Enhancing Clinical Decision Support in Nephrology: Addressing Algorithmic Bias Through Artificial Intelligence Governance.

There has been a steady rise in the use of clinical decision support (CDS) tools to guide Nephrology, as well as general clinical care. Through guidance set by federal agencies and concerns raised by clinical investigators, there has been an equal rise in understanding whether such tools exhibit algorithmic bias leading to unfairness. This has spurred the more fundamental question of whether sensitive variables such as race should be included in CDS tools. In order to properly answer this question, it is necessary to understand how algorithmic bias arises. We break down three sources of bias encountered when using electronic health record data to develop CDS tools: (1) use of proxy variables, (2) observability concerns and (3) underlying heterogeneity. We discuss how answering the question of whether to include sensitive variables like race often hinges more on qualitative considerations than on quantitative analysis, dependent on the function that the sensitive variable serves. Based on our experience with our own institution's CDS governance group, we show how health system-based governance committees play a central role in guiding these difficult and important considerations. Ultimately, our goal is to foster a community practice of model development and governance teams that emphasizes consciousness about sensitive variables and prioritizes equity.

Predictive Accuracy of Stroke Risk Prediction Models Across Black and White Race, Sex, and Age Groups.

Importance: Stroke is the fifth-highest cause of death in the US and a leading cause of serious long-term disability with particularly high risk in Black individuals. Quality risk prediction algorithms, free of bias, are key for comprehensive prevention strategies. Objective: To compare the performance of stroke-specific algorithms with pooled cohort equations developed for atherosclerotic cardiovascular disease for the prediction of new-onset stroke across different subgroups (race, sex, and age) and to determine the added value of novel machine learning techniques. Design, Setting, and Participants: Retrospective cohort study on combined and harmonized data from Black and White participants of the Framingham Offspring, Atherosclerosis Risk in Communities (ARIC), Multi-Ethnic Study for Atherosclerosis (MESA), and Reasons for Geographical and Racial Differences in Stroke (REGARDS) studies (1983-2019) conducted in the US. The 62 482 participants included at baseline were at least 45 years of age and free of stroke or transient ischemic attack. Exposures: Published stroke-specific algorithms from Framingham and REGARDS (based on self-reported risk factors) as well as pooled cohort equations for atherosclerotic cardiovascular disease plus 2 newly developed machine learning algorithms. Main Outcomes and Measures: Models were designed to estimate the 10-year risk of new-onset stroke (ischemic or hemorrhagic). Discrimination concordance index (C index) and calibration ratios of expected vs observed event rates were assessed at 10 years. Analyses were conducted by race, sex, and age groups. Results: The combined study sample included 62 482 participants (median age, 61 years, 54% women, and 29% Black individuals). Discrimination C indexes were not significantly different for the 2 stroke-specific models (Framingham stroke, 0.72; 95% CI, 0.72-073; REGARDS self-report, 0.73; 95% CI, 0.72-0.74) vs the pooled cohort equations (0.72; 95% CI, 0.71-0.73): differences 0.01 or less (P values >.05) in the combined sample. Significant differences in discrimination were observed by race: the C indexes were 0.76 for all 3 models in White vs 0.69 in Black women (all P values <.001) and between 0.71 and 0.72 in White men and between 0.64 and 0.66 in Black men (all P values ≤.001). When stratified by age, model discrimination was better for younger (<60 years) vs older (≥60 years) adults for both Black and White individuals. The ratios of observed to expected 10-year stroke rates were closest to 1 for the REGARDS self-report model (1.05; 95% CI, 1.00-1.09) and indicated risk overestimation for Framingham stroke (0.86; 95% CI, 0.82-0.89) and pooled cohort equations (0.74; 95% CI, 0.71-0.77). Performance did not significantly improve when novel machine learning algorithms were applied. Conclusions and Relevance: In this analysis of Black and White individuals without stroke or transient ischemic attack among 4 US cohorts, existing stroke-specific risk prediction models and novel machine learning techniques did not significantly improve discriminative accuracy for new-onset stroke compared with the pooled cohort equations, and the REGARDS self-report model had the best calibration. All algorithms exhibited worse discrimination in Black individuals than in White individuals, indicating the need to expand the pool of risk factors and improve modeling techniques to address observed racial disparities and improve model performance.

Presurgical and Postsurgical Opioid Rates in Patients Undergoing Total Shoulder Replacement Surgery.

