Evaluating the psychometric properties of the Hispanic Stress Inventory-2 Simplified version among a diverse sample of Latinos who smoke.

OBJECTIVE: Acculturation stress can negatively impact Latinos immigrant mental and physical health related behaviors such as smoking. It is essential to have validated and updated instruments that allow the evaluation of acculturation stress on this population. This study aims to evaluate the psychometric properties of an abbreviated version of the Hispanic Stress Inventory Version 2 (HSI2) immigration scale among Latinos who smoke. METHODS: The study consisted of a secondary data analysis from a baseline assessment of Decídetexto, a mobile health (mHealth) smoking cessation randomized clinical trial. Of 457 Latinos included in the parent study, 352 immigrants who smoke were included. Construct validity was analyzed by completing a Pearson correlation coefficient matrix. Structural validity was analyzed using an Exploratory Factor Analysis (EFA). Cronbach alpha analysis was used to estimate the internal consistency of the items constituting a factor. RESULTS: The results included an abbreviated version of the HSI2 including 52 items. From the Pearson correlation coefficient matrix with a cutoff point of 0.4, 22 of the 52 items were excluded. From the Pearson correlation coefficient matrix with a cutoff point of 0.4, 22 items were excluded. Exploratory Factor Analysis (EFA) results in six factors extracted, explaining 69.1% of the variance. According to the EFA, two items were relocated in different factors from the original scale. The HSI2 30 items scale reflected excellent reliability with a Cronbach's alpha coefficient of 0.93. The six factors reflect acceptable to excellent reliability, ranging from 0.77-0.93 across factors. The median for the HSI2 total score was 34.00 (25-45) out of a possible total score of 150. CONCLUSION: Results confirmed acceptable psychometric properties of the HSI2 simplified 30-item version and provided a reliable and shorter measure of acculturation stress for Latinos groups. Having a valid and reduced measure of acculturation stress is the first step in understanding diverse ethnic groups of Latinos that are at higher risk of presenting health risk behaviors such as smoking. The present results provided the possibility of assessing the impact of acculturation stress among adults who smoke.

Investigating Ethical Tradeoffs in Crisis Standards of Care through Simulation of Ventilator Allocation Protocols.

Introduction: Arguments over the appropriate Crisis Standards of Care (CSC) for public health emergencies often assume that there is a tradeoff between saving the most lives, saving the most life-years, and preventing racial disparities. However, these assumptions have rarely been explored empirically. To quantitatively characterize possible ethical tradeoffs, we aimed to simulate the implementation of five proposed CSC protocols for rationing ventilators in the context of the COVID-19 pandemic. Methods: A Monte Carlo simulation was used to estimate the number of lives saved and life-years saved by implementing clinical acuity-, comorbidity- and age-based CSC protocols under different shortage conditions. This model was populated with patient data from 3707 adult admissions requiring ventilator support in a New York hospital system between April 2020 and May 2021. To estimate lives and life-years saved by each protocol, we determined survival to discharge and estimated remaining life expectancy for each admission. Results: The simulation demonstrated stronger performance for age- and comorbidity-sensitive protocols. For a capacity of 1 bed per 2 patients, ranking by age bands saves approximately 28.7 lives and 3408 life-years per thousand patients, while ranking by Sequential Organ Failure Assessment (SOFA) bands saved the fewest lives (13.2) and life-years (416). For all protocols, we observed a positive correlation between lives saved and life-years saved. For all protocols except lottery and the banded SOFA, significant disparities in lives saved and life-years saved were noted between White non-Hispanic, Black non-Hispanic, and Hispanic sub-populations. Conclusion: While there is significant variance in the number of lives saved and life-years saved, we did not find a tradeoff between saving the most lives and saving the most life-years. Moreover, concerns about racial discrimination in triage protocols require thinking carefully about the tradeoff between enforcing equality of survival rates and maximizing the lives saved in each sub-population.

