The Effects of Osteoarthritis on Depressive Symptomatology Among Older U.S. Military Veterans.

Osteoarthritis (OA) is a leading cause of disability among older adults. By 2050, approximately 60 million will suffer from arthritis adding up to a total societal cost of $65 billion. Chronic illnesses resulting in pain, and functional decline have been associated with depression in previous studies.A causal model was developed and tested using structural equation modeling that examined depression scores of 503 older (age 50-85), male Veterans with moderate to severe symptomatic OA of the knee\hip.The results of the structural equation modeling produced a final model of depressive symptomatology that fit the data well (Chi square = 12.23, DF = 11, p = .346; TLI = .99; CFI = 1.00; RMSEA = .02).The findings indicate the central role that OA severity (pain, stiffness, and functional difficulties) plays in the mental health of older Veterans in terms of the level of reported depressive symptoms.

Racial and Neighborhood-Level Disparities in COVID-19 Incidence among Patients on Hemodialysis in New York City.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected socially disadvantaged populations. Whether disparities in COVID-19 incidence related to race/ethnicity and socioeconomic factors exist in the hemodialysis population is unknown. METHODS: Our study involved patients receiving in-center hemodialysis in New York City. We used a validated index of neighborhood social vulnerability, the Social Vulnerability Index (SVI), which comprises 15 census tract-level indicators organized into four themes: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. We examined the association of race/ethnicity and the SVI with symptomatic COVID-19 between March 1, 2020 and August 3, 2020. COVID-19 cases were ascertained using PCR testing. We performed multivariable logistic regression to adjust for demographics, individual-level social factors, dialysis-related medical history, and dialysis facility factors. RESULTS: Of the 1378 patients on hemodialysis in the study, 247 (17.9%) developed symptomatic COVID-19. In adjusted analyses, non-Hispanic Black and Hispanic patients had significantly increased odds of COVID-19 compared with non-Hispanic White patients. Census tract-level overall SVI, modeled continuously or in quintiles, was not associated with COVID-19 in unadjusted or adjusted analyses. Among non-Hispanic White patients, the socioeconomic status SVI theme, the minority status and language SVI theme, and housing crowding were significantly associated with COVID-19 in unadjusted analyses. CONCLUSIONS: Among patients on hemodialysis in New York City, there were substantial racial/ethnic disparities in COVID-19 incidence not explained by neighborhood-level social vulnerability. Neighborhood-level socioeconomic status, minority status and language, and housing crowding were positively associated with acquiring COVID-19 among non-Hispanic Whites. Our findings suggest that socially vulnerable patients on dialysis face disparate COVID-19-related exposures, requiring targeted risk-mitigation strategies.

Accuracy of Hospital Discharge Codes in Medicare Claims for Knee and Hip Replacement Patients.

BACKGROUND: Despite the importance of the hospital discharge destination field ("discharge code" hereafter) for research and payment reform, its accuracy is not well established. OBJECTIVES: The aim of this study was to examine the accuracy of discharge codes in Medicare claims. DATA SOURCES: 2012-2015 Medicare claims of knee and hip replacement patients. RESEARCH DESIGN: We identified patients' discharge location in claims and compared it with the discharge code. We also used a mixed-effects logistic regression to examine the association of patient and hospital characteristics with discharge code accuracy. RESULTS: Approximately 9% of discharge codes were inaccurate. Long-term care hospital discharge codes had the lowest accuracy rate (41%), followed by acute care transfers (72%), inpatient rehabilitation facility (80%), and home discharges (83%). Most misclassifications occurred within 2 broad groups of postacute care settings: home-based and institutional care. The odds of inaccurate discharge codes were higher for Medicaid-enrolled patients and safety-net and low-volume hospitals. CONCLUSIONS: Inaccurate hospital discharge coding may have introduced bias in studies relying on these codes (eg, evaluations of Medicare bundled payment models). Inaccuracy was more common among Medicaid-enrolled patients and safety-net and low-volume hospitals, suggesting more potential bias in existing study findings pertaining to these patients and hospitals.

Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity.

OBJECTIVE: Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. METHODS: We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. RESULTS: The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42). CONCLUSIONS: Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

Musculoskeletal Urgent Care Centers in Connecticut Restrict Patients with Medicaid Insurance Based on Policy and Location.

