The role of Medicaid home- and community-based services in use of Medicare post-acute care.

OBJECTIVE: Medicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled. DATA SOURCES: National Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018. STUDY DESIGN: We estimated the relationship between prior Medicaid HCBS use and PAC (skilled nursing facilities [SNF] or home health) utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups. DATA EXTRACTION METHODS: The primary sample included 887,598 hospital discharges from community-dwelling duals who had an eligible index hospitalization between April 1, 2016, and September 30, 2018. PRINCIPAL FINDINGS: We found HCBS use was associated with a 9 percentage-point increase in the use of home health relative to SNF, conditional on using PAC, and a meaningful reduction in length of stay for those using SNF. In addition, in our primary sample, we found HCBS use to be associated with an overall increase in PAC use, given that the absolute increase in home health use was larger than the absolute decrease in SNF use. In other words, the use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings. CONCLUSION: Our findings indicate potential synergies between Medicaid-funded HCBS and increased use of home-based PAC, suggesting policymakers should cautiously consider these dynamics in HCBS expansion efforts.

Association Between Acute Exposure to Crime and Individual Systolic Blood Pressure.

INTRODUCTION: Hypertension is associated with adverse cardiovascular outcomes and is geographically concentrated in urban underserved neighborhoods. This study examines the temporal-spatial association between individual exposure to violent crime and blood pressure. METHODS: A retrospective observational cohort study analyzed 39,211 patients with 227,595 blood pressure measurements from 2014 to 2016 at 3 outpatient clinics at an academic medical center in Chicago. Patients were included in the study if they had documentation of blood pressure in the medical record and resided in census tracts with >1,000 observations. Geocoded violent crime events were obtained from the Chicago Police Department. Individual-level exposure was defined on the basis of spatial and temporal buffers around each patient's home. Spatial buffers included 100-, 250-, 500-, and 1,000-meter disc radii, and temporal buffers included 7, 30, and 60 days preceding each outpatient appointment. Systolic blood pressure measurements (mmHg) were abstracted from the electronic health record. Analysis was performed in 2019-2020. RESULTS: For each violent crime event within 100 meters from home, systolic blood pressure increased by 0.14 mmHg within 7 days of exposure compared with 0.08 mmHg at 30 days of exposure. In analyses stratified by neighborhood cluster, systolic blood pressure increased by 0.37 mmHg among patients in the suburban affluent cluster relative to that among those in an extreme poverty cluster for the same spatial and temporal buffer. CONCLUSIONS: Exposure to a violent crime event was associated with increased blood pressure, with gradient effects by both distance and time from exposure.

A retrospective analysis of high sensitivity cardiac troponin-T ranges in non-myocardial infarction emergency department visits.

INTRODUCTION: Current evidence suggests that high sensitivity cardiac troponin-T (hs-cTnT) values differ based on sex, race, age, and kidney function. However, most studies examining the relationship of hs-cTnT and these individual factors are in healthy participants, leading to difficulty in interpreting hs-cTnT values in the Emergency Department (ED) setting. We seek to examine the relationship between hs-cTnT values and sex, race, age, and kidney function in a contemporary, urban academic setting. METHODS: ED visits from June 2018 through April 2019 with at least 1 hs-cTnT and no diagnosis of acute myocardial infarction (AMI) at an academic medical center in the south side of Chicago were retrospectively analyzed. Median hs-cTnT values were stratified by sex (male or female), race (African American or Caucasian), age, estimated glomerular filtration rate (eGFR), and stage of chronic kidney disease. RESULTS: 9679 encounters, representing 7989 distinct patients, were included for analysis (age 58 ± 18 years, 59% female, 85% black). Males had significantly higher median hs-cTnT values than females (16 [8-34] vs. 9 [6-22] ng/L, p < 0.001), African Americans had a significantly lower median value than Caucasians (10 [6-24] vs. 15 [6-29] ng/L, p < 0.001), and those with atrial fibrillation (27 [16-48] vs. 9 [6-19] ng/L, p < 0.001) and heart failure (28 [14-48] vs. 8 [6-15] ng/L, p < 0.001) had higher median values than those without. Median hs-cTnT values increased significantly with increased age and decreased eGFR. All relationships continued to be significant even after multivariable regression of sex, age, race, eGFR, presence of atrial fibrillation, and presence of heart failure (p < 0.01). CONCLUSIONS: Analysis of hs-cTnT in non-AMI patients during ED encounters showed that males have higher values than females, African Americans have lower values than Caucasians, those with atrial fibrillation and heart failure have higher values than those without, and that older age and lower eGFR were associated with higher median values.

Social determinants of health and hospital readmissions: can the HOSPITAL risk score be improved by the inclusion of social factors?

