Readmission Rates and Episode Costs for Alzheimer Disease and Related Dementias Across Hospitals in a Statewide Collaborative.

Importance: There has been a paucity of research examining the risk and cost of readmission among patients with Alzheimer disease and related dementias (ADRD) after a planned hospitalization for a broad set of medical and surgical procedures. Objective: To examine 30-day readmission rates and episode costs, including readmission costs, for patients with ADRD compared with their counterparts without ADRD across Michigan hospitals. Design, Setting, and Participants: This retrospective cohort study used 2012 to 2017 Michigan Value Collaborative data across different medical and surgical services stratified by ADRD diagnosis. A total of 66 676 admission episodes of care that occurred between January 1, 2012, and June 31, 2017, were identified for patients with ADRD using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes for ADRD, along with 656 235 admission episodes in patients without ADRD. Using a generalized linear model framework, this study risk adjusted, price standardized, and performed episode payment winsorization. Payments were risk adjusted for age, sex, Hierarchical Condition Categories, insurance type, and prior 6-month payments. Selection bias was accounted for using multivariable logistic regression with propensity score matching without replacement using calipers. Data analysis was performed from January to December 2019. Exposure: Presence of ADRD. Main Outcomes and Measures: Main outcomes were 30-day readmission rate at the patient and county levels, 30-day readmission cost, and 30-day total episode cost across 28 medical and surgical services. Results: The study included 722 911 hospitalization episodes, of which 66 676 were related to patients with ADRD (mean [SD] age, 83.4 [8.6] years; 42 439 [63.6%] female) and 656 235 were related to patients without ADRD (mean [SD] age, 66.0 [15.4] years; 351 246 [53.5%] female). After propensity score matching, 58 629 hospitalization episodes were included for each group. Readmission rates were 21.5% (95% CI, 21.2%-21.8%) for patients with ADRD and 14.7% (95% CI, 14.4%-15.0%) for patients without ADRD (difference, 6.75 percentage points; 95% CI, 6.31-7.19 percentage points). Cost of 30-day readmission was $467 higher (95% CI of difference, $289-$645) among patients with ADRD ($8378; 95% CI, $8263-$8494) than those without ($7912; 95% CI, $7776-$8047). Across all 28 service lines examined, total 30-day episode costs were $2794 higher for patients with ADRD vs patients without ADRD ($22 371 vs $19 578; 95% CI of difference, $2668-$2919). Conclusions and Relevance: In this cohort study, patients with ADRD had higher readmission rates and overall readmission and episode costs than their counterparts without ADRD. Hospitals may need to be better equipped to care for patients with ADRD, especially in the postdischarge period. Considering that any type of hospitalization may put patients with ADRD at a high risk of 30-day readmission, judicious preoperative assessment, postoperative discharge, and care planning are strongly advised for this vulnerable patient population.

Socioeconomic Status and Glycemic Control in Type 2 Diabetes; Race by Gender Differences.

Background: This study aimed to investigate differences in the association between socioeconomic status (SES) and glycemic control in type 2 diabetes mellitus (DM) across race by gender groups. Methods: Using a convenient sampling strategy, participants were 112 patients with type 2 DM who were prescribed insulin (ns = 38 Black women, 34 Black men, 14 White women, and 26 White men, respectively). Linear regression was used to test the associations between sociodemographic variables (race, gender, SES, governmental insurance) and Hemoglobin A1c (HbA1c) in the pooled sample and within subgroups defined by race and gender. Results: In the pooled sample, neither SES nor governmental insurance were associated with HbA1c. However, the race by gender interaction approached statistical significance (B = 0.34, 95% CI = -0.24-3.00, p =0.094), suggesting higher HbA1c in Black women, compared to other race by gender groups. In stratified models, SES (B = -0.33, 95% CI = -0.10-0.00, p = 0.050), and governmental insurance (B = 0.35, 95% CI = 0.05-2.42, p = 0.042) were associated with HbA1c for Black men, but not for any of the other race by gender subgroups. Conclusion: Socioeconomic factors may relate to health outcomes differently across race by gender subgroups. In particular, SES may be uniquely important for glycemic control of Black men. Due to lack of generalizability of the findings, additional research is needed.

Improving the assessment of depression remission with the Remission Evaluation and Mood Inventory Tool.

