Income variability and incident cardiovascular disease in diabetes: a population-based cohort study.

BACKGROUND AND AIMS: Longitudinal change in income is crucial in explaining cardiovascular health inequalities. However, there is limited evidence for cardiovascular disease (CVD) risk associated with income dynamics over time among individuals with type 2 diabetes (T2D). METHODS: Using a nationally representative sample from the Korean National Health Insurance Service database, 1 528 108 adults aged 30-64 with T2D and no history of CVD were included from 2009 to 2012 (mean follow-up of 7.3 years). Using monthly health insurance premium information, income levels were assessed annually for the baseline year and the four preceding years. Income variability was defined as the intraindividual standard deviation of the percent change in income over 5 years. The primary outcome was a composite event of incident fatal and nonfatal CVD (myocardial infarction, heart failure, and stroke) using insurance claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated after adjusting for potential confounders. RESULTS: High-income variability was associated with increased CVD risk (HRhighest vs. lowest quartile 1.25, 95% CI 1.22-1.27; Ptrend < .001). Individuals who experienced an income decline (4 years ago vs. baseline) had increased CVD risk, which was particularly notable when the income decreased to the lowest level (i.e. Medical Aid beneficiaries), regardless of their initial income status. Sustained low income (i.e. lowest income quartile) over 5 years was associated with increased CVD risk (HRn = 5 years vs. n = 0 years 1.38, 95% CI 1.35-1.41; Ptrend < .0001), whereas sustained high income (i.e. highest income quartile) was associated with decreased CVD risk (HRn = 5 years vs. n = 0 years 0.71, 95% CI 0.70-0.72; Ptrend < .0001). Sensitivity analyses, exploring potential mediators, such as lifestyle-related factors and obesity, supported the main results. CONCLUSIONS: Higher income variability, income declines, and sustained low income were associated with increased CVD risk. Our findings highlight the need to better understand the mechanisms by which income dynamics impact CVD risk among individuals with T2D.

Mid- and long-term risk of atrial fibrillation among breast cancer surgery survivors.

BACKGROUND: The risk of incident atrial fibrillation (AF) among breast cancer survivors, especially for younger women, and cancer treatment effects on the association remain unclear. This study aimed to investigate the risk of AF among breast cancer survivors and evaluate the association by age group, length of follow-up, and cancer treatment. METHODS: Using data from the Korean Health Insurance Service database (2010-2017), 113,232 women newly diagnosed with breast cancer (aged ≥ 18 years) without prior AF history who underwent breast cancer surgery were individually matched 1:5 by birth year to a sample female population without cancer (n = 566,160) (mean[SD] follow-up, 5.1[2.1] years). Sub-distribution hazard ratios (sHRs) and 95% confidence intervals (CIs) considering death as a competing risk were estimated, adjusting for sociodemographic factors and cardiovascular/non-cardiovascular comorbidities. RESULTS: BCS had a slightly increased AF risk compared to their cancer-free counterparts (sHR 1.06; 95% CI 1.00-1.13), but the association disappeared over time. Younger BCS (age < 40 years) had more than a 2-fold increase in AF risk (sHR 2.79; 95% CI 1.98-3.94), with the association remaining similar over 5 years of follow-up. The increased risk was not observed among older BCS, especially those aged > 65 years. Use of anthracyclines was associated with increased AF risk among BCS (sHR 1.57; 95% CI 1.28-1.92), which was more robust in younger BCS (sHR 1.94; 95% CI 1.40-2.69 in those aged ≤ 50 years). CONCLUSIONS: Our findings suggest that younger BCS had an elevated risk of incident AF, regardless of the length of follow-up. Use of anthracyclines may be associated with increased mid-to-long-term AF risk among BCS.

Comparison of the characteristics of the population eligible for lung cancer screening under 2013 and population newly eligible under 2021 US Preventive Services Task Force recommendations.