BACKGROUND: Musculoskeletal urgent care centers are a new development in the urgent care landscape. Anecdotally, these centers are known to screen patients based on their insurance status, denying care to those with Medicaid insurance. It is important to know whether the practice of denying musculoskeletal urgent care to patients with Medicaid insurance is widespread because this policy could exacerbate existing musculoskeletal healthcare disparities. QUESTIONS/PURPOSES: (1) Do musculoskeletal urgent care centers in Connecticut provide access for patients with Medicaid insurance? (2) Do musculoskeletal urgent care centers have the same Medicaid policies as the entities that own them? (3) Are musculoskeletal urgent care centers more likely to be located in affluent neighborhoods? METHODS: An online search was conducted to create a list of musculoskeletal urgent care centers in Connecticut. Each center was interviewed over the telephone using a standardized list of questions to determine ownership and Medicaid policy. Next, the entities that owned these musculoskeletal centers were called and asked the same questions about their Medicaid policy. Medicaid policy was compared between musculoskeletal urgent care centers and the practices that owned them. The median household income for each ZIP code containing a musculoskeletal urgent care center was compared with the median household income for Connecticut. The median household income was also compared between the ZIP codes of musculoskeletal urgent care centers that accepted or denied patients with Medicaid insurance. RESULTS: Of the 29 musculoskeletal urgent care centers in Connecticut, only four (13%) accepted patients regardless of their insurance type, 19 (66%) did not accept any form of Medicaid insurance, and six (21%) required that certain requisites and stipulations be met for patients with Medicaid insurance to receive access, such as only permitting a patient for an initial visit and then referring them to a local hospital system for all future encounters, or only permitting patients with Medicaid insurance who lived in the same town as the clinic. All 29 musculoskeletal urgent care centers were owned by private practice groups and nine of 14 of these groups had the same policy towards patients with Medicaid insurance as their respective musculoskeletal urgent care centers. All 29 musculoskeletal urgent care centers were co-located in a private practice clinic office. Musculoskeletal urgent care centers were located in areas with greater median household incomes than the Connecticut state median (95% CI, USD 112,322 to USD 84,613 versus the state median of USD 73,781; p = 0.001). CONCLUSIONS: Most musculoskeletal urgent care centers in Connecticut do not accept patients with Medicaid insurance and have similar or stricter Medicaid policies as the groups that own them. Additionally, musculoskeletal urgent care centers were located in affluent neighborhoods. These findings are important because they suggest private practices are using musculoskeletal urgent care centers to capture patients with more favorable insurance. This is likely a result of the relatively low Medicaid reimbursement rates in Connecticut and reflects a need for an increase in either reimbursement or incentives to treat patients with Medicaid insurance. The financial impact of capturing well-insured patients from public and academic medical centers and directing Medicaid patients to these urgent care centers is not known. Additionally, although most of these 29 musculoskeletal urgent care clinics denied care to patients with Medicaid, the specific healthcare disparities caused by decreased access to care must be further studied.

Social determinants of health and survivorship in parotid cancer: An analysis of the National Cancer Database.

BACKGROUND: Given the rarity of parotid cancer, there is relatively few data published regarding outcomes. Utilizing the large sample population of the National Cancer Database (NCDB), we aim to examine the relationship between two key social determinants of health, demographics and socioeconomic status (SES), and parotid malignancy survival rates. METHODS: Our analytic sample consists of patients with a diagnosis of primary malignancy of the parotid gland between 2004 and 2012 in the NCDB. We used univariable and multivariable Cox proportional hazard models to evaluate the relationship between overall survival rate and two key social determinants of health: demographics and SES. RESULTS: 15,815 cases met inclusion criteria. Average age was 60.1 years and 8255 were male (52.2%). Median overall survival was 121 months with 5-year overall survival of 67.4%. Male sex and older age at diagnosis were associated with poorer overall survival (p < 0.0001). We found that Asian Americans compared to whites had better overall survival (HR 0.75; 95% CI [0.58-0.95]). Black patients had improved survival compared to whites on univariate (HR 0.71; 95% CI [0.64-0.79]); but not multivariate analysis. Hispanic ethnicity and higher education level were protective (HR 0.76 95% CI [0.63-0.91] and HR 0.84 95% CI [0.74-0.96], respectively). We found no significant survival association based on income level. CONCLUSION: In this national sample of patients with parotid malignancy, a rare form of cancer, we found a significant correlation between important social determinants of health and overall survival rate. Females, Asian-Americans, Hispanics, and patients with higher education level have better overall survival.

Advancing Health Services Research to Eliminate Health Care Disparities.

Findings from health services research highlight continuing health care disparities in the United States, especially in the areas of access to health care and quality of care. Although attention to health care disparities has increased, considerable knowledge gaps still exist. A better understanding of how cultural, behavioral, and health system factors converge and contribute to unequal access and differential care is needed. Research-informed approaches for reducing health care disparities that are feasible and capable of sustained implementation are needed to inform policymakers. More important, for health equity to be achieved, it is essential to create a health care system that provides access, removes barriers to care, and provides equally effective treatment to all persons living in the United States.