OBJECTIVE: The Remission Evaluation and Mood Inventory Tool (REMIT) is a practical 5-item self-report measure of key positive mood states associated with recovering from depression, as distinct from depressive symptoms per se. The study goal was to identify a clinically useful threshold for interpreting REMIT responses in the context of mild to moderate depressive symptoms. METHODS: This was a secondary analysis of a cross-sectional dataset initially used to develop and validate the REMIT. Primary care patients being treated for depressive symptoms of either mild or moderate severity (n = 247 and 240, respectively) rated their perceived degree of depression remission prior to completing the Patient Health Questionnaire-8 (PHQ-8) and the REMIT. We summed the totals of the latter two measures to form the PHQ + REMIT index. RESULTS: Receiver Operating Characteristics analysis indicated that the PHQ + REMIT threshold ≥ 13 was associated with good sensitivity (92%) and acceptable specificity (43%) to the absence of patient-perceived remission. In contrast, the PHQ had only 21% specificity at this sensitivity level. Area under the curve was 0.815 (95% C.I.: 0.765-0.865), which was significantly greater than that of the PHQ-8 alone (area under the curve = 0.745, 95% C.I.: 0.691-0.805, p(diff) = 0.0002). Threshold performance was unaffected by adjustment for demographic characteristics and variation in remission percentage. Compared with standard symptom-based classification, using the REMIT reclassified 27% of mildly symptomatic patients as remitted. CONCLUSIONS: Using the REMIT with patients who have mild to moderate depressive symptoms improves the assessment of patient-perceived remission, which is indicated by a summed PHQ + REMIT index of less than 13. Longitudinal research is needed to test whether this broadened patient-centered approach to assessing remission improves clinical decision making and long-term outcomes.

Mobile health monitoring to characterize depression symptom trajectories in primary care.

BACKGROUND: Classification of depression severity can guide treatment decisions. This study examined whether using repeated mobile health assessments to determine symptom trajectories is a potentially useful method for classifying depression severity. METHODS: 344 primary care patients with depression were identified and recruited as part of a program of mobile health symptom monitoring and self-management support. Depression symptoms were measured weekly via interactive voice response (IVR) calls using the Patient Health Questionnaire (PHQ-9). Trajectory analysis of weekly IVR PHQ-9 scores from baseline through week 6 was used to subgroup patients according to similar trajectories. Multivariable linear regression was used to determine whether the trajectories predicted 12-week PHQ-9 scores after adjusting for baseline and 6-week PHQ-9 scores. RESULTS: The optimal trajectory analysis model included 5 non-intersecting trajectories. The subgroups of patients assigned to each trajectory had mean baseline PHQ-9s of 19.7, 14.5, 9.5, 5.0, and 2.0, and respective mean decreases in PHQ-9s over six weeks of .3, 2.0, 3.6, 2.3, and 1.9. In regression analyses, each trajectory significantly predicted 12-week PHQ-9 scores (using the modal trajectory as a reference) after adjusting for both baseline and 6-week PHQ-9 scores. LIMITATIONS: Treatment history was unknown, findings may not be generalizable to new episodes of treatment. CONCLUSIONS: Depression symptom trajectories based on mobile health assessments are predictive of future depression outcomes, even after accounting for typical assessments at baseline and a single follow-up time point. Approaches to classify patients׳ disease status that involve multiple repeated assessments may provide more accurate and useful information for depression management compared to lower frequency monitoring.

Improvements in illness self-management and psychological distress associated with telemonitoring support for adults with diabetes.

OBJECTIVE: The objective of this observational open label trial was to characterize changes in diabetes self-management and psychological distress associated with a mobile health (mHealth) interactive voice response (IVR) self-management support program. METHODS: For 3-6 months, 301 patients with diabetes received weekly IVR calls assessing health status and self-care and providing tailored pre-recorded self-management support messages. Patients could participate together with an informal caregiver who received suggestions on self-management support, and patients' clinicians were notified automatically when patients reported significant problems. RESULTS: Patients completed 84% of weekly calls, providing 5682 patient-weeks of data. Thirty-nine percent participated with an informal caregiver. Outcome analyses adjusted for study design factors and sociodemographics indicated significant pre-post improvement in medication adherence, physical functioning, depressive symptoms, and diabetes-related distress (all p values <0.001). Analyses of self-management problems indicated that as the intervention proceeded, there were significant improvements in patients' IVR-reported frequency of weekly medication adherence, SMBG performance, checking feet, and frequency of abnormal self-monitored blood glucose readings (all p values <0.001). CONCLUSIONS: We conclude that the combined program of automated telemonitoring, clinician notification, and informal caregiver involvement was associated with consistent improvements in medication adherence, diabetes self-management behaviors, physical functioning, and psychological distress. A randomized controlled trial is needed to verify these encouraging findings.