PURPOSE: In 2021, the United States Preventive Services Task Force (USPSTF) revised their 2013 recommendations for lung cancer screening eligibility by lowering the pack-year history from 30+ to 20+ pack-years and the recommended age from 55 to 50 years. Simulation studies suggest that Black persons and females will benefit most from these changes, but it is unclear how the revised USPSTF recommendations will impact geographic, health-related, and other sociodemographic characteristics of those eligible. METHODS: This cross-sectional study employed data from the 2017-2020 Behavioral Risk Factor Surveillance System surveys from 23 states to compare age, gender, race, marital, sexual orientation, education, employment, comorbidity, vaccination, region, and rurality characteristics of the eligible population according to the original 2013 USPSTF recommendations with the revised 2021 USPSTF recommendations using chi-squared tests. This study compared those originally eligible to those newly eligible using the BRFSS raking-dervived weighting variable. RESULTS: There were 30,190 study participants. The results of this study found that eligibility increased by 62.4% due to the revised recommendations. We found that the recommendation changes increased the proportion of eligible females (50.1% vs 44.1%), Black persons (9.2% vs 6.6%), Hispanic persons (4.4% vs 2.7%), persons aged 55-64 (55.8% vs 52.6%), urban-dwellers(88.3% vs 85.9%), unmarried (3.4% vs 2.5%) and never married (10.4% vs 6.6%) persons, as well as non-retirees (76.5% vs 56.1%) Respondents without comorbidities and COPD also increased. CONCLUSION: It is estimated that the revision of the lung cancer screening recommendations decreased eligibility disparities in sex, race, ethnicity, marital status, respiratory comorbidities, and vaccination status. Research will be necessary to estimate whether uptake patterns subsequently follow the expanded eligibility patterns.

Maximizing Readmission Reduction in Colon Cancer Patients.

INTRODUCTION: Multiple studies have identified risk factors for readmission in colon cancer patients. We need to determine which risk factors, when modified, produce the greatest decrease in readmission for patients so that limited resources can be used most effectively by implementing targeted evidence-based performance improvements. We determined the potential impact of various modifiable risk factors on reducing 30-d readmission in colon cancer patients. METHODS: We used a cohort design with the 2012-2020 American College of Surgeons' National Surgical Quality Improvement Program data to track colon cancer patients for 30 d following surgery. Colon cancer patients who received colectomies and were discharged alive were included. Readmission (to the same or another hospital) for any reason within 30 d of the resection was the outcome measure. Modifiable risk factors were the use of minimally invasive surgery (MIS) versus open colectomy, mechanical bowel preparation, preoperative antibiotic use, functional status, smoking, complications (deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke, infections, anastomotic leakage, prolonged postoperative ileus, extensive blood loss, and sepsis), serum albumin, and hematocrit. RESULTS: 111,691 patients with colon cancer were included in the analysis. About half of the patients were male, most were aged 75 or older, and were discharged home. Overall, 11,138 patients (10.0%) were readmitted within 30 d of surgery. In adjusted analysis, the reduction in readmission would be largest by preventing both prolonged ileus and by switching open colectomies to MIS (28.0% relative reduction) followed by preventing anastomotic leaks (6.2% relative reduction). Improving other modifiable risk factors would have a more limited impact. CONCLUSIONS: The focus of readmission reduction should be on preventing prolonged ileus, increasing the use of MIS, and preventing anastomotic leaks.

Racial and skin color mediated disparities in pulse oximetry in infants and young children.

Race-based and skin pigmentation-related inaccuracies in pulse oximetry have recently been highlighted in several large electronic health record-based retrospective cohort studies across diverse patient populations and healthcare settings. Overestimation of oxygen saturation by pulse oximeters, particularly in hypoxic states, is disparately higher in Black compared to other racial groups. Compared to adult literature, pediatric studies are relatively few and mostly reliant on birth certificates or maternal race-based classification of comparison groups. Neonates, infants, and young children are particularly susceptible to the adverse life-long consequences of hypoxia and hyperoxia. Successful neonatal resuscitation, precise monitoring of preterm and term neonates with predominantly lung pathology, screening for congenital heart defects, and critical decisions on home oxygen, ventilator support and medication therapies, are only a few examples of situations that are highly reliant on the accuracy of pulse oximetry. Undetected hypoxia, especially if systematically different in certain racial groups may delay appropriate therapies and may further perpetuate health care disparities. The role of biological factors that may differ between racial groups, particularly skin pigmentation that may contribute to biased pulse oximeter readings needs further evaluation. Developmental and maturational changes in skin physiology and pigmentation, and its interaction with the operating principles of pulse oximetry need further study. Importantly, clinicians should recognize the limitations of pulse oximetry and use additional objective measures of oxygenation (like co-oximetry measured arterial oxygen saturation) where hypoxia is a concern.

Adherence to Extended Venous Thromboembolism Prophylaxis and Outcomes After Complex Gastrointestinal Oncologic Surgery.