BACKGROUND: The purpose of this study was to describe the pre- and postsurgical opioid prescription rates and average morphine milligram equivalents (MME) per day in patients undergoing total shoulder replacement (TSR) procedures. METHODS: Patients undergoing TSR were identified from the electronic health records (EMR). In addition to patient demographics, opioid prescription 12-months presurgery and postsurgery were recorded. Patients were categorized into two groups: patients with no opioid prescriptions within 12 months before surgery and patients with an opioid prescription after surgery. McNemar tests were conducted to test for significant presurgical to postsurgical changes in opioid rate changes. The Wilcoxon signed rank test was used to test for significant pre- to postsurgical changes in average MME/day/person, and bivariate logistic regression analyses and covariate-adjusted logistic regressions were used to predict postsurgical opioid prescriptions. RESULTS: Overall, 1,076 patients underwent TSR. More than 900 patients received presurgical opioid prescriptions. There was a significant increase (p = .0015) in pre-surgical to postsurgical prescription rates. Postsurgical opioid prescriptions were 4.6 times more likely to be prescribed to a pre-surgical non-opioid patient than an opioid patient (p < .0001). Among those prescribed an opioid, the median dosage was <50 MME/day and over 82% of patients were at low overdose risk. Patients with comorbidities and without pre-surgical alcohol use were more likely to receive postsurgical opioids. Postsurgical opioid prescriptions were 4.6 times more likely to be prescribed to a presurgical non-opioid patient than an opioid patient (p < .0001). More than 80% of patients undergoing TSR received presurgical opioids. Among those prescribed any opioid, the median dosage was <50 MME/day and greater than 82% of patients were at low overdose risk. CONCLUSIONS: Although presurgical non-opioid patients were more likely to receive a postsurgical opioid prescription, based on dosage, most patients were at low risk for an opioid-related overdose or death according to CDC guidelines.

Hospital Utilization for Coronary Artery Disease, 1997-2014.

BACKGROUND: Coronary artery disease (CAD) is the leading cause of cardiovascular morbidity, mortality, and healthcare costs in the United States. There are few reports on how public health and payment reforms might have influenced inpatient hospital use among patients with CAD. OBJECTIVE: This study describes trends in hospital discharges, hospital charges, and discharge destinations in a national sample of patients with CAD between 1997 and 2014. METHODS: This was a longitudinal study with descriptive analysis of the Healthcare Cost and Utilization Project of National Inpatient Sample data. FINDINGS: During this study period, the total number of discharges was 1 333 996. Patients with CAD between 65 and 84 years old were among the highest users of inpatient hospital services, followed by those in the 45- to 64-year age group. The death rate increased from 5961 to 7217 per 10 000 patients during this time. The mean charge increased more than 5 times, from $9100 to $49 643. There was a large difference in mean hospital charges in urban ($51 666) and rural ($25 548) locations in 2014. Coronary artery disease patients with private insurance paid more than those with Medicaid and Medicare plans. The discharge to home and healthcare costs increased by 4.1% and 4.8%, respectively. CONCLUSION AND IMPLICATIONS: Future researchers should use data sets, such as Medicare claims/Medical Expenditure Panel Study, that can provide comprehensive insights into patient-level factors influencing the use of inpatient care services among patients with CAD. Healthcare providers in posthospital settings should be well skilled in providing advanced cardiac rehabilitation and education to patients with CAD.

Do heavy-duty and passenger vehicle emissions standards reduce per capita emissions of oxides of nitrogen? Evidence from Europe.

Oxides of nitrogen are among the most dangerous emissions to human health and to the environment. In European nations, road transportation contributes to approximately 40% of emissions of oxides of nitrogen with the dominant share coming from passenger and freight transport. To help mitigate emissions of oxides of nitrogen, the European Union (EU) has implemented vehicular emissions standards. This paper studies the effect of EU vehicular emissions standards on per capita emissions of oxides of nitrogen in European nations during the period 2000 to 2017, both for on-road vehicular emissions and at the economy level. To do this, pollution is modelled as a byproduct of economic production. After controlling for economic growth, historical per capita levels of emissions of oxides of nitrogen, and a series of geographic and technological factors, it is determined that the vehicular emissions standards put in place by the EU decrease per capita levels of emissions of oxides of nitrogen. More precisely, reducing the heavy duty emissions standard by 1 g/kWh leads to as much as a 7% reduction in per capita on-road emissions of oxides of nitrogen. Reducing the passenger vehicle emissions standards for both diesel and gasoline engines enhances this effect, resulting in an even greater reduction in per capita emissions of oxides of nitrogen. These results further suggest that any rebound effect taking place is outweighed by the reduction in emissions of oxides of nitrogen from lowering emissions standards.