Testing a Positive Psychological Intervention for Osteoarthritis.

OBJECTIVE: Osteoarthritis is a leading cause of disability for which there is no cure. Psychosocial-oriented treatments are underexplored. We developed and tested an intervention to build positive psychological skills (e.g., gratitude) to reduce osteoarthritis symptom severity, including pain and functioning, and to improve psychosocial well-being in patients with knee or hip osteoarthritis. DESIGN: Two-arm randomized design with six-month follow-up. SETTING: An academic Veterans Affairs Medical Center. SUBJECTS: Patients aged 50 years or older with knee or hip osteoarthritis and pain ratings of 4 or higher. METHODS: Patients (N = 42) were randomized to a six-week program containing positive skill-building activities or neutral control activities tailored to the patient population. Adherence was assessed by telephone each week. We assessed osteoarthritis symptom severity (WOMAC Osteoarthritis Index) and measures of well-being (positive affect, negative affect, and life satisfaction) at baseline and by telephone one, three, and six months after the program ended. We used linear mixed models to examine changes over time. RESULTS: The majority (64%) of patients completed more than 80% of their weekly activities. Patients in the positive (vs neutral) program reported significantly more improvement over time in osteoarthritis symptom severity (P = 0.02, Cohen's d = 0.86), negative affect (P = 0.03, Cohen's d = 0.50), and life satisfaction (P = 0.02, Cohen's d = 0.36). CONCLUSIONS: The study successfully engaged patients with knee or hip osteoarthritis in a six-week intervention to build positive psychological skills. Improving osteoarthritis symptom severity and measures of psychosocial well-being, the intervention shows promise as a tool for chronic pain management.

Does a Patient-centered Educational Intervention Affect African-American Access to Knee Replacement? A Randomized Trial.

BACKGROUND: A TKA is the most effective and cost-effective surgical option for moderate to severe osteoarthritis (OA) of the knee. Yet, black patients are less willing to undergo knee replacement surgery than white patients. Decision aids help people understand treatment options and consider the personal importance of possible benefits and harms of treatments, including TKA. QUESTIONS/PURPOSES: We asked: (1) Does a patient-centered intervention consisting of a decision aid for knee OA and motivational interviewing improve the proportion of referrals of blacks with knee OA to orthopaedic surgery? (2) Does the intervention increase patients' willingness to undergo TKA? METHODS: Adults who self-identified as black who were at least 50 years old with moderate to severe knee OA were enrolled from urban primary care clinics in a two-group randomized, controlled trial. A total of 1253 patients were screened for eligibility, and 760 were excluded for not meeting inclusion criteria, declining to participate, or other reasons. Four hundred ninety-three patients were randomized and completed the intervention; three had missing referral data at followup. The mean age of the patients was 61 years, and 51% were women. The majority had an annual household income less than USD 15,000. Participants in the treatment group were shown a decision-aid video and had a brief session with a trained counselor in motivational interviewing. Participants in the control group received an educational booklet about OA that did not mention joint replacement. The two groups had comparable demographic and socioeconomic characteristics. The primary outcome was referral to orthopaedic surgery 12 months after treatment exposure. Receipt of referral was defined as the receipt of a recommendation or prescription from a primary care provider for orthopaedic evaluation. The secondary outcome was change in patient willingness to undergo TKA based on patient self-report. RESULTS: The odds of receiving a referral to orthopaedic surgery did not differ between the two study groups (36%, 90 of 253 of the control group; 32%, 76 of 240 of the treatment group; odds ratio [OR], 0.81; 95% CI, 0.56-1.18; p = 0.277). At 2 weeks followup, there was no difference between the treatment and the control groups in terms of increased willingness to consider TKA relative to baseline (34%, 67 of 200 patients in the treatment group; 33%, 68 of 208 patients in the control group; OR, 1.06; p = 0.779). At 12 months followup, the percent increase in willingness to undergo TKA still did not differ between patients in the treatment and control groups (29%, 49 of 174 in the treatment group; 27%, 51 of 191 in the control group; OR, 1.10; p = 0.679). CONCLUSION: A combination decision aid and motivational interviewing strategy was no better than an educational pamphlet in improving patients' preferences toward joint replacement surgery for knee OA. The type of intervention treatment also did not affect access to surgical evaluation. Other tools that target patient knowledge, beliefs, and attitudes regarding surgical treatments for OA may be further developed and tested in the future. LEVEL OF EVIDENCE: Level I, therapeutic study.