BACKGROUND: Clinical guidelines recommend extended venous thromboembolism (VTE) prophylaxis for cancer patients after major gastrointestinal (GI) operations. However, adherence to the guidelines has been low, and the clinical outcomes not well defined. METHODS: This study retrospectively analyzed a random 10 % sample of the 2009-2022 IQVIA LifeLink PharMetrics Plus database, an administrative claims database representative of the commercially insured population of the United States. The study selected cancer patients undergoing major pancreas, liver, gastric, or esophageal surgery. The primary outcomes were 90-day post-discharge VTE and bleeding. RESULTS: The study identified 2296 unique eligible operations. During the index hospitalization, 52 patients (2.2 %) experienced VTE, 74 patients (3.2 %) had postoperative bleeding, and 140 patients (6.1 %) had a hospital stay of at least 28 days. The remaining 2069 operations comprised 833 pancreatectomies, 664 hepatectomies, 295 gastrectomies, and 277 esophagectomies. The median age of the patients was 49 years, and 44 % were female. Extended VTE prophylaxis prescriptions were filled for 176 patients (10.4 % for pancreas, 8.1 % for liver, 5.8 % for gastric cancer, and 6.5 % for esophageal cancer), and the most used agent was enoxaparin (96 % of the patients). After discharge, VTE occurred for 5.2 % and bleeding for 5.2 % of the patients. The findings showed no association of extended VTE prophylaxis with post-discharge VTE (odds ratio [OR], 1.54; 95 % confidence interval [CI], 0.81-2.96) or bleeding (OR, 0.72, 95 % CI, 0.32-1.61). CONCLUSIONS: The majority of the cancer patients undergoing complex GI surgery did not receive extended VTE prophylaxis according to the current guidelines, and their VTE rate was not higher than for the patients who received it.

Factors associated with breast cancer screening services use among women in the United States: An application of the Andersen's Behavioral Model of Health Services Use.

This study applied Andersen's Behavioral Model of Health Services Use to examine predisposing, enabling, and need factors associated with adherence to the United States Preventive Services Task Force (USPSTF) guidelines for breast cancer screening (BCS). Multivariable logistic regression was used to determine factors of BCS services utilization among 5484 women aged 50-74 from the 2019 National Health Interview Survey. Predisposing factors significantly associated with use of BCS services were: being a Black (odds-ratios [OR]:1.49; 95% confidence interval [CI]:1.14-1.95) or a Hispanic woman (OR:2.25; CI:1.62-3.12); being married/partnered (OR:1.32, CI:1.12-1.55); having more than a bachelor's degree (OR: 1.62; CI:1.14-2.30); and living in rural areas (OR:0.72; CI:0.59-0.92). Enabling factors were: poverty level [≤138% federal poverty level (FPL) (OR:0.74; CI:0.56-0.97), >138-250% FPL (OR:0.77; CI:0.61-0.97), and > 250-400% FPL (OR:0.77; CI:0.63-0.94)]; being uninsured (OR:0.29; CI:0.21-0.40); having a usual source of care at a physician office (OR:7.27; CI:4.99-10.57) or other healthcare facilities (OR:4.12; CI:2.68-6.33); and previous breast examination by a healthcare professional (OR:2.10; CI:1.68-2.64). Need factors were: having fair/poor health (OR:0.76; CI:0.59-0.97) and being underweight (OR:0.46; CI:0.30-0.71). Disparities in BCS services utilization by Black and Hispanic women have been reduced. Disparities still exist for uninsured and financially restrained women living in rural areas. Addressing disparities in BCS uptake and improving adherence to USPSTF guidelines may require revamping policies that address disparities in enabling resources, such as health insurance, income, and health care access.

Associations between neighborhood disinvestment and breast cancer outcomes within a populous state registry.

BACKGROUND: Breast cancer (BrCa) outcomes vary by social environmental factors, but the role of built-environment factors is understudied. The authors investigated associations between environmental physical disorder-indicators of residential disrepair and disinvestment-and BrCa tumor prognostic factors (stage at diagnosis, tumor grade, triple-negative [negative for estrogen receptor, progesterone receptor, and HER2 receptor] BrCa) and survival within a large state cancer registry linkage. METHODS: Data on sociodemographic, tumor, and vital status were derived from adult women who had invasive BrCa diagnosed from 2008 to 2017 ascertained from the New Jersey State Cancer Registry. Physical disorder was assessed through virtual neighborhood audits of 23,276 locations across New Jersey, and a personalized measure for the residential address of each woman with BrCa was estimated using universal kriging. Continuous covariates were z scored (mean ± standard deviation [SD], 0 ± 1) to reduce collinearity. Logistic regression models of tumor factors and accelerated failure time models of survival time to BrCa-specific death were built to investigate associations with physical disorder adjusted for covariates (with follow-up through 2019). RESULTS: There were 3637 BrCa-specific deaths among 40,963 women with a median follow-up of 5.3 years. In adjusted models, a 1-SD increase in physical disorder was associated with higher odds of late-stage BrCa (odds ratio, 1.09; 95% confidence interval, 1.02-1.15). Physical disorder was not associated with tumor grade or triple-negative tumors. A 1-SD increase in physical disorder was associated with a 10.5% shorter survival time (95% confidence interval, 6.1%-14.6%) only among women who had early stage BrCa. CONCLUSIONS: Physical disorder is associated with worse tumor prognostic factors and survival among women who have BrCa diagnosed at an early stage.