Informal care provided in US nursing homes: Reduced from 2010 to 2021 and lower for Medicaid residents.

BACKGROUND: Little is known about the trend of informal care (unpaid care provided by family or other caregivers) provided to nursing home residents before or during the COVID-19 pandemic. This study assessed this trend during 2010-2021, for all and Medicaid versus non-Medicaid residents. METHODS: Using data from the RAND Health and Retirement Study longitudinal file, our study sample included a total of 2025 resident-years (860 for Medicaid and 1165 for non-Medicaid residents). We fit two-part regression models to determine adjusted trends in average amount of informal care over time, and difference by resident Medicaid status. RESULTS: Informal care received by residents reduced substantially over time, from an average of 39.2 h in the past month of interview in 2010-11 to 23.2 h in 2018-19, and then to 11.2 h in the COVID-19 pandemic (2020-21). The reduced hours were due to both reduced percentages of nursing home residents who received any informal care and reduced hours of care among those who did receive it over time. Multivariable analyses confirmed this trend and similar downward trends for Medicaid versus non-Medicaid residents. Medicaid residents on average received 10.02 fewer hours of informal care per month (95% confidence interval -17.16, -2.87; p = 0.006) than non-Medicaid residents after adjustment for resident characteristics and time trends. CONCLUSION: Informal care provided to nursing home residents during 2010-2021 reduced over time, especially during the COVID-19 pandemic (2020-21). Medicaid residents tended to receive less informal care than non-Medicaid residents.

Higher levels of state funding for Home- and Community-Based Services linked to better state performances in Long-Term Services and Supports.

OBJECTIVE: To examine the relationship between the level of state funding for Home- and Community-Based Services (HCBS) and state overall and dimension-specific performances in Long-Term Services and Supports (LTSS). DATA SOURCES AND STUDY SETTING: We employed state-level secondary data from the Medicaid LTSS Annual Expenditures Reports, the American Association of Retired Persons (AARP) State Scorecards, the U.S. Census, and Federal Reserve Economic data, spanning the timeframe of 2010-2020. STUDY DESIGN: Overall state LTSS rankings, along with dimension-specific rankings, were modeled separately against state Medicaid spending on HCBS relative to total Medicaid spending on LTSS. All models were adjusted for state covariates, secular trend, and state fixed effects. DATA COLLECTION/EXTRACTION METHODS: The study sample included all 50 states and the District of Columbia. However, California, Delaware, Illinois, and Virginia were excluded from FY2019 due to missing data on Medicaid HCBS expenditures. PRINCIPAL FINDINGS: Every 10 percentage-point increase in the proportion of Medicaid LTSS spending to HCBS demonstrated 2.05 points improvement (95% confidence interval [CI]: -3.88 to 0.22, p = 0.03) in rankings for state overall LTSS system performance, 2.92 points improvement (95% CI: -4.87 to 0.98, p < 0.01) in rankings for the Choice of Setting and Provider dimension, as well as 1.73 points (95% CI: -3.14 to 0.32, p = 0.02) ranking improvement in the dimension of Effective Transitions. CONCLUSIONS: Our study suggested promising effects of increased state funding for HCBS on LTSS performance.

Development and validation of multivariable predictive models for recurrence and mortality following nonoperative management of sigmoid volvulus.