BACKGROUND: The HOSPITAL Risk Score (HRS) predicts 30-day hospital readmissions and is internationally validated. Social determinants of health (SDOH) such as low socioeconomic status (SES) affect health outcomes and have been postulated to affect readmission rates. We hypothesized that adding SDOH to the HRS could improve its predictive accuracy. METHODS: Records of 37,105 inpatient admissions at the University of Chicago Medical Center were reviewed. HRS was calculated for each patient. Census tract-level SDOH then were combined with the HRS and the performance of the resultant "Social HRS" was compared against the HRS. Patients then were assigned to 1 of 7 typologies defined by their SDOH and a balanced dataset of 14,235 admissions was sampled from the larger dataset to avoid over-representation by any 1 sociodemographic group. Principal component analysis and multivariable linear regression then were performed to determine the effect of SDOH on the HRS. RESULTS: The c-statistic for the HRS predicting 30-day readmission was 0.74, consistent with published values. However, the addition of SDOH to the HRS did not improve the c-statistic (0.71). Patients with unfavorable SDOH (no high-school, limited English, crowded housing, disabilities, and age > 65 yrs) had significantly higher HRS (p < 0.05 for all). Overall, SDOH explained 0.2% of the HRS. CONCLUSION: At an urban tertiary care center, the addition of census tract-level SDOH to the HRS did not improve its predictive power. Rather, the effects of SDOH are already reflected in the HRS.

SALAD-BAAR: A numerical risk score for hospital admission or emergency department presentation in ambulatory patients with cardiovascular disease.

BACKGROUND: While many interventions to reduce hospital admissions and emergency department (ED) visits for patients with cardiovascular disease have been developed, identifying ambulatory cardiac patients at high risk for admission can be challenging. HYPOTHESIS: A computational model based on readily accessible clinical data can identify patients at risk for admission. METHODS: Electronic health record (EHR) data from a tertiary referral center were used to generate decision tree and logistic regression models. International Classification of Disease (ICD) codes, labs, admissions, medications, vital signs, and socioenvironmental variables were used to model risk for ED presentation or hospital admission within 90 days following a cardiology clinic visit. Model training and testing were performed with a 70:30 data split. The final model was then prospectively validated. RESULTS: A total of 9326 patients and 46 465 clinic visits were analyzed. A decision tree model using 75 patient characteristics achieved an area under the curve (AUC) of 0.75 and a logistic regression model achieved an AUC of 0.73. A simplified 9-feature model based on logistic regression odds ratios achieved an AUC of 0.72. A further simplified numerical score assigning 1 or 2 points to each variable achieved an AUC of 0.66, specificity of 0.75, and sensitivity of 0.58. Prospectively, this final model maintained its predictive performance (AUC 0.63-0.60). CONCLUSION: Nine patient characteristics from routine EHR data can be used to inform a highly specific model for hospital admission or ED presentation in cardiac patients. This model can be simplified to a risk score that is easily calculated and retains predictive performance.

Community Health Workers Reduce Rehospitalizations and Emergency Department Visits for Low-Socioeconomic Urban Patients With Heart Failure.

BACKGROUND: Low-socioeconomic, urban, minority patients with heart failure (HF) often have unique barriers to care. Community health workers (CHWs) are specially trained laypeople who serve as liaisons between underserved communities and the health system. It is not known whether CHWs improve outcomes in low-socioeconomic, urban, minority patients with HF. HYPOTHESIS: CHWs reduce rehospitalizations, emergency department (ED) visits, and healthcare costs for low-socioeconomic urban patients with HF. METHODS: Patients admitted with acute decompensated HF were assigned to receive weekly visits by CHW after discharge. Patients were propensity score matched with controls who received usual care. HF-related rehospitalizations, ED visits, and inpatient costs were compared for 12 months following index admission versus the same period before. RESULTS: Twenty-eight patients who received weekly visits from a CHW for 12 months after discharge were matched with 28 control patients who did not receive CHWs. Patients who received a CHW had a 75% decrease in HF-related ED visits (0.71 vs. 0.18 visits per patient, P < 0.001), an 89% decrease in HF-related readmissions (0.64 vs. 0.07 admissions per patient, P < 0.005), and a significant decrease in inpatient cost for HF-related visits. In controls receiving usual care, there was no significant change in hospitalizations, ED visits, or costs. CONCLUSIONS: In conclusion, CHWs are associated with reduced rehospitalizations, ED visits, and inpatient costs in low-socioeconomic, urban, minority patients with HF. CHWs may be a cost-effective method to reduce health care utilization and improve outcomes for this population.

Association of Rising Violent Crime With Blood Pressure and Cardiovascular Risk: Longitudinal Evidence From Chicago, 2014-2016.

BACKGROUND: The purpose of this study was to examine the longitudinal association between rising violent crime and elevated blood pressure (BP). METHODS: We analyzed 217,816 BP measurements from 17,783 adults during a temporal surge in violent crime in Chicago (2014-2016). Serial observations were abstracted from the electronic health record at an academic medical center and paired to the City of Chicago Police Data Portal. The violent crime rate (VCR) was calculated as the number of violent crimes per 1,000 population per year for each census tract. Longitudinal multilevel regression models were implemented to assess elevated BP (systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg) as a function of the VCR, adjusting for patient characteristics, neighborhood characteristics, and time effects. Secondary dependent measures included elevated heart rate, obesity, missed outpatient appointments, all-cause hospital admissions, and cardiovascular hospital admissions. RESULTS: At baseline, the median VCR was 41.3 (interquartile range: 15.2-66.8), with a maximum rise in VCR of 59.1 over the 3-year surge period. A 20-unit rise in the VCR was associated with 3% higher adjusted odds of having elevated BP (95% confidence interval [CI]: 1.01-1.06), 8% higher adjusted odds of missing an outpatient appointment (95% CI: 1.03-1.13), and 6% higher adjusted odds of having a cardiovascular-related hospital admission (95% CI: 1.01-1.12); associations were not significant for elevated heart rate and obesity. CONCLUSION: Rising violent crime was associated with increased BP during a temporal crime surge.