Age- and sex-specific predictors of inpatient rehabilitation facility discharge destination for adult patients with traumatic brain injury.

OBJECTIVE: : To determine age- and sex-specific predictors of discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. DESIGN: : Secondary analysis of Uniform Data System for Medical Rehabilitation data. METHODS: : Logistic regression of patients (N = 221,961) age ≥18, TBI diagnosis, admitted to IRF between 2002 and 2018. OUTCOME: : Discharge destination (subacute vs. home/community settings). RESULTS: : Approximately 16% were discharged to subacute vs. 84% home. Younger versus older adults had lower odds of subacute discharge [OR = 0.72; 95% CI: 0.69, 0.76]. Younger females had lower odds of subacute discharge (vs. home) than older females [OR = 0.68; 95% CI: 0.63, 0.74]; younger males had lower odds of subacute discharge (vs. home) than older males [OR = 0.74; 95% CI: 0.70, 0.78]. Younger females versus younger males had lower odds of subacute discharge (vs. home) [OR = 0.83; 95% CI: 0.79, 0.87]. Older females versus older males had lower odds of subacute discharge (vs. home) [OR = 0.93; 95% CI: 0.90, 0.97]. Predictors of discharge destination for age- and sex-stratified groups varied. CONCLUSIONS: : Younger (vs. older) and female (vs. male) patients had lower odds of subacute discharge vs. home.

Inpatient rehabilitation facility discharge destination among younger adults with traumatic brain injury: differences by race and ethnicity.

OBJECTIVE: : To determine the association of race and ethnicity with discharge destination among patients with traumatic brain injury (TBI) receiving inpatient rehabilitation facility (IRF) care. DESIGN: Secondary analysis using Uniform Data System for Medical Rehabilitation data. METHODS: : Patients (N = 99,614) diagnosed with TBI, age 18-64, admitted for IRF care between 2002 and 2018. Logistic regression was used to analyze data. OUTCOME: : Discharge destination (home/community vs. subacute settings). RESULTS: : Most younger adults (age 18-64) with TBI were discharged home (89.24%) after IRF care vs. subacute (10.76%). Of those discharged home, 63.16% were white, 10.42% Black, 8.94% Hispanic/Latino, and 6.72% other races/ethnicities. After adjusting for covariates, patients who were Hispanic/Latino [OR = 1.26; 95% CI: 1.15, 1.37] and other race/ethnicities [OR = 1.10; 95% CI: 1.00, 1.21] (vs. White) had higher odds of discharge home vs. subacute. There was no difference in discharge destination for Black patients (vs. white). Predictors of discharge destination for groups stratified by race/ethnicity varied. CONCLUSIONS: : Younger patients with TBI who were Hispanic/Latino or other races/ethnicities (vs. white) were more likely to go home vs. subacute. Findings can be used to inform IRF planning, resource allocation, and transitional care planning.

Group Coaching Among African-American Individuals with Prediabetes in a Faith-Based Setting.

Roughly 88 million adults have prediabetes and over 84% are unaware that they even have prediabetes. African-Americans have an increased risk of being diagnosed with prediabetes. Faith-based organizations have a history of serving as a primary source of social support for African-Americans. Parishioners with prediabetes from four African-American churches participated in free, evidence-based group coaching to learn how to manage and control risk factors associated with type 2 diabetes. The weekly group coaching sessions took place at a local church and they were co-facilitated by two trained professionals: a lifestyle coach and a nurse practitioner. At the conclusion of the 16-week group coaching sessions, participants had a decrease in hemoglobin A1C levels, an increase in minutes of physical activity per week, and an improvement in knowledge and behavior.

Quality of life in older adults receiving hemodialysis: a qualitative study.