Understanding Drivers of Coronavirus Disease 2019 (COVID-19) Racial Disparities: A Population-Level Analysis of COVID-19 Testing Among Black and White Populations.

BACKGROUND: Disparities in coronavirus disease 2019 (COVID-19) testing-the pandemic's most critical but limited resource-may be an important but modifiable driver of COVID-19 inequities. METHODS: We analyzed data from the Missouri State Department of Health and Senior Services on all COVID-19 tests conducted in the St Louis and Kansas City regions. We adapted a well-established tool for measuring inequity-the Lorenz curve-to compare COVID-19 testing rates per diagnosed case among Black and White populations. RESULTS: Between 14/3/2020 and 15/9/2020, 606 725 and 328 204 COVID-19 tests were conducted in the St Louis and Kansas City regions, respectively. Over time, Black individuals consistently had approximately half the rate of testing per case than White individuals. In the early period (14/3/2020 to 15/6/2020), zip codes in the lowest quartile of testing rates accounted for only 12.1% and 8.8% of all tests in the St Louis and Kansas City regions, respectively, even though they accounted for 25% of all cases in each region. These zip codes had higher proportions of residents who were Black, without insurance, and with lower median incomes. These disparities were reduced but still persisted during later phases of the pandemic (16/6/2020 to 15/9/2020). Last, even within the same zip code, Black residents had lower rates of tests per case than White residents. CONCLUSIONS: Black populations had consistently lower COVID-19 testing rates per diagnosed case than White populations in 2 Missouri regions. Public health strategies should proactively focus on addressing equity gaps in COVID-19 testing to improve equity of the overall response.

Association between eye-level greenness and lung function in urban Chinese children.

BACKGROUND: Health effects of greenness perceived by residents at eye level has received increasing attention. However, the associations between eye-level greenness and respiratory health are unknown. The aim of the study was to investigate the associations between exposure to eye-level greenness and lung function in children. METHODS: From 2012 to 2013, a total of 6740 school children in seven cities in northeast China were recruited into this cross-sectional study. Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), peak expiratory flow rate (PEF), and maximum mid expiratory flow rate (MMEF) were measured to evaluate lung function and to define lung impairment. Eye-level greenness was extracted from segmented Tencent Map street view images, and a corresponding green view index (GVI) was calculated. Higher GVIs mean more greenness coverage. Mixed-effects logistic regressions were used to estimate the health effects on lung impairment per interquartile range (IQR) increase in GVI. Linear regressions were used to estimate the associations between GVI and lung function. The health effects of ambient air pollutants were also assessed, including particulate matter with an aerodynamic diameter <1.0 µm (PM1), <2.5 µm (PM2.5), <10 µm (PM10) as well as nitrogen dioxide (NO2). RESULTS: An increase of GVI800m was associated with lung impairment in FEV1, FVC, PEF and MMEF, with ORs ranging from 0.68 (95% CI: 0.59, 0.79) to 0.83 (95% CI: 0.74, 0.93). The associations between an IQR increase of GVI800m and FEV1 (48.15 ml, 95% CI: 30.33-65.97 ml), FVC (50.57 ml, 95% CI: 30.65-70.48 ml), PEF (149.59 ml/s, 95% CI: 109.79-189.38 ml/s), and MMEF (61.18 ml/s, 95% CI: 31.07-91.29 ml/s) were significant, and PM1, PM2.5, and PM10 were found to be mediators of this relationship. CONCLUSION: More eye-level greenness was associated with better lung function and reduced impairment. However, eye-level greenness associations with lung function became non-significant once lower particulate matter air pollution exposures were considered.

Increased 30-Day Mortality Risk in Patients With Diabetes Mellitus After Colon Cancer Surgery: A Mediation Analysis.