AIM: Sigmoid volvulus is a challenging condition, and deciding between elective surgery or expectant management can be complex. The aim of this study was to develop a tool for predicting the risk of recurrent sigmoid volvulus and all-cause mortality within 1 year following initial nonoperative management. METHOD: This is a retrospective cohort study using Medicare claims data from 2016 to 2018 of beneficiaries admitted urgently/emergently for volvulus, undergoing colonic decompression and discharged alive without surgery (excluding those discharged to hospice). The primary outcomes were recurrent sigmoid volvulus and all-cause mortality within 1 year. Proportional hazards models and logistic regression were employed to identify risk factors and develop prediction equations, which were subsequently validated. RESULTS: Among the 2078 patients managed nonoperatively, 36.1% experienced recurrent sigmoid volvulus and 28.6% died within 1 year. The prediction model for recurrence integrated age, sex, race, palliative care consultations and four comorbidities, achieving area under the curve values of 0.63 in both the training and testing samples. The model for mortality incorporated age, palliative care consultations and nine comorbidities, with area under the curve values of 0.76 in the training and 0.70 in the testing sample. CONCLUSION: This study provides a straightforward predictive tool that utilizes easily accessible data to estimate individualized risks of recurrent sigmoid volvulus and all-cause mortality for older adults initially managed nonoperatively. The tool can assist clinicians and patients in making informed decisions about such risks. While the accuracy of the calculator was validated, further confirmation through external validation and prospective studies would enhance its clinical utility.

Are Black and Latino adolescents being asked if they use electronic cigarettes and advised not to use them? Results from a community-based survey.

Objective: This study aimed to explore whether African American/Black and Hispanic/Latino adolescents are being asked about electronic cigarette (e-cigarette) use (vaping) and advised not to use them. Methods: In 2021, adolescents (N = 362) with no vaping history, self-identified as African American/Black and/or Hispanic/Latino, and able to read and speak English and/or Spanish were recruited through partner schools and community-based organizations. Participants completed a survey reporting sociodemographic characteristics (e.g., race/ethnicity, gender, and language of preference) and they were asked about e-cigarette use and/or were advised not to use them by a health professional. Results: In total, 12% of African American/Black and 5% of Hispanic/Latino participants reported not seeing a health professional in the year prior to enrollment. Of the participants who reported visiting a health professional, 50.8% reported being asked and advised about vaping. Over one-quarter (28.4%) of participants were neither asked nor advised regarding vaping. Compared to English-speaking participants, Spanish-speaking participants were significantly less likely to be asked about e-cigarette use (45.2 vs. 63.9%, p = 0.009) and advised not to use them (40.3 vs. 66.9%, p < 0.001). Moreover, compared to African American/Black participants, Hispanic/Latino participants were significantly less likely to be advised not to use e-cigarettes (52.9 vs. 68.6%, p = 0.018). Furthermore, compared to male participants, female participants were significantly less likely to be advised not to use e-cigarettes (51.3 vs. 68.2%, p = 0.003). Conclusion: Compared to English-speaking participants, Spanish-speaking participants were significantly less likely to self-report being asked about e-cigarette use and advised not to use them. Moreover, Hispanic/Latino and female adolescents were significantly less likely to self-report being advised not to use e-cigarettes compared to their Black/African American and male counterparts. Future research is needed to improve health professional attention toward asking about and advising against vaping among adolescents.

Using logistic regression models to investigate the effects of high-sensitivity cardiac troponin T confounders on ruling in acute myocardial infarction.

OBJECTIVES: Confounding factors, including sex, age, and renal dysfunction, affect high-sensitivity cardiac troponin T (hs-cTnT) concentrations and the acute myocardial infarction (AMI) diagnosis. This study assessed the effects of these confounders through logistic regression models and evaluated the diagnostic performance of an optimized, integrated prediction model. METHODS: This retrospective study included a primary derivation cohort of 18,022 emergency department (ED) patients at a US medical center and a validation cohort of 890 ED patients at a Canadian medical center. Hs-cTnT was measured with 0/3 h sampling. The primary outcome was index AMI diagnosis. Logistic regression models were optimized to predict AMI using delta hs-cTnT and its confounders as covariates. The diagnostic performance of model cutoffs was compared to that of the hs-cTnT delta thresholds. Serial logistic regressions were carried out to evaluate the relationship between covariates. RESULTS: The area under the curve of the best-fitted model was 0.95. The model achieved a 90.0% diagnostic accuracy in the validation cohort. The optimal model cutoff yielded comparable performance (90.5% accuracy) to the optimal sex-specific delta thresholds (90.3% accuracy), with 95.8% agreement between the two diagnostic methods. Serial logistic regressions revealed that delta hs-cTnT played a more predominant role in AMI prediction than its confounders, among which sex is more predictive of AMI (total effect coefficient 1.04) than age (total effect coefficient 0.05) and eGFR (total effect coefficient -0.008). CONCLUSIONS: The integrated prediction model incorporating confounding factors does not outperform hs-cTnT delta thresholds. Sex-specific hs-cTnT delta thresholds remain to provide the highest diagnostic accuracy.