PURPOSE: Patient priorities for quality of life change with age. We conducted a qualitative study to identify quality of life themes of importance to older adults receiving dialysis and the extent to which these are represented in existing quality of life instruments. METHODS: We conducted semi-structured interviews with 12 adults aged ≥ 75 years receiving hemodialysis to elicit participant perspectives on what matters most to them in life. We used framework analysis methodology to process interview transcripts (coding, charting, and mapping), identify major themes, and compare these themes by participant frailty status. We examined for representation of our study's subthemes in the Kidney Disease Quality of Life (KDQOL-36) and the World Health Organization Quality of Life for Older Adults (WHOQOL-OLD) instruments. RESULTS: Among the 12 participants, average age was 81 (4.2) years, 7 African-American, 6 women, and 6 met frailty criteria. We identified two major quality of life themes: (1) having physical well-being (subthemes: being able to do things independently, having symptom control, maintaining physical health, and being alive) and (2) having social support (subthemes: having practical social support, emotional social support, and socialization). Perspectives on the subthemes often varied by frailty status. For example, being alive meant surviving from day-to-day for frail participants, but included a desire for new life experiences for non-frail participants. The majority of the subthemes did not correspond with domains in the KDQOL-36 and WHOQOL-OLD instruments. CONCLUSION: Novel instruments are likely needed to elicit the dominant themes of having physical well-being and having social support identified by older adults receiving dialysis.

Hospital Readmission and Costs of Total Knee Replacement Surgery in 2009 and 2014: Potential Implications for Health Care Managers.

The purpose of this article is to describe changes in hospital readmissions and costs for US hospital patients who underwent total knee replacement (TKR) in 2009 and 2014. Data came from the Healthcare Cost and Utilization Project net-Nationwide Readmissions Database. Compared with 2009, overall 30-day rates of readmissions after TKR decreased by 15% in 2014. Rates varied by demographics: readmission rates were lower for younger patients, males, Medicare recipients, and those with higher incomes. Overall, costs rose 20% across TKR groups. This report is among the first to describe changes in hospital readmissions and costs for TKR patients in a national sample of US acute care hospitals. Findings offer hospital managers a mechanism to benchmark their facilities' performances.

Hospital Readmission in Total Hip Replacement Patients in 2009 and 2014.

OBJECTIVE: To document changes in 30-day hospital readmission rates and causes for returning to the hospital for care in THR patients. DESIGN: Retrospective cross-sectional descriptive design. SETTING: Community-based acute care hospitals. PARTICIPANTS: Total sample size (N=142,022) included THR patients (identified as ICD-9-CM procedure code 81.51) in 2009 (n=31,232) and (n=32,863) in 2014. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: 30-Day hospital readmission. RESULTS: The overall readmission rate decreased by 1.3% from 2009 to 2014. The decrease in readmission rates varied by groups, with lesser improvements seen in THR patients who were younger, with private insurance, and residing in lower-income and rural communities. Device complications were the leading cause of readmission in THR patients, increasing from 19.8% in 2009 to 23.9% in 2014. CONCLUSIONS: There has been little decrease in hospital 30-day readmission rates for US community hospitals between 2009 and 2014. Findings from this brief report indicate patient groups at greater risk for 30-day hospital readmission as well as leading causes for readmission in THR patients which can inform the development of tailored interventions for reduction.

Management Team Perceptions of Risks and Strategies for Preventing Falls Among Short-Stay Patients in Nursing Homes.

We sought to understand strategies reported by members of the nursing home management team used to prevent falls in short-stay nursing home patients. Using Donabedian's model of structure, process, and outcomes, we interviewed 16 managers from 4 nursing homes in central North Carolina. Nursing home managers identified specific barriers to fall prevention among short-stay patients including rapid changes in functional and cognitive status, staff unfamiliarity with short-stay patient needs and patterns, and policies impacting care. Few interventions for reducing falls among short-stay patients were used at the structure level (eg, specialized units, workload ratio, and staffing consistency); however, many process-level interventions were used (eg, patient education on problem solving, self-care/mobility, and safety). We described several barriers to fall prevention among short-stay patients in nursing homes. From these descriptions, we propose three interventions that might reduce falls for short-stay patients and could be tested in future research: (1) clustering short-stay patients within a physical location to permit higher staff-patient ratios and enhanced surveillance, (2) population-based prevention interventions to supplement existing individually tailored prevention strategies (eg, toileting schedules, medication review for all), and (3) transitional care interventions that transmit key information from hospitals to nursing homes.

Self-Care and Mobility Following Postacute Rehabilitation for Older Adults With Hip Fracture: A Multilevel Analysis.