Do attitudes and beliefs regarding complementary and alternative medicine impact its use among patients with cancer? A cross-sectional survey.

BACKGROUND: Complementary and alternative medicine (CAM) incorporates treatments used by cancer survivors in an attempt to improve their quality of life. Although population studies have identified factors associated with its use, to the best of the authors knowledge, assessment of why patients use CAM or the barriers against its use have not been examined to date. METHODS: The authors conducted a cross-sectional survey study in the thoracic, breast, and gastrointestinal medical oncology clinics at an academic cancer center. Clinical and demographic variables were collected by self-report and chart abstraction. Attitudes and beliefs were measured using the validated Attitudes and Beliefs about CAM (ABCAM) instrument. This instrument divides attitudes and beliefs into 3 domains: expected benefits, perceived barriers, and subjective norms. RESULTS: Among 969 participants (response rate, 82.7%) surveyed between June 2010 and September 2011, patient age ≤65 years, female sex, and college education were associated with a significantly greater expected benefit from CAM (P<.0001 for all). Nonwhite patients reported more perceived barriers to CAM use compared with white patients (P<.0001), but had a similar degree of expected benefit (P = .76). In a multivariate logistic regression analysis, all domains of the ABCAM instrument were found to be significantly associated with CAM use (P<.01 for all) among patients with cancer. Attitudes and beliefs regarding CAM explained much more variance in CAM use than clinical and demographic variables alone. CONCLUSIONS: Attitudes and beliefs varied by key clinical and demographic characteristics, and predicted CAM use. By developing CAM programs based upon attitudes and beliefs, barriers among underserved patient populations may be removed and more patient centered care may be provided.

Race, Pain, and Beliefs Associated with Interest in Complementary and Alternative Medicine among Inner City Veterans.

OBJECTIVE: To investigate the prevalence and determinants of complementary and alternative medicine (CAM) interest level among a racially diverse cohort of inner city veterans who receive primary care at the VA Medical Center. DESIGN: Cross-sectional survey study SETTING: Philadelphia VA Medical Center SUBJECTS: Primary care patients (n = 258) METHODS: Interest in CAM was measured using a single item question. Patient treatment beliefs were assessed using validated instruments. We evaluated factors associated with patient interest in CAM using a multivariate logistic regression model. RESULTS: In this sample of 258 inner city primary care VA patients, interest in CAM was high 80% (n = 206). Interest in CAM was strongly associated with African American race [adjusted odds ratio (AOR) 2.19, 95% Confidence Interval (CI) 1.05-4.60, P = 0.037], higher levels of education (AOR 4.33, 95% CI 1.80-10.40, P = 0.001), presence of moderate to severe pain (AOR 2.02, 95% CI 1.02-4.78, P = 0.043), and expectations of benefit from CAM use (AOR 1.21, 95% CI 1.06-1.36, P = 0.004). CONCLUSIONS: CAM approaches have broad appeal within this inner city cohort of veterans, particularly among African Americans, those that experience pain and those that expect greater benefit from CAM. These findings may inform the development of patient-centered integrative pain management for veterans.

US veterans use vitamins and supplements as substitutes for prescription medication.

BACKGROUND: Vitamins and supplements are the most commonly used form of complementary and alternative medicine in the United States. Growing research suggests that patients substitute vitamins and supplements for their prescription medications. The reasons might include cost of prescription medications and discordant patient and doctor health belief systems. OBJECTIVES: To investigate the prevalence of substitution of vitamins and supplements for prescription medications among veterans who receive care in the VA health care system and whether substitution is associated with prescription rationing due to cost, treatment beliefs, or distrust of the health system. RESEARCH DESIGN: Cross-sectional observational survey. SUBJECTS: Primary care patients (n=275) at the Philadelphia VA Medical Center. MEASURES: Medication substitution, prescription medication rationing, treatment beliefs, and health system distrust were measured with structured instruments. Multivariate logistic regression was performed with substitution as the dependent variable. RESULTS: A significant number of primary care patients in the VA system use vitamins and supplements 206 (75%). The prevalence of medication substitution is high 48 (18%). Medication substitution is strongly associated with prescription rationing due to cost (adjusted odds ratio 6.3, 95% confidence interval: 2.0-19.5, P=0.001). Similarly, greater belief in complementary and alternative approaches to care positively predicts medication substitution (adjusted odds ratio 1.08, 95% confidence interval: 1.01-1.15, P=0.011). There is no significant association between health system distrust and likelihood of medication substitution. CONCLUSIONS: Medication substitution is prevalent in this sample of inner city primary care patients who receive care in the VA system. Cost of prescriptions and belief in the value of complementary and alternative approaches to care appear to be associated with this patient-driven treatment decision.