BACKGROUND: Patients with (versus without) diabetes mellitus who develop colon cancer are at increased risk of dying within 30 days after surgery. OBJECTIVE: The purpose of this study was to identify potential mediators of the effect of diabetes mellitus on all-cause 30-day mortality risk after surgery for colon cancer. DESIGN: A retrospective cohort study was conducted using the 2013-2015 National Surgical Quality Improvement Program data. SETTING: The study was conducted at various hospitals across the United States (from 435 to 603 hospitals). PATIENTS: Patients who underwent resection for colon cancer with or without obstruction based on the National Surgical Quality Improvement Program colectomy module were included. Patients who had ASA physical status classification V or metastatic disease and those who presented emergently were excluded. Patients were classified as "no diabetes," "diabetes not requiring insulin," or "diabetes requiring insulin." Potential reasons for increased risk of dying within 30 days were treatment related, comorbidity, health behaviors, surgical complications, and biomarkers of underlying disease. MAIN OUTCOME MEASURES: We measured all-cause 30-day mortality. RESULTS: Of 26,060 patients, 18.8% (n = 4905) had diabetes mellitus that was treated with insulin (n = 1595) or other antidiabetic agents (n = 3340). Patients with diabetes mellitus had a 1.57 (95% CI, 1.23-1.99) higher unadjusted odds of dying within 30 days versus patients without diabetes mellitus. In the multivariable model, 76.7% of the association between diabetes mellitus and 30-day mortality was explained; patients with diabetes mellitus were equally likely to die within 30 days versus those without diabetes mellitus (OR = 1.05 (95% CI, 0.81-1.35)). Anemia and sepsis explained 33.7% and 15.2% of the effect of diabetes mellitus on 30-day mortality (each p < 0.0001). Treatment-related variables, cardiovascular disease, surgical complications, and biomarkers played limited roles as mediators. LIMITATIONS: The study was limited to larger hospitals, and limited information about duration and type of diabetes mellitus was available. CONCLUSIONS: Better management and prevention of anemia and sepsis among patients with diabetes mellitus may reduce their increased risk of death after colon cancer resection. See Video Abstract at http://links.lww.com/DCR/B140. AUMENTO DEL RIESGO DE MORTALIDAD A 30 DÍAS EN PACIENTES DIABETICOS LUEGO DE CIRUGÍA DE CÁNCER DE COLON: ANÁLISIS DE MEDIACIÓN: Los pacientes con (y sin) diabetes que desarrollan cáncer de colon tienen un mayor riesgo de morir dentro de los 30 días posteriores a la cirugía.Identificar los posibles mediadores del efecto de la diabetes sobre el riesgo de mortalidad dentro los 30 días, por cualquier causa después de cirugía por cáncer de colon.Estudio de cohortes retrospectivo entre 2013-2015 utilizando los datos del Programa Nacional de Mejoría en Calidad Quirúrgica.Entre 435 a 603 hospitales en los Estados Unidos.Se incluyeron aquellos pacientes sometidos a resección por cáncer de colon con o sin obstrucción según el módulo de colectomía Programa Nacional de Mejoría en Calidad Quirúrgica. Se excluyeron los pacientes estadío V de la clasificación de la Sociedad Estadounidense de Anestesiólogos (ASA), aquellos con enfermedad metastásica y aquellos operados de urgencia. Los pacientes se clasificaron como "sin diabetes,' "con diabetes que no requiere insulina" o "con diabetes que requiere insulina.' Las posibles razones para un mayor riesgo de morir dentro de los 30 días estuvieron relacionadas con el tratamiento, la comorbilidad, los comportamientos de salud, las complicaciones quirúrgicas y los biomarcadores de enfermedad.Mortalidad de cualquier orígen dentro los 30 días depués de la cirugía.De 26'060 pacientes, 18.8% (n = 4,905) tenían diabetes tratada con insulina (n = 1,595) u otros agentes antidiabéticos (n = 3,340). Los pacientes con diabetes tenían 1.57 (IC 95%: 1.23-1.99) mayores probabilidades no ajustadas de morir dentro de los 30 días en comparación con los pacientes sin diabetes. En el modelo multivariable, se explicó que el 76,7% de la asociación entre diabetes y mortalidad a los 30 días; los pacientes con diabetes tenían la misma probabilidad de morir dentro de los 30 días que aquellos sin diabetes (OR: 1.05; IC 95%: 0.81-1.35). La anemia y la sepsis explicaron el 33,7% y el 15,2% del efecto de la diabetes en la mortandad a 30 días (p <0,0001). Las variables relacionadas con el tratamiento, las enfermedades cardiovasculares, las complicaciones quirúrgicas y los biomarcadores jugaron un papel limitado como mediadores.Estudio limitado a hospitales más grandes e información limitada sobre la duración y el tipo de diabetes.Una mejor prevención y manejo de la anemia y la sepsis en los pacientes con diabetes puede reducir el mayor riesgo de muerte después de la resección del cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B140.