OBJECTIVE: To examine contextual (facility and community) and individual factors associated with self-care and mobility outcomes among Medicare hip fracture patients receiving inpatient rehabilitation. DESIGN: Retrospective cohort study of 3 linked data files: Inpatient Rehabilitation Facility-Patient Assessment Instrument, Provider of Services, and Area Health Resources. Multilevel modeling was used to examine the effects of contextual and individual factors on self-care and mobility outcomes. SETTING: Inpatient rehabilitation facilities (IRFs). PARTICIPANTS: Medicare hip fracture patients (N=35,264; mean age, 81y) treated in IRFs (N=1072) in 2012. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-care (eating, grooming, bathing, upper and lower body dressing, toileting) and mobility (walk/wheelchair, stairs) at discharge. RESULTS: Mean ± SD self-care and mobility scores at admission were 3.17±.87 and 1.24±.51, respectively; mean ± SD self-care and mobility scores at discharge were 5.03±1.09 and 3.31±1.54, respectively. Individual and contextual levels explained 44.4% and 21.6% of the variance in self-care at discharge, respectively, and 19.5% and 1.9% of the variance in mobility at discharge, respectively. At the individual level, age, race/ethnicity, cognitive and motor FIM scores at admission, and tier comorbidities explained variance in self-care and mobility; sex and length of stay explained variance only in self-care. At the contextual level, facilities' case mix (mean patient age, percent non-Hispanic white, mean self-care score at admission) and structural characteristics (rural location, freestanding, for-profit ownership) explained variance only in self-care; facilities' case mix (mean patient age, percent non-Hispanic white, percent living with social support, mean mobility score at admission) explained variance in mobility. Community variables were nonsignificant. CONCLUSIONS: Individual and facility factors were significant predictors of discharge self-care and mobility among Medicare hip fracture patients in IRFs. The findings may improve quality of IRF services to hip fracture patients and inform risk adjustment methods.

The Effects of Social Support on Physical Functioning in Older African Americans: Longitudinal Results from the Baltimore Study of Black Aging.

INTRODUCTION: Compared with other racial/ethnic groups, African Americans have higher rates of chronic conditions and suffer a disproportionate burden of disability. We aimed to examine the effects of social support on physical functioning among older African Americans. METHODS: We analyzed a sample of 448 urban, community-dwelling, older African Americans (aged 48-98 years) from the Baltimore Study of Black Aging. Baseline physical functioning was collected between 2006 and 2008 (wave 1), and change in physical functioning was collected between 2009 and 2011 (wave 2), physical functioning was assessed by self-reported limitations in 7 activities of daily living-eating, dressing, grooming, walking, bathing, using the toilet, and transferring in and out of bed-using a binary variable to indicate whether the individual had difficulty performing each specific activity. Social support was measured by how frequently participants provided/received goods and services, financial assistance, transportation, companionship, advice, or encouragement (never [0], rarely [1], sometimes [2], frequently [3]). Negative binomial regression models were used to test the effects of social support given, received, and a ratio (support received/support given) on physical functioning for those who improved and those who declined in physical functioning. RESULTS: Participants reported physical functioning at wave 1 (1.24, standard deviation [SD] = 1.98) and at wave 2 (0.34, SD = 0.83). Average social support given was 7.49 (SD = 3.26), and average social support received was 7.81 (SD = 3.17). Those who improved in physical function gave less social support and had lower social support ratios; social support received had no effect. Those who remained stable or declined in physical function gave more social support; neither social support received nor social ratio had an effect. CONCLUSION: Social support given and social support received as well as the ratio should be considered when seeking to understand how physical functioning changes over time among older African Americans.

Relationship Between Chronic Conditions and Disability in African American Men and Women.