Willingness and access to joint replacement among African American patients with knee osteoarthritis: a randomized, controlled intervention.

OBJECTIVE: African American patients are significantly less likely to undergo knee replacement for the management of knee osteoarthritis (OA). Racial difference in preference (willingness) has emerged as a key factor. This study was undertaken to examine the efficacy of a patient-centered educational intervention on patient willingness and the likelihood of receiving a referral to an orthopedic clinic. METHODS: A total of 639 African American patients with moderate-to-severe knee OA from 3 Veterans Affairs primary care clinics were enrolled in a randomized, controlled trial with a 2 × 2 factorial design. Patients were shown a knee OA decision-aid video with or without brief counseling. The main outcome measures were change in patient willingness and receipt of a referral to an orthopedic clinic. Also assessed were whether patients discussed knee pain with their primary care provider or saw an orthopedic surgeon within 12 months of the intervention. RESULTS: At baseline, 67% of the participants were definitely/probably willing to consider knee replacement, with no difference among the groups. The intervention increased patient willingness (75%) in all groups at 1 month. For those who received the decision aid intervention alone, the gains were sustained for up to 3 months. By 12 months postintervention, patients who received any intervention were more likely to report engaging their provider in a discussion about knee pain (92% versus 85%), to receive a referral to an orthopedic surgeon (18% versus 13%), and for those with a referral, to attend an orthopedic consult (61% versus 50%). CONCLUSION: An educational intervention significantly increased the willingness of African American patients to consider knee replacement. It also improved the likelihood of patient-provider discussion about knee pain and access to surgical evaluation.

Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups.

Hip and knee replacement have been marked by racial and ethnic disparities in both utilization and postoperative adverse events among Medicare beneficiaries, but limited knowledge exists regarding racial and ethnic differences in joint replacement care among Medicaid beneficiaries. To close this gap, this study used Medicaid claims in 2018 and described racial and ethnic differences in the utilization and postoperative adverse events of elective joint replacements among Medicaid beneficiaries. Among the 2,260,272 Medicaid beneficiaries, 5987 had an elective joint replacement in 2018. Asian (0.05%, 95% confidence interval [CI]: 0.03%-0.07%) and Hispanic beneficiaries (0.12%, 95% CI: 0.07%-0.18%) received joint replacements less frequently than American Indian and Alaska Native (0.41%, 95% CI: 0.27%-0.55%), Black (0.33%, 95% CI: 0.19%-0.48%), and White (0.37%, 95% CI: 0.25%-0.50%) beneficiaries. Black patients demonstrated the highest probability of 90-day emergency department visits (34.8%, 95% CI: 32.7%-37.0%) among all racial and ethnic groups and a higher probability of 90-day readmission (8.0%, 95% CI: 6.9%-9.0%) than Asian (3.4%, 95% CI: 0.7%-6.0%) and Hispanic patients (4.4%, 95% CI: 3.4%-5.3%). These findings indicate evident disparities in postoperative adverse events across racial and ethnic groups, with Black patients demonstrating the highest probability of 90-day emergency department visits. This study represents an initial exploration of the racial and ethnic differences in joint replacement care among Medicaid beneficiaries and lay the groundwork for further investigation into contributing factors of the observed disparities.

Boosting photocatalytic water splitting of TiO2 using metal (Ru, Co, or Ni) co-catalysts for hydrogen generation.

The photocatalytic activity of titanium dioxide (TiO2) nanoparticles toward hydrogen generation can be significantly improved via the loading of various metals e.g., Ru, Co, Ni as co-catalysts. The metal co-catalysts are loaded into TiO2 nanoparticles via different deposition methods; incipient wet impregnation (Imp), hydrothermal (HT), or photocatalytic deposition (PCD). Among all of the tested materials, 0.1 wt% Ru-TiO2 (Imp) provided the highest initial hydrogen catalytic rate of 23.9 mmol h-1 g-1, compared to 10.82 and 16.55 mmol h-1 g-1 for 0.3 wt% Ni-TiO2 (Imp) and 0.3 wt% Co-TiO2 (Imp), respectively. The loading procedures, co-catalyst metals type, and their loading play a significant role in elevating the photocatalytic activity of pristine TiO2 semiconductors toward hydrogen generation. Redox transition metals e.g., Co and Ni exhibit comparable photocatalytic performance to expensive elements such as Ru.