Evaluating the Immediate Impact of Graphic Messages for Vaping Prevention among Black and Latino Adolescents: A Randomized Controlled Trial.

The purpose of this pilot study was to assess the immediate impact of vaping prevention graphic messages on the susceptibility to future vaping among Black and Latino adolescents (ages 12 to 17). Graphic messages (available in English and Spanish) were developed using participatory research procedures with Black and Latino adolescents. Recruitment was conducted by a team of diverse, bilingual (English and Spanish), trained recruiters. Participants (n = 362) were randomized in a 1:1:1:1 schema to receive one of four graphic messages (health rewards, financial rewards, autonomy, and social norms). Overall, all graphic messages but one showed a slight decrease in the number of participants susceptible to future vaping, though none of these differences was statistically significant. The graphic message on health rewards decreased the number of participants susceptible to future vaping the most (55.7% vs. 50%, at pre- vs. post-viewing, p = 0.125), followed by the graphic messages on social norms and autonomy (55.1% vs. 52.8%, p = 0.687; 55.4% vs. 52.2%, p = 0.435; respectively). The graphic message on financial rewards increased the number of participants susceptible to future vaping slightly (52.7% vs. 53.8%, p = 1.00). Future research is needed to evaluate susceptibility to future vaping before and after exposure to different and/or repeated vaping prevention graphic messages.

Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias.

Importance: Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare's mandatory bundled payment reform-the Comprehensive Care for Joint Replacement (CJR) model-was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. Objective: To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. Design Setting and Participants: This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. Results: The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, -0.13 to -0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, -0.12 to -0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, -0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: -0.03, 95% CI, -0.09 to 0.02; P = .27). Conclusions and Relevance: In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.

Proactive and Reactive Recruitment of Black and Latino Adolescents in a Vaping Prevention Randomized Controlled Trial.

The purpose of this study was to assesses the effectiveness of proactive and reactive methods in the recruitment of Black and Latino adolescents into a vaping-prevention randomized controlled trial (RCT). This study also assessed the characteristics of study participants by recruitment method. Proactive recruitment strategies included study presentations at community-based events (e.g., festivals, health fairs), school-based events (e.g., back-to-school events, after-school programs), and recreational centers (e.g., fitness centers, malls). Reactive recruitment strategies included study advertisements via social media (e.g., Facebook posts shared by local community-based organizations), word of mouth, and an academic-based research hub. Using proactive and reactive methods, in a 4-month period, 362 Black and Latino adolescents were successfully enrolled into the RCT. Compared to the proactive method, adolescents screened reactively were equally likely to be eligible but significantly more likely to enroll in the study. However, both proactive and reactive strategies made notable contributions to the overall recruitment effort. Moreover, proactive and reactive methods attracted adolescents with different characteristics (e.g., age, gender, sexual orientation, etc.). These findings suggest that both proactive and reactive recruitment strategies should be implemented for studies interested in recruiting a diverse sample of Black and Latino adolescents.

Lonely older adults are more likely to delay or avoid medical care during the coronavirus disease 2019 pandemic.