Spatial predictive properties of built environment characteristics assessed by drop-and-spin virtual neighborhood auditing.

BACKGROUND: Virtual neighborhood audits have been used to visually assess characteristics of the built environment for health research. Few studies have investigated spatial predictive properties of audit item responses patterns, which are important for sampling efficiency and audit item selection. We investigated the spatial properties, with a focus on predictive accuracy, of 31 individual audit items related to built environment in a major Metropolitan region of the Northeast United States. METHODS: Approximately 8000 Google Street View (GSV) scenes were assessed using the CANVAS virtual audit tool. Eleven trained raters audited the 360° view of each GSV scene for 10 sidewalk-, 10 intersection-, and 11 neighborhood physical disorder-related characteristics. Nested semivariograms and regression Kriging were used to investigate the presence and influence of both large- and small-spatial scale relationships as well as the role of rater variability on audit item spatial properties (measurement error, spatial autocorrelation, prediction accuracy). Receiver Operator Curve (ROC) Area Under the Curve (AUC) based on cross-validated spatial models summarized overall predictive accuracy. Correlations between predicted audit item responses and select demographic, economic, and housing characteristics were investigated. RESULTS: Prediction accuracy was better within spatial models of all items accounting for both small-scale and large- spatial scale variation (vs large-scale only), and further improved with additional adjustment for rater in a majority of modeled items. Spatial predictive accuracy was considered 'Excellent' (0.8 ≤ ROC AUC < 0.9) for full models of all but four items. Predictive accuracy was highest and improved the most with rater adjustment for neighborhood physical disorder-related items. The largest gains in predictive accuracy comparing large- + small-scale to large-scale only models were among intersection- and sidewalk-items. Predicted responses to neighborhood physical disorder-related items correlated strongly with one another and were also strongly correlated with racial-ethnic composition, socioeconomic indicators, and residential mobility. CONCLUSIONS: Audits of sidewalk and intersection characteristics exhibit pronounced variability, requiring more spatially dense samples than neighborhood physical disorder audits do for equivalent accuracy. Incorporating rater effects into spatial models improves predictive accuracy especially among neighborhood physical disorder-related items.

Trends in the risk and burden of second primary malignancy among survivors of smoking-related cancers in the United States.

While there are a growing number of cancer survivors, this population is at increased risk of developing second primary malignancies (SPMs). We described the incidence, most common tumor sites, and trends in burden of SPM among survivors of the most commonly diagnosed smoking-related cancers. The current study was a population-based study of patients diagnosed with a primary malignancy from the top 10 smoking-related cancer sites between 2000 and 2014 from Surveillance, Epidemiology, and End Results data. SPM risks were quantified using standardized incidence ratios (SIRs) and excess absolute risks (EARs) per 10,000 person-years at risk (PYR). Trends in the burden of SPM were assessed using Joinpoint regression models. A cohort of 1,608,607 patients was identified, 119,980 (7.5%) of whom developed SPM (76% of the SPMs were smoking-related). The overall SIR of developing second primary malignancies was 1.51 (95% CI, 1.50-1.52) and the EAR was 73.3 cases per 10,000 PYR compared to the general population. Survivors of head and neck cancer had the highest risk of developing a SPM (SIR = 2.06) and urinary bladder cancer had the highest excess burden (EAR = 151.4 per 10,000 PYR). The excess burden of SPM for all smoking-related cancers decreased between 2000 and 2003 (annual percentage change [APC] = -13.7%; p = 0.007) but increased slightly between 2003 and 2014 (APC = 1.6%, p = 0.032). We show that 1-in-12 survivors of smoking-related cancers developed an SPM. With the significant increase in the burden of SPM from smoking-related cancers in the last decade, clinicians should be cognizant of long-term smoking-related cancer risks among these patients as part of their survivorship care plans.

Association of Patient Social, Cognitive, and Functional Risk Factors with Preventable Hospitalizations: Implications for Physician Value-Based Payment.