Cost-utility of extracorporeal cardiopulmonary resuscitation in patients with cardiac arrest.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) is a resource-intensive tool that provides haemodynamic and respiratory support in patients who have suffered cardiac arrest. In this study, we investigated the cost-utility of ECPR (cost/QALY) in cardiac arrest patients treated at our institution. METHODS: We performed a retrospective review of patients who received ECPR following cardiac arrest between 2012 and 2018. All medical care-associated charges with ECPR and subsequent hospital admission were recorded. The quality-of-life of survivors was assessed with the Health Utilities Index Mark II. The cost-utility of ECPR was calculated with cost and quality-of-life data. RESULTS: ECPR was used in 32 patients (15/32 in-hospital, 47%) with a median age of 55.0 years (IQR 46.3-63.3 years), 59% male and 66% African American. The median duration of ECPR support was 2.1 days (IQR 0.9-3.8 days). Survival to hospital discharge was 16%. The median score of the Health Utilities Index Mark II at discharge for the survivors was 0.44 (IQR 0.32-0.52). The median operating cost for patients undergoing ECMO was $125,683 per patient (IQR $49,751-$206,341 per patient). The calculated cost-utility for ECPR was $56,156/QALY gained. CONCLUSIONS: The calculated cost-utility is within the threshold considered cost-effective in the United States (<$150,000/QALY gained). These results are comparable to the cost-effectiveness of heart transplantation for end-stage heart failure. Larger studies are needed to assess the cost-utility of ECPR and to identify whether other factors, such as patient characteristics, affect the cost-utility benefit.

Molecular Evolution of MDM1, a "Duplication-Resistant" Gene in Vertebrates.

BACKGROUND: The mouse double minute 1 (Mdm1) gene was first reported and cloned in mouse tumor cell lines as an oncogene candidate. Later, it was found that mutation of Mdm1 might cause age-related retinal degeneration 2 in mice by genetic linkage analysis. Additionally, the MDM1 protein was found to be expressed in the centrosomes, cilia, and the nucleus of multiciliated tracheal epithelial cells in mice. These observations suggest that MDM1 may have some basal functions in cell physiology. However, the evolutionary history of this gene and its expression during embryonic development remain largely unexplored. RESULTS: Using molecular phylogenetic analysis, we found that the MDM1 gene encoded an evolutionarily conserved protein across all metazoans. We also found that the MDM1 gene was in a conserved synteny in vertebrates. In almost all the species that were analyzed, there was only one MDM1 gene based on current genome annotations. Since vertebrate genomes underwent two to three rounds of whole-genome duplications around the origin of the vertebrates, it is interesting that only one MDM1 ohnolog was retained. This observation implies that other MDM1 ohnologs were lost after the whole-genome duplications. Furthermore, using whole-mount in situ hybridization, we found that mdm1 was expressed in the forebrain, nephric ducts, and tail buds during zebrafish early embryonic development. CONCLUSION: MDM1 is an evolutionary conserved gene, and its homologous genes can be traced back to basal metazoan lineages. In vertebrates, the MDM1 gene is in a conserved synteny and there is only one MDM1 ohnolog suggesting it is a "duplication-resistant" gene. Its expression patterns in early zebrafish embryos indicate that mdm1 may play important roles in the development of the central nervous system, kidneys, and hematopoietic system.

Evolutionary and developmental analysis reveals KANK genes were co-opted for vertebrate vascular development.

Gene co-option, usually after gene duplication, in the evolution of development is found to contribute to vertebrate morphological innovations, including the endothelium-based vascular system. Recently, a zebrafish kank gene was found expressed in the vascular vessel primordium, suggesting KANK genes are a component of the developmental tool kit for the vertebrate vascular system. However, how the KANK gene family is involved in vascular vessel development during evolution remains largely unknown. First, we analyzed the molecular evolution of the KANK genes in metazoan, and found that KANK1, KANK2, KANK3 and KANK4 emerged in the lineage of vertebrate, consistent with the two rounds of vertebrate whole-genome duplications (WGD). Moreover, KANK genes were further duplicated in teleosts through the bony-fish specific WGD, while only kank1 and kank4 duplicates were retained in some of the examined fish species. We also found all zebrafish kank genes, except kank1b, are primarily expressed during embryonic vascular development. Compared to invertebrate KANK gene expression in the central nervous system, the vascular expression of zebrafish kank genes suggested KANK genes were co-opted for vertebrate vascular development. Given the cellular roles of KANK genes, our results suggest that this co-option may facilitate the evolutionary origin of vertebrate vascular vessels.