OBJECTIVES: To examine the relationship between loneliness and self-reported delay or avoidance of medical care among community-dwelling older adults during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Analyses of data from a nationally representative survey administered in June of 2020, in COVID-19 module of the Health and Retirement Study. Bivariate and multivariable analyses determined associations of loneliness with the likelihood of, reasons for, and types of care delay or avoidance. RESULTS: The rate of care delay or avoidance since March of 2020 was 29.1% among all respondents (n = 1997), and 10.1% higher for lonely (n = 1,150%, 57.6%) versus non-lonely respondents (33.5% vs. 23.4%; odds ratio = 1.59, p = 0.003 after covariate adjustment). The differences were considerably larger among several subgroups such as those with emotional/psychiatric problems. Lonely older adults were more likely to cite "Decided it could wait," "Was afraid to go," and "Couldn't afford it" as reasons for delayed or avoided care. Both groups reported dental care and doctor's visit as the two most common care delayed or avoided. CONCLUSIONS: Loneliness is associated with a higher likelihood of delaying or avoiding medical care among older adults during the pandemic.

State social distancing restrictions and nursing home outcomes.

The COVID-19 poses a disproportionate threat to nursing home residents. Although recent studies suggested the effectiveness of state social distancing measures in the United States on curbing COVID-19 morbidity and mortality among the general population, there is a lack of evidence as to how these state orders may have affected nursing home patients or what potential negative health consequences they may have had. In this longitudinal study, we evaluated changes in state strength of social distancing restrictions from June to August of 2020, and their associations with the weekly numbers of new COVID-19 cases, new COVID-19 deaths, and new non-COVID-19 deaths in nursing homes of the US. We found that stronger state social distancing measures were associated with improved COVID-19 outcomes (case and death rates), reduced across-facility disparities in COVID-19 outcomes, and somewhat increased non-COVID-19 death rate, although the estimates for non-COVID-19 deaths were sensitive to alternative model specifications.

Trends in racial and ethnic disparities in coronavirus disease 2019 (COVID-19) outcomes among nursing home residents.

OBJECTIVES: To evaluate trends in racial and ethnic disparities in weekly cumulative rates of coronavirus disease 2019 (COVID-19) cases and deaths in Connecticut nursing homes. DESIGN: Longitudinal analysis of nursing-home COVID-19 reports and other databases. Multivariable negative binomial models were used to estimate disparities in COVID-19 incidence and fatality rates across nursing-home groups with varying proportions of racial and ethnic minority residents, defined as low-, medium-, medium-high-, and high-proportion groups. Trends in such disparities were estimated from week 1 (April 13) to week 10 (ending on June 19, 2020). SETTING: The study was conducted across 211 nursing homes. RESULTS: The average number of cases ranged from 6.1 cases per facility for the low-proportion group to 11.7 cases per facility for the high-proportion group in week 1, and from 26.7 to 58.5 cases per facility in week 10. Compared to the low-proportion group, the adjusted incidence rate ratios (IRRs) for the high-proportion group were 1.18 (95% confidence interval [CI], 0.77-1.80; P > .10) in week 1 and 1.54 (95% CI, 1.05-2.25; P < .05) in week 10, showing a 30% (95% CI, 5%-62%) relative increase (P < .05). The average weekly number of COVID-19-related deaths ranged from 0 to 0.3 deaths per facility for different groups in week 1, and from 7.6 to 13.3 deaths per facility in week 10. Adjusted disparities in fatalities similarly increased over time. CONCLUSIONS: Connecticut nursing homes caring for predominately racial and ethnic minority residents tended to have higher COVID-19 incidence and fatality rates. These across-facility disparities increased during the early periods of the pandemic.

Sex-Specific Absolute Delta Thresholds for High-Sensitivity Cardiac Troponin T.

