancer, including 0.75% (95% confidence interval: 0.71-0.78%) with endometrial carcinoma and 0.22% (95% confidence interval: 0.20-0.23%) with uterine sarcoma. The prevalence of leiomyosarcoma was 0.15% (95% confidence interval: 0.13-0.17%). Seventy-one percent of the endometrial carcinomas and 58.0% of the uterine sarcomas were at localized stage. The risk for occult uterine cancer ranged from 0.10% in women aged 18-29 years to 4.40% in women aged ≥75 years; and varied from 0.14% in women undergoing hysterectomy for endometriosis to 0.62% for uterine fibroids and 8.43% for postmenopausal bleeding. The risk of occult uterine cancer was also significantly associated with race/ethnicity, obesity, comorbidity, and personal history of malignancy. Prediction models incorporating these risk factors had high negative predictive values (99.8% for endometrial carcinoma and 99.9% for uterine sarcoma) and good rule-out accuracy despite low positive predictive value. CONCLUSIONS: In women undergoing hysterectomy for presumed benign indications, 0.96% had unexpected uterine cancer. Patient characteristics such as age, surgical indication, and medical history may help guide risk stratification.

Hospital variation in utilization and success of trial of labor after a prior cesarean.

BACKGROUND: Trial of labor after cesarean delivery is an effective and safe option for women without contraindications. OBJECTIVES: The objective of the study was to examine hospital variation in utilization and success of trial of labor after cesarean delivery and identify associated institutional characteristics and patient outcomes. STUDY DESIGN: Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with 1 prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized utilization and success rates of trial of labor after cesarean delivery were estimated for each hospital after accounting for differences in patient case mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of trial of labor after cesarean delivery and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' utilization and success rates of trial of labor after cesarean delivery. RESULTS: In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals, with a median of 35.2% (10th to 90th percentile range: 10.2-67.1%) and 40.5% (10th to 90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of trial of labor after cesarean delivery demonstrated an inverted U-shaped relationship such that low or excessively high use of trial of labor after cesarean delivery was associated with lower success rate. Compared with other births, those delivered at hospitals with above-the-median utilization and success rates of trial of labor after cesarean delivery had a higher risk for uterine rupture (adjusted risk ratio, 2.74, P < .001), severe newborn respiratory complications (adjusted risk ratio, 1.46, P < .001), and severe newborn neurological complications/trauma (adjusted risk ratio, 2.48, P < .001), but they had a lower risk for severe newborn infection (adjusted risk ratio, 0.80, P = .003) and overall severe unexpected newborn complications (adjusted risk ratio, 0.86, P < .001) as well as shorter length of stays (adjusted mean ratio, 0.948 for mothers and 0.924 for newborns, P < .001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of trial of labor after cesarean delivery. However, rural location and higher local malpractice insurance premium were negatively associated with the utilization of trial of labor after cesarean delivery, whereas for-profit ownership was associated with lower success rate. CONCLUSION: Utilization and success rates of trial of labor after cesarean delivery varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (eg, increase availability of trial of labor after cesarean delivery at hospitals with low utilization rates while being more selective at hospitals with high utilization rates, and targeted support for lower capacity hospitals).

Optimal maternal and neonatal outcomes and associated hospital characteristics.