Toward a more comprehensive assessment of depression remission: the Remission Evaluation and Mood Inventory Tool (REMIT).

OBJECTIVE: Depression remission continues to be defined in terms of resolution of the Diagnostic and Statistical Manual of Mental Disorders criteria symptoms. However, it may be useful to assess additional symptoms as part of a more complete evaluation of remission. We sought to develop an adjunct self-report measure that can be used with commonly used depression measures when assessing remission. METHODS: Secondary data analysis and expert input were used to develop candidate items that were evaluated cross-sectionally in 1003 primary care clinician-identified depressed patients from two practice-based research networks. Multivariable regression analysis, with self-assessed recovery as the dependent variable, identified five symptoms that contributed significantly beyond the Patient Health Questionnaire (PHQ)-8. Further analysis was performed in selected subsamples. RESULTS: Emotional control, contentedness, future seeming dark, ability to bounce back and happiness yielded an 11% increase in R(2) beyond 60% yielded by the PHQ-8. The summed Remission Evaluation and Mood Inventory Tool (REMIT) 5 items have a mean=9.6 (S.D.=4.5), range 0-20 and reliability of 0.86. Subsample analysis showed incremental R(2) ranging from 9% in men to 15% in African-Americans. CONCLUSION: Depression remission is a multidimensional concept that includes important nondepressive symptom dimensions. These important dimensions can be measured using a self-report instrument feasible for routine primary care. Pending longitudinal validation, REMIT5 is a promising tool for depression management.

Patient-reported perceptions of side effects of antihyperglycemic medication and adherence to medication regimens in persons with diabetes mellitus.

BACKGROUND: With recent media attention to drug safety, patients may have heightened concerns about the side effects of medications that may affect their compliance with treatment. OBJECTIVES: The purpose of this study was to determine the proportion of patients with type 2 diabetes mellitus who perceived having experienced side effects of antihyperglycemic medications, the proportion of these patients who communicated their concerns to physicians, and the potential association between the perception of experiencing side effects and adherence to medication regimens. METHODS: Patients with diabetes were identified through the claims of a Midwest US managed care organization, using Health Plan Employer Data and Information Set criteria. Questionnaires were mailed to randomly selected patients. Patients receiving oral antihyperglycemic medications were selected as prospective subjects. Patients were excluded if they were receiving insulin. RESULTS: The responses of 445 patients meeting the study criteria were collected and analyzed. The subjects were pre-dominantly white, with a mean (SD) age of 56 (11) years and a mean duration of diabetes of 7.3 (8.8) years. One hundred forty-eight (33%) subjects reported a perception of having experienced side effects of antihyperglycemic medication; 126 (85%) subjects reported that they had communicated these concerns to their physicians. Analysis of the subjects' responses indicated an association between the perception of having experienced side effects and nonadherence to antihyperglycemic medication regimens (beta=-0.15; P < 0.010). CONCLUSIONS: Nearly one third of subjects with diabetes receiving oral noninsulin antihyperglycemic medications reported a perception of having experienced medication-related side effects. Despite the large portion of subjects who reported that they had communicated these concerns to their physicians, the perception of experiencing medication-related side effects was significantly associated with nonadherence to antihyperglycemic drug regimens.

Assessment of depressive symptoms in deaf persons.