BACKGROUND: Sex differences in high-sensitivity cardiac troponin (hs-cTn) concentrations from healthy populations have led to the establishment of sex-specific upper reference limits for hs-cTn assays. This study assessed the performance of sex-specific delta (i.e., changes in concentrations) thresholds for the hs-cTnT assay for ruling in acute myocardial infarction (AMI) in different emergency department (ED) populations. METHODS: This retrospective study consisted of 2 cohorts (Cohort 1 derivation and Cohort 2 validation). Cohort 1 consisted of 18 056 ED patients who had serial hs-cTnT measured using a 0-h/3-h algorithm at a US medical center, with Cohort 2 consisting of 1137 ED patients with 0-h/3-h sampling at a Canadian medical center. The primary outcome was AMI diagnosis with sex-specific deltas derived based on the Youden index and specificity estimates (i.e., ≥90%) in Cohort 1 and validated in Cohort 2. RESULTS: In Cohort 1, 42% of all patients had 0-h hs-cTnT above the sex-specific 99th percentile. Males had higher 0-h hs-cTnT (median 17 ng/L) and absolute deltas (median 2 ng/L) than females (0-h median 11 ng/L, P < 0.0001; deltas median 1 ng/L, P < 0.0001) in non-AMI patients but not in patients with AMI. For ruling in AMI, the sex-specific delta thresholds based on 90% specificity (14 ng/L for males, 11 ng/L for females) performed best and resulted in 91% diagnostic accuracy in both males and females. The sex-specific delta thresholds yielding high specificity estimates were confirmed in the validation data set. CONCLUSIONS: Sex-specific absolute delta thresholds can be used to rule in AMI and are robust across different study populations.

Asthma biologics: Real-world effectiveness, impact of switching biologics, and predictors of response.

BACKGROUND: Confirmation of effectiveness of asthma biologics in the real world is desirable because patient characteristics and experiences may differ from those included in randomized controlled trials. OBJECTIVE: To evaluate real-world effectiveness of asthma biologics and identify predictors of response. METHODS: We performed a retrospective study in patients with severe asthma receiving biologics. The primary outcome was change in clinically significant exacerbations at 12 months after starting biologic therapy, compared with 12 months before. Secondary outcomes were change in severe exacerbations, maintenance oral corticosteroid (OCS) dose, prebronchodilator forced expiratory volume in 1 second (FEV1), and asthma control test scores. Subgroup analyses were performed for subjects who were biologic naive or not. A stepwise logistic regression model was performed to compare responders to nonresponders. RESULTS: A total of 112 patients were included. Biologic therapy was associated with a 59% reduction in clinically significant exacerbations (P < .001), 65% reduction in severe exacerbations (P < .001), and 54% reduction in maintenance OCS dose (P = .001) in the 12 months after starting therapy. Biologics also resulted in improvement in prebronchodilator FEV1 (P = .002) and Asthma Control Test score (P < .001). Subjects who were previously on another biologic also experienced significant improvements in exacerbation frequency, maintenance OCS dose, and asthma control. Responders were more likely to be nonsmokers and have higher baseline FEV1, gastroesophageal reflux disease, and eosinophil counts greater than 500 cells/µL. CONCLUSION: In a real-world setting, biologic therapy in asthma is effective in improving exacerbations, asthma control, and lung function. Patients who have a suboptimal response to 1 biologic can still benefit from treatment with a different biologic.

Association of the Comprehensive Care for Joint Replacement Model With Disparities in the Use of Total Hip and Total Knee Replacement.