BACKGROUND: Ambulatory care-sensitive condition (ACSC) hospitalizations are used to evaluate physicians' performance in Medicare value-based payment programs. However, these measures may disadvantage physicians caring for vulnerable populations because they omit social, cognitive, and functional factors that may be important determinants of hospitalization. OBJECTIVE: To determine whether social, cognitive, and functional risk factors are associated with ACSC hospitalization rates and whether adjusting for them changes outpatient safety-net providers' performance. DESIGN: Using data from the Medicare Current Beneficiary Survey, we conducted patient-level multivariable regression to estimate the association (as incidence rate ratios (IRRs)) between patient-reported social, cognitive, and functional risk factors and ACSC hospitalizations. We compared outpatient safety-net and non-safety-net providers' performance after adjusting for clinical comorbidities alone and after additional adjustment for social, cognitive, and functional factors captured in survey data. SETTING: Safety-net and non-safety-net clinics. PARTICIPANTS: Community-dwelling Medicare beneficiaries contributing 38,616 person-years from 2006 to 2013. MEASUREMENTS: Acute and chronic ACSC hospitalizations. RESULTS: After adjusting for clinical comorbidities, Alzheimer's/dementia (IRR 1.30, 95% CI 1.02-1.65), difficulty with 3-6 activities of daily living (ADLs) (IRR 1.43, 95% CI 1.05-1.94), difficulty with 1-2 instrumental ADLs (IADLs, IRR 1.54, 95% CI 1.26-1.90), and 3-6 IADLs (IRR 1.90, 95% CI 1.49-2.43) were associated with acute ACSC hospitalization. Low income (IRR 1.28, 95% CI 1.03-1.58), lack of educational attainment (IRR 1.33, 95% CI 1.04-1.69), being unmarried (IRR 1.18, 95% CI 1.01-1.36), difficulty with 1-2 IADLs (IRR 1.30, 95% CI 1.05-1.60), and 3-6 IADLs (IRR 1.44, 95% CI 1.16-1.80) were associated with chronic ACSC hospitalization. Adding these factors to standard Medicare risk adjustment eliminated outpatient safety-net providers' performance gap (p < .05) on ACSC hospitalization rates relative to non-safety-net providers. CONCLUSIONS: Social, cognitive, and functional risk factors are independently associated with ACSC hospitalizations. Failure to account for them may penalize outpatient safety-net providers for factors that are beyond their control.

Testing the Feasibility of Using Ecological Momentary Assessment to Collect Real-Time Behavior and Mood to Predict Technology-Measured HIV Medication Adherence.

Identifying distinct patterns of behavior and mood in natural environments that interrupt medication adherence among individuals with HIV will be useful in informing intervention development. This pilot study assessed the initial efficacy of using ecologic momentary assessment to define patterns of alcohol use, mood, and medication adherence. Participants reported intraday alcohol use and mood using app-enabled smartphones and MEMSCap pill bottles to measure medication adherence. There were 34 enrolled participants, 29 of whom completed the 28-day study. Participants drank a mean of 7.75 days of the study period. The positive and negative affect scores ranged from 10 to 50, with a mean of 25.7 and 11.4 for each, respectively. The average medication adherence for the sample was 94.1%. These findings suggest these types of data collection methods are increasingly acceptable in measuring real-time mood and behavior, which may better inform interventions addressed at increasing HIV adherence practices.

Recurrent Patellar Instability: Implications of Preoperative Patellar Crepitation on the Status of the Patellofemoral Articular Cartilage.

BACKGROUND: The purpose of the study was to quantify the frequency, severity, and location of patellofemoral (PF) articular cartilage changes recurrent patellar instability treated surgically in patients with preoperative clinical patellar crepitation. METHODS: A single-surgeon database was queried for all knees with recurrent patellar instability between 3/2000 and 6/2012 (n=214). Only knees which underwent knee arthroscopy during the surgical treatment were included (n=148). PF articular cartilage condition was assessed arthroscopically. RESULTS: There were 148 knees in 130 patients (mean age, 16 y), which met inclusion criteria. There were 93 females and 37 males. Diagnoses were dislocations [122 (82.4%)] and subluxations (26). Preoperatively 28 knees (18.9%) had PF crepitation. Statistical analysis demonstrated preoperative PF crepitation was correlated with medial patellar facet lesions (P=0.0022) and were 3.6 times more likely to have medial patellar facet lesions. Crepitation was correlated with the higher outerbridge (OB) patellar grades (P<0.0001) and larger patellar lesion size (P=0.0021). At arthroscopy 89 knees (60.5%) had patellar articular cartilage damage with a mean OB grade of 1.3 (0 to 4) and mean size of 93.2 mm (0 to 750). The femoral articular cartilage was identified in 29 knees (19.7%) with a mean OB grade of 0.44 (0 to 4). CONCLUSIONS: PF articular damage was present in 63% of knees, which were surgically treated for patellar instability. The patella was involved in 61% (mean, 129 mm) and femoral trochlea in 20% (mean 166 mm) of knees. Knee with preoperative PF crepitation (20% of cohort) more commonly had medial patellar facet lesions with higher OB grades, and larger patellar lesion size than knees without preoperative crepitation. Because of the high frequency of patellar (83%) and femoral (36%) articular damage documented at the time of surgical reconstruction, visualization of the PF joint is recommended when knees have preoperative PF crepitation. LEVEL OF EVIDENCE: Level IV.