BACKGROUND: Race differences in chronic conditions and disability are well established; however, little is known about the association between specific chronic conditions and disability in African Americans. This is important because African Americans have higher rates and earlier onset of both chronic conditions and disability than white Americans. METHODS: We examined the relationship between chronic conditions and disability in 602 African Americans aged 50 years and older in the Baltimore Study of Black Aging. Disability was measured using self-report of difficulty in activities of daily living (ADL). Medical conditions included diagnosed self-reports of asthma, depressive symptoms, arthritis, cancer, diabetes, cardiovascular disease (CVD), stroke, and hypertension. RESULTS: After adjusting for age, high school graduation, income, and marital status, African Americans who reported arthritis (women: odds ratio (OR)=4.87; 95% confidence interval(CI): 2.92-8.12; men: OR=2.93; 95% CI: 1.36-6.30) had higher odds of disability compared to those who did not report having arthritis. Women who reported major depressive symptoms (OR=2.59; 95% CI: 1.43-4.69) or diabetes (OR=1.83; 95% CI: 1.14-2.95) had higher odds of disability than women who did not report having these conditions. Men who reported having CVD (OR=2.77; 95% CI: 1.03-7.41) had higher odds of disability than men who did not report having CVD. CONCLUSIONS: These findings demonstrate the importance of chronic conditions in understanding disability in African Americans and how it varies by gender. Also, these findings underscore the importance of developing health promoting strategies focused on chronic disease prevention and management to delay or postpone disability in African Americans. PUBLICATION INDICES: Pubmed, Pubmed Central, Web of Science database.

The Relationship between Pain, Disability, and Sex in African Americans.

Older African Americans consistently report diminished capacities to perform activities of daily living (ADL) compared with other racial groups. The extent to which bodily pain is related to declining abilities to perform ADL/ADL disability in African Americans remains unclear, as does whether this relationship exists to the same degree in African American men and women. For nurses to provide optimal care for older African Americans, a better understanding of the relationship between bodily pain and ADL disability and how it may differ by sex is needed. The aim of this study was to examine whether pain, age, education, income, marital status and/or comorbid conditions were associated with ADL disabilities in older African American women and men. This was a cross-sectional descriptive study. The sample included 598 participants (446 women, 152 men) from the first wave of the Baltimore Study on Black Aging. African American women (odds ratio [OR] = 4.06; 95% confidence interval [CI] 2.63-6.26) and African American men (OR = 6.44; 95% CI = 2.84-14.57) who reported bodily pain had greater ADL disability than those who did not report bodily pain. Having two or more comorbid conditions also was significantly associated with ADL disability in African American women (OR = 3.95; 95% CI: 2.09-7.47). Further work is needed to understand pain differences between older African American women and men to develop interventions that can be tailored to meet the individual pain needs of both groups.

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012.

PURPOSE: To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012. DESIGN: Longitudinal retrospective design METHODS: Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data. FINDINGS: A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44-65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased. CONCLUSION: We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings. CLINICAL RELEVANCE: Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

Performance-based outcomes of inpatient rehabilitation facilities treating hip fracture patients in the United States.

OBJECTIVE: To examine the influence of facility and aggregate patient characteristics of inpatient rehabilitation facilities (IRFs) on performance-based rehabilitation outcomes in a national sample of IRFs treating Medicare beneficiaries with hip fracture. DESIGN: Secondary data analysis. SETTING: U.S. Medicare-certified IRFs (N=983). PARTICIPANTS: Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community. RESULTS: Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P<.001] and Hispanics [P<.001], higher percentage of women [P=.030], higher motor function on admission [P<.001], longer length of stay [P<.001]) and facility characteristics (freestanding [P<.001], rural [P<.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P<.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P<.001], higher motor function on admission [P<.001]). No facility characteristics were associated with the percentage discharged to the community. CONCLUSIONS: Performance-based measurement offers health policymakers, administrators, clinicians, and consumers a major opportunity for securing health system improvement by benchmarking or comparing their outcomes with those of other similar facilities. These results might serve as the basis for benchmarking and quality-based reimbursement to IRFs for 1 impairment group: hip fracture.

A Qualitative Study of the Social Relationship Experiences Across the Life Course Among Black/African American Women Aging With HIV in the South.

ABSTRACT: Black/African American women continue to be disproportionately affected by HIV, facing multiple intersecting challenges that influence how they age and effectively manage their health. Supportive social relationships have been shown to help mitigate challenges and improve health in women with HIV, but little is known about Black/African American women's perceptions of social relationships. Guided by Life Course Theory, in-depth life history interviews were conducted with 18 Black/African American women aged 50+ years. In older adulthood, most important relationships among Black/African American women were with their adult children and grandchildren, intimate partners, God, and friends from the community. Factors that influenced relationships over time included: (a) a desire to build a community; (b) a need to empower oneself and give back; (c) yearning to engage the younger generation; and (d) battling HIV stigma. Older Black/African American women with HIV played a critical role in the education of the younger generation.