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This cohort study assesses the association of pain phenotypes and pain multimorbidity with cerebral palsy subtypes among Medicare beneficiaries.
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STUDY OBJECTIVE: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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.
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PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
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COVID-19 , Influenza Humana , Atenção Primária à Saúde , Sistema de Registros , SARS-CoV-2 , Humanos , COVID-19/epidemiologia , Masculino , Feminino , Estados Unidos/epidemiologia , Atenção Primária à Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Influenza Humana/epidemiologia , Adulto , Idoso , Prevalência , Doença Crônica/epidemiologiaRESUMO
INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.
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STUDY DESIGN: 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. SETTING: 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). METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
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Doença de Alzheimer , Demência , Traumatismos da Medula Espinal , Humanos , Traumatismos da Medula Espinal/epidemiologia , Doença de Alzheimer/epidemiologia , Doença de Alzheimer/etiologia , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Longitudinais , Idoso , Estudos de Casos e Controles , Demência/epidemiologia , Demência/etiologia , Estudos Retrospectivos , Incidência , Estudos de Coortes , Fatores de Risco , Idoso de 80 Anos ou mais , Estados Unidos/epidemiologiaRESUMO
Background and objective: 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). Methods: 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. Key findings and limitations: 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). Conclusions and clinical implications: 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. Patient summary: 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.
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Objective: 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. Methods: 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. Results: 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)]. Conclusions: TM, relative to commercial insurance, was associated with lower receipt of preventive care and higher PPH risk among adults with disability.
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OBJECTIVE: To examine trends in end-of-life care services and satisfaction among Veterans undergoing any inpatient surgery. SUMMARY BACKGROUND DATA: 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. METHODS: We performed a retrospective, cross-sectional analysis of Veterans who died within 90 days of undergoing inpatient surgery between 01/2010 and 12/2019. 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 multivariable linear regression model to identify factors associated with the greatest change. RESULTS: Our cohort consisted of 155,250 patients with a mean age of 73.6 years (standard deviation 11.6). Over the study period, rates of palliative care consultation and hospice use increased more than two-fold (28.1% to 61.1% and 18.9% to 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 ACGME accreditation were hospital-level factors associated with the greatest changes. CONCLUSIONS: 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.
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OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
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COVID-19 , Úlcera por Pressão , Adulto , Humanos , Estudos Retrospectivos , Úlcera por Pressão/epidemiologia , Pandemias , Doença Iatrogênica/epidemiologia , COVID-19/epidemiologiaRESUMO
PURPOSE: 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. DESIGN: Retrospective cohort study. SETTING: Optum's Clinformatics® Data Mart Database (2007-2018) of administrative health claims. SUBJECTS: 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. MEASURES: 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. ANALYSIS: 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. RESULTS: 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. CONCLUSION: Findings identify health-promoting resources that may mitigate health disparities in adults aging with disability.
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Pessoas com Deficiência , Humanos , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Pessoas com Deficiência/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto , Doenças Cardiovasculares/epidemiologia , Características de Residência/estatística & dados numéricos , Idoso , Fatores de Risco , Características da Vizinhança/estatística & dados numéricos , Disrafismo Espinal/epidemiologia , Traumatismos da Medula Espinal/epidemiologia , Paralisia Cerebral/epidemiologia , Esclerose Múltipla/epidemiologia , IncidênciaAssuntos
COVID-19 , Doenças Cardiovasculares , Humanos , American Heart Association , SARS-CoV-2 , Sistema de RegistrosRESUMO
OBJECTIVES: 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. DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization registry. PATIENTS: Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020. MEASUREMENTS AND MAIN RESULTS: 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). CONCLUSIONS: 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.
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Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Parada Cardíaca Extra-Hospitalar , Humanos , Adolescente , Adulto , Pessoa de Meia-Idade , Idoso , Estudos Retrospectivos , Parada Cardíaca/terapia , Sistema de Registros , Parada Cardíaca Extra-Hospitalar/terapia , Resultado do TratamentoRESUMO
BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
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Neoplasias da Mama , Mamoplastia , Humanos , Feminino , Mastectomia , Neoplasias da Mama/cirurgia , Neoplasias da Mama/patologia , Estudos Retrospectivos , Estudos de Coortes , Tecido Adiposo/transplante , Transplante AutólogoRESUMO
Importance: 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. Objective: 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. Design, Setting, and Participants: 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. Exposures: Surge in ED visit volumes for children with viral and respiratory illnesses from September 1 through December 31, 2022. Main Outcomes and Measures: 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). Results: A total of 2â¯761â¯361 ED visits across 25 EDs in 2021 and 2022 were included. From September 1 to December 31, 2022, there were 301â¯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. Conclusions and Relevance: 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.
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Serviços Médicos de Emergência , Viroses , Criança , Humanos , Adolescente , Estudos de Coortes , Estudos Retrospectivos , Serviço Hospitalar de Emergência , Tratamento de Emergência , Viroses/epidemiologia , Viroses/terapiaRESUMO
BACKGROUND: 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. OBJECTIVES: 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. METHODS: 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. RESULTS: 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'. CONCLUSION: 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.
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Serviço Hospitalar de Emergência , Hospitalização , Feminino , Humanos , Idoso , Tempo de Internação , Assistência Ambulatorial , Pacientes Internados , Estudos RetrospectivosRESUMO
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.
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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.
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Disparidades nos Níveis de Saúde , Embolia Pulmonar , Feminino , Humanos , Masculino , Negro ou Afro-Americano , Estudos de Coortes , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Estados Unidos/epidemiologia , BrancosRESUMO
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.
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OBJECTIVES: 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). STUDY DESIGN: 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. RESULTS: 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. CONCLUSIONS: 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.
Assuntos
Incontinência Urinária por Estresse , Humanos , Feminino , Avaliação de Resultados em Cuidados de Saúde , Incontinência Urinária por Estresse/cirurgiaRESUMO
INTRODUCTION: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.