Suicide risk among cancer survivors: Head and neck versus other cancers.

BACKGROUND: Cancer survivors face psychosocial issues that increase their risk of suicide. This study examined the risk of suicide across cancer sites, with a focus on survivors of head and neck cancer (HNC). METHODS: The Surveillance, Epidemiology, and End Results 18-registry database (from 2000 to 2014) was queried for the top 20 cancer sites in the database, including HNC. The outcome of interest was suicide as a cause of death. The mortality rate from suicide was estimated for HNC sites and was compared with rates for 19 other cancer sites that were included in the study. Poisson regression was used to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) for 1) HNC versus non-HNC sites (the other 19 cancer sites combined), and 2) HNC versus each individual cancer site. Models were stratified by sex, controlling for race, marital status, age, year, and stage at diagnosis. RESULTS: There were 404 suicides among 151,167 HNC survivors from 2000 to 2014, yielding a suicide rate of 63.4 suicides per 100,000 person-years. In this timeframe, there were 4493 suicides observed among 4219,097 cancer survivors in the study sample, yielding an incidence rate of 23.6 suicides per 100,000 person-years. Compared with survivors of other cancers, survivors of HNC were almost 2 times more likely to die from suicide (aRR, 1.97; 95% CI, 1.77-2.19). There was a 27% increase in the risk of suicide among HNC survivors during the period from 2010 to 2014 (aRR, 1.27; 95% CI, 1.16-1.38) compared with the period from 2000 to 2004. CONCLUSIONS: Although survival rates in cancer have improved because of improved treatments, the risk of death by suicide remains a problem for cancer survivors, particularly those with HNC.

An evaluation of a potential calcium channel blocker-lower-extremity edema-loop diuretic prescribing cascade.

OBJECTIVES: Dihydropyridine calcium channel blockers (DH-CCB) are associated with lower-extremity edema (LEE). Loop diuretics have been used inappropriately to treat DH-CCB-associated LEE, constituting a prescribing cascade (PC). The aim of this work was to identify the prevalence and factors associated with potential DH-CCB-LEE-loop diuretic PC. METHODS: The 2014 National Ambulatory Medical Care Survey was used to identify patient visits in which a DH-CCB was continued. The definition of a potential PC was the continuation or initiation of a loop diuretic in the absence of congestive heart failure, cancer, obstructive sleep apnea, chronic kidney disease or end-stage renal disease, obesity, or resistant hypertension. Multivariable logistic regression was used to identify factors related to a potential PC, including demographic information, number of medications, number of patient visits in the previous 12 months, and comorbid conditions. RESULTS: Among the estimated 47.5 million patient visits in which a DH-CCB was continued, 4.6% had a potential PC. Visits in patients 65 to 84 years of age (odds ratio [OR] 2.56, 95% CI 1.20-5.43) and 85 years of age and older (OR 3.89, 95% CI 1.76-8.61) were more likely to have potential PC compared with patients 18 to 64 years of age. Visits in patients with 5 to 7 (OR 3.75, 95% CI 1.72-8.19), 8 to 11 (OR 2.20, 95% CI 1.09-4.44), and 12 or more (OR 5.23, 95% CI 2.29-11.94) medications were more likely to have potential PC compared with patients with 4 or fewer medications. CONCLUSION: A potential DH-CCB-associated LEE loop diuretic PC was present in approximately 2.2 million patient visits in which DH-CCB was continued. Older age and an increasing number of concomitant medications were associated with this potential PC.

Operationalizing Population Health Management in Practice.

We synthesized practitioner perspectives on how to integrate a community-based program into a healthcare system. Three focus groups and four in-depth interviews in Greene County, Missouri addressed: the population served, collaborations, service delivery design, training, data collection, and funding. Participants identified the following: integration as a way to increase population health outcomes through mutually beneficial partnerships; education and awareness of community-based resources; coordination of services to avoid duplication and maximize niche skills; smooth transitions across programs; and information sharing.