BACKGROUND: This study aims to examine hospital variation in both maternal and neonatal morbidities and identify institutional characteristics associated with hospital performance in a combined measure of maternal and neonatal outcomes. METHODS: Using the California Linked Birth File containing data from birth certificate and hospital discharge records, we identified 1 322 713 term births delivered at 248 hospitals during 2010-2012. For each hospital, a risk-standardized rate of severe maternal morbidities and a risk-standardized rate of severe newborn morbidities were calculated after adjusting for patient clinical risk factors. Hospitals were ranked based on combined information on their maternal and newborn morbidity rates. RESULTS: Risk-standardized severe maternal and severe newborn morbidity rates varied substantially across hospitals (10th to 90th percentile range = 67.5-148.2 and 141.8-508.0 per 10 000 term births, respectively), although there was no significant association between the two (P = 0.15). Government hospitals (non-Federal) were more likely than other hospitals to be in worse rank quartiles (P value for trend = 0.004), whereas larger volume was associated with better rank among hospitals in the first three quartiles (P = 0.004). The most prevalent morbidities that differed progressively across hospital rank quartiles were severe hemorrhage, disseminated intravascular coagulation, and heart failure during procedure/surgery for mothers, and severe infection, respiratory complication, and shock/resuscitation for neonates. CONCLUSIONS: Hospitals with low maternal morbidity rates may not have low neonatal morbidity rates and vice versa, highlighting the importance of assessing joint maternal-newborn outcomes in order to fully characterize a hospital's obstetrical performance. Hospitals with smaller volume and government ownership tend to have less desirable outcomes and warrant additional attention in future quality improvement efforts.

Perceived Stress After Acute Myocardial Infarction: A Comparison Between Young and Middle-Aged Women Versus Men.

OBJECTIVE: The aim of the study was to examine how psychological stress changes over time in young and middle-aged patients after experiencing an acute myocardial infarction (AMI) and whether these changes differ between men and women. METHODS: We analyzed data obtained from 2358 women and 1151 men aged 18 to 55 years hospitalized for AMI. Psychological stress was measured using the 14-item Perceived Stress Scale (PSS-14) at initial hospitalization and at 1 month and 12 months after AMI. We used linear mixed-effects models to examine changes in PSS-14 scores over time and sex differences in these changes, while adjusting for patient characteristics and accounting for correlation among repeated observations within patients. RESULTS: Overall, patients' perceived stress decreased over time, especially during the first month after AMI. Women had higher levels of perceived stress than men throughout the 12-month period (difference in PSS-14 score = 3.63, 95% confidence interval = 3.08 to 4.18, p < .001), but they did not differ in how stress changed over time. Adjustment for patient characteristics did not alter the overall pattern of sex difference in changes of perceived stress over time other than attenuating the magnitude of sex difference in PSS-14 score (difference between women and men = 1.74, 95% confidence interval = 1.32 to 2.16, p < .001). The magnitude of sex differences in perceived stress was similar in patients with versus without post-AMI angina, even though patients with angina experienced less improvement in PSS-14 score than those without angina. CONCLUSIONS: In young and middle-aged patients with AMI, women reported higher levels of perceived stress than men throughout the first 12 months of recovery. However, women and men had a similar pattern in how perceived stress changed over time.

Associations between Deceased-Donor Urine Injury Biomarkers and Kidney Transplant Outcomes.

Assessment of deceased-donor organ quality is integral to transplant allocation practices, but tools to more precisely measure donor kidney injury and better predict outcomes are needed. In this study, we assessed associations between injury biomarkers in deceased-donor urine and the following outcomes: donor AKI (stage 2 or greater), recipient delayed graft function (defined as dialysis in first week post-transplant), and recipient 6-month eGFR. We measured urinary concentrations of microalbumin, neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), IL-18, and liver-type fatty acid binding protein (L-FABP) from 1304 deceased donors at organ procurement, among whom 112 (9%) had AKI. Each biomarker strongly associated with AKI in adjusted analyses. Among 2441 kidney transplant recipients, 31% experienced delayed graft function, and mean±SD 6-month eGFR was 55.7±23.5 ml/min per 1.73 m(2) In analyses adjusted for donor and recipient characteristics, higher donor urinary NGAL concentrations associated with recipient delayed graft function (highest versus lowest NGAL tertile relative risk, 1.21; 95% confidence interval, 1.02 to 1.43). Linear regression analyses of 6-month recipient renal function demonstrated that higher urinary NGAL and L-FABP concentrations associated with slightly lower 6-month eGFR only among recipients without delayed graft function. In summary, donor urine injury biomarkers strongly associate with donor AKI but provide limited value in predicting delayed graft function or early allograft function after transplant.