Importance: The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and income. Results of this study could be the basis for a Medicare payment reform that addresses inequities in joint replacement care. Objective: To examine the association of the CJR model with racial/ethnic and socioeconomic disparities in the use of elective THR and TKR among older Medicare beneficiaries after accounting for the population of patients who were at risk or eligible for these surgical procedures. Design, Setting, and Participants: This cohort study used the 2013 to 2017 national Medicare data and multivariable logistic regressions with triple-differences estimation. Medicare beneficiaries who were aged 65 to 99 years, entitled to Medicare, alive at the end of the calendar year, and residing either in the 67 metropolitan statistical areas (MSAs) mandated to participate in the CJR model or in the 104 control MSAs were identified. A subset of Medicare beneficiaries with a diagnosis of arthritis underwent THR or TKR. Data were analyzed from March to December 2020. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether a beneficiary underwent THR or TKR. Key independent variables were MSA treatment status, pre- or post-CJR model implementation phase, combination of race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic beneficiaries) and dual eligibility, and their interactions. Logistic regression models were used to control for patient characteristics, MSA fixed effects, and time trends. Results: The 2013 cohort included 4 447 205 Medicare beneficiaries, of which 2 025 357 (45.5%) resided in MSAs with the CJR model. The cohort's mean (SD) age was 77.18 (7.95) years, and it was composed of 2 951 140 female (66.4%), 3 928 432 non-Hispanic White (88.3%), and 657 073 dually eligible (14.8%) beneficiaries. Before the CJR model implementation, rates were highest among non-Hispanic White non-dual-eligible beneficiaries at 1.25% (95% CI, 1.24%-1.26%) for THR use and 2.28% (95% CI, 2.26%-2.29%) for TKR use in MSAs with CJR model. Compared with MSAs without the CJR model and the analogous race/ethnicity and dual-eligibility group, the CJR model was associated with a 0.10 (95% CI, 0.05-0.15; P < .001) percentage-point increase in TKR use for non-Hispanic White non-dual-eligible beneficiaries, a 0.11 (95% CI, 0.004-0.21; P = .04) percentage-point increase for non-Hispanic White dual-eligible beneficiaries, a 0.15 (95% CI, -0.29 to -0.01; P = .04) percentage-point decrease for non-Hispanic Black non-dual-eligible beneficiaries, and a 0.18 (95% CI, -0.34 to -0.01; P = .03) percentage-point decrease for non-Hispanic Black dual-eligible beneficiaries. These CJR model-associated changes in TKR use were 0.25 (95% CI, -0.40 to -0.10; P = .001) percentage points lower for non-Hispanic Black non-dual-eligible beneficiaries and 0.27 (95% CI, -0.45 to -0.10; P = .002) percentage points lower for non-Hispanic Black dual-eligible beneficiaries compared with the model-associated changes for non-Hispanic White non-dual-eligible beneficiaries. No association was found between the CJR model and a widening of the THR use gap among race/ethnicity and dual eligibility groups. Conclusions and Relevance: Results of this study indicate that the CJR model was associated with a modest increase in the already substantial difference in TKR use among non-Hispanic Black vs non-Hispanic White beneficiaries; no difference was found for THR. These findings support the widespread concern that payment reform has the potential to exacerbate disparities in access to joint replacement care.

Smooth ROC curve estimation via Bernstein polynomials.

The receiver operating characteristic (ROC) curve is commonly used to evaluate the accuracy of a diagnostic test for classifying observations into two groups. We propose two novel tuning parameters for estimating the ROC curve via Bernstein polynomial smoothing of the empirical ROC curve. The new estimator is very easy to implement with the naturally selected tuning parameter, as illustrated by analyzing both real and simulated data sets. Empirical performance is investigated through extensive simulation studies with a variety of scenarios where the two groups are both from a single family of distributions (symmetric or right skewed) or one from a symmetric and the other from a right skewed distribution. The new estimator is uniformly more efficient than the empirical ROC estimator, and very competitive to eleven other existing smooth ROC estimators in terms of mean integrated square errors.

Association of state social distancing restrictions with nursing home COVID-19 and non-COVID-19 outcomes.

The COVID-19 poses a disproportionate threat to nursing home residents. Although recent studies suggested the effectiveness of state social distancing measures in the United States on curbing COVID-19 morbidity and mortality among the general population, there is lack of evidence as to how these state orders may have affected nursing home patients or what potential negative health consequences they may have had. In this longitudinal study, we evaluated changes in state strength of social distancing restrictions from June to August of 2020, and their associations with the weekly numbers of new COVID-19 cases, new COVID-19 deaths, and new non-COVID-19 deaths in nursing homes of the US. We found that stronger state social distancing measures were associated with improved COVID-19 outcomes (case and death rates), reduced across-facility disparities in COVID-19 outcomes, but more deaths due to non-COVID-19 reasons among nursing home residents.