BACKGROUND: Evidence suggests that Deaf people may have a greater prevalence of depressive symptoms. However, it is unclear whether commonly used written screening instruments are accurate with this population because of their unique cultural and linguistic factors. SETTING: Deaf persons (n = 71) residing in southeastern Michigan. METHODS: Subjects completed the Zung Self-Rated Depression Scale in both the written (ZSDS-W) and American Sign Language (ZSDS-S) formats and the Hamilton Depression Scale (HAM-D) in American Sign Language in counterbalanced order, followed by a Test Of Reading Comprehension (TORC). They also provided extensive data on demographic, hearing loss, language use, social and health care use variables. RESULTS: Mean subject age was 52 years, 63% of subjects were women, 95% were Caucasian, and 47% were married (87% to another deaf/hard of hearing person). Thirty percent had a college degree and 20% had less than a 10th grade education. The ZSDS-W and ZSDS-S scores were highly correlated (r = +0.79), although the mean ZSDS-W score was 2.8 points higher (P = .001). The ZSDS-S correlated more highly (r = 0.80) with the HAM-D than the ZSDS-W (r = 0.71). There was a significant interaction effect (P < .001) such that the ZSDS-W and HAM-D were significantly associated among higher literacy subjects (beta = 0.80, P < .001) but not lower literacy subjects (beta = 0.20, P = .183). There were no other significant associations between depression scores and numerous demographic, educational, hearing loss, social or language variables. CONCLUSIONS: Compared with the conventional ZSDS-W, the ZSDS-S more accurately assesses depression severity among deaf persons with lower English literacy. However, given the greater sensitivity of the ZSDS-W and the practical barriers to ZSDS-S in physician practices, further research should determine which modality is best for routine depression screening.

The relationship of guideline-concordant depression treatment and patient adherence to oral diabetes medications.

BACKGROUND: Many patients with diabetes experience depression, yet it is unclear if the treatment of depression in diabetic patients is concordant with national guidelines, and whether appropriate antidepressant use is associated with better diabetes self-care behaviors. OBJECTIVES: The purpose of this study was to (1) determine whether antidepressant medication use for managed care enrollees with type 2 diabetes was concordant with The Agency for Healthcare Research and Quality depression treatment guidelines; and (2) examine the relationship between guideline concordance and oral diabetes medication adherence. METHODS: Retrospective analyses were conducted using medical/pharmacy claims for 2001 from a managed care organization in the midwestern United States. Subjects were adults with type 2 diabetes treated with oral medications only. The subjects were divided into 3 groups: (1) guideline-concordant users of antidepressants; (2) those who received antidepressants not in concordance with the guidelines; and (3) nonusers of antidepressants. Antidepressant users were determined to be in concordance with the acute phase treatment guidelines if they filled at least 90 days supply of antidepressant drugs within 118 days of the first fill. Adherence to diabetes medications was measured by the medication possession ratio. A 1-way analysis of variance with Scheffe's test was used to compare the antihyperglycemic medication possession ratio across the three groups. RESULTS: One hundred eighty-two (12.5%) of the 1454 subjects initiated treatment with antidepressants. Eighty-nine (48.9%) of the 182 antidepressant users were in concordance with the acute phase treatment guidelines. Subjects with subconcordant antidepressant use had a lower mean diabetes medication possession ratio than those with either guideline-concordant use or no use (F=14.3, P<.01). CONCLUSION: Over half of the diabetic patients initiating treatment for depression did not receive therapy in concordance with the Agency for Healthcare Research and Quality guidelines. Patients whose antidepressant use was not concordant with the guidelines were also less adherent to diabetes medications.

Toward cost-effectiveness analysis in the diagnosis and treatment of insomnia.

Insomnia is believed to have high prevalence, cost, and impact. However, comprehensive cost-effectiveness analyses (CEAs) of different diagnostic and treatment strategies have not been performed. Part of the reason is that limited data are available on prevalence, costs, and outcomes, each of which is key elements of any CEA. The authors conducted a MEDLINE search to review available literature. Epidemiological surveys have yielded variable results, depending on operational definitions and populations studied. Cost estimates have varied widely depending on whether indirect costs are included and which costs are considered. Impact on health-related quality of life appears to be substantial, but effects on utility scores-necessary to compare cost-effectiveness of insomnia management to that of other health care interventions-have not been reported. Furthermore, much of the data on health-related quality of life is cross-sectional, and cannot be used to test whether the identified associations are causal. The authors conclude that effective insomnia management holds promise as a cost-effective health care intervention. However, the CEA models that eventually may support this hypothesis will require accurate measures of direct and indirect costs, health state utility in treated and untreated insomnia, and prevalence data based on widely-accepted case definitions.