Hospital Phenotypes in the Management of Patients Admitted for Acute Myocardial Infarction.

OBJECTIVES: To characterize hospital phenotypes by their combined utilization pattern of percutaneous coronary interventions (PCI), coronary artery bypass grafting (CABG) procedures, and intensive care unit (ICU) admissions for patients hospitalized for acute myocardial infarction (AMI). RESEARCH DESIGN: Using the Premier Analytical Database, we identified 129,138 hospitalizations for AMI from 246 hospitals with the capacity for performing open-heart surgery during 2010-2013. We calculated year-specific, risk-standardized estimates of PCI procedure rates, CABG procedure rates, and ICU admission rates for each hospital, adjusting for patient clinical characteristics and within-hospital correlation of patients. We used a mixture modeling approach to identify groups of hospitals (ie, hospital phenotypes) that exhibit distinct longitudinal patterns of risk-standardized PCI, CABG, and ICU admission rates. RESULTS: We identified 3 distinct phenotypes among the 246 hospitals: (1) high PCI-low CABG-high ICU admission (39.2% of the hospitals), (2) high PCI-low CABG-low ICU admission (30.5%), and (3) low PCI-high CABG-moderate ICU admission (30.4%). Hospitals in the high PCI-low CABG-high ICU admission phenotype had significantly higher risk-standardized in-hospital costs and 30-day risk-standardized payment yet similar risk-standardized mortality and readmission rates compared with hospitals in the low PCI-high CABG-moderate ICU admission phenotype. Hospitals in these phenotypes differed by geographic region. CONCLUSIONS: Hospitals differ in how they manage patients hospitalized for AMI. Their distinctive practice patterns suggest that some hospital phenotypes may be more successful in producing good outcomes at lower cost.

Use of urine biomarker-derived clusters to predict the risk of chronic kidney disease and all-cause mortality in HIV-infected women.

BACKGROUND: Although individual urine biomarkers are associated with chronic kidney disease (CKD) incidence and all-cause mortality in the setting of HIV infection, their combined utility for prediction remains unknown. METHODS: We measured eight urine biomarkers shown previously to be associated with incident CKD and mortality risk among 902 HIV-infected women in the Women's Interagency HIV Study: N-acetyl-ß-d-glucosaminidase (NAG), kidney injury molecule-1 (KIM-1), alpha-1 microglobulin (α1m), interleukin 18, neutrophil gelatinase-associated lipocalin, albumin-to-creatinine ratio, liver fatty acid-binding protein and α-1-acid-glycoprotein. A group-based cluster method classified participants into three distinct clusters using the three most distinguishing biomarkers (NAG, KIM-1 and α1m), independent of the study outcomes. We then evaluated associations of each cluster with incident CKD (estimated glomerular filtration rate <60 mL/min/1.73 m(2) by cystatin C) and all-cause mortality, adjusting for traditional and HIV-related risk factors. RESULTS: Over 8 years of follow-up, 177 CKD events and 128 deaths occurred. The first set of clusters partitioned women into three groups, containing 301 (Cluster 1), 470 (Cluster 2) and 131 (Cluster 3) participants. The rate of CKD incidence was 13, 21 and 50% across the three clusters; mortality rates were 7.3, 13 and 34%. After multivariable adjustment, Cluster 3 remained associated with a nearly 3-fold increased risk of both CKD and mortality, relative to Cluster 1 (both P < 0.001). The addition of the multi-biomarker cluster to the multivariable model improved discrimination for CKD (c-statistic = 0.72-0.76, P = 0.0029), but only modestly for mortality (c = 0.79-0.80, P = 0.099). Clusters derived with all eight markers were no better for discrimination than the three-biomarker clusters. CONCLUSIONS: For predicting incident CKD in HIV-infected women, clusters developed from three urine-based kidney disease biomarkers were as effective as an eight-marker panel in improving risk discrimination.