Cost of Care for Patients With Cirrhosis.

INTRODUCTION: There are limited longitudinal data on the cost of treating patients with cirrhosis, which hampers value-based improvement initiatives. METHODS: We conducted a retrospective cohort study of patients with cirrhosis seen in the Veterans Affairs health care system from 2011 to 2015. Patients were followed up through 2019. We identified a sex-matched and age-matched control cohort without cirrhosis. We estimated incremental annual health care costs attributable to cirrhosis for 4 years overall and in subgroups based on severity (compensated, decompensated), cirrhosis complications (ascites, encephalopathy, varices, hepatocellular cancer, acute kidney injury), and comorbidity (Deyo index). RESULTS: We compared 39,361 patients with cirrhosis with 138,964 controls. The incremental adjusted costs for caring of patients with cirrhosis were $35,029 (95% confidence interval $32,473-$37,585) during the first year and ranged from $14,216 to $17,629 in the subsequent 3 years. Cirrhosis complications accounted for most of these costs. Costs of managing patients with hepatic encephalopathy (year 1 cost, $50,080) or ascites ($50,364) were higher than the costs of managing patients with varices ($20,488) or hepatocellular cancer ($37,639) in the first year. Patients with acute kidney injury or those who had multimorbidity were the most costly at $64,413 and $66,653 in the first year, respectively. DISCUSSION: Patients with cirrhosis had substantially higher health care costs than matched controls and multimorbid patients had even higher costs. Cirrhosis complications accounted for most of the excess cost, so preventing complications has the largest potential for cost saving and could serve as targets for improvement.

Factors Associated With Increased Reading Frequency in Children Exposed to Reach Out and Read.

OBJECTIVE: A 2014 American Academy of Pediatrics Policy Statement on Literacy Promotion recommends providers endorse daily caregiver-child reading during health supervision visits. Reach Out and Read (ROR) is a widely used model of office-based early literacy promotion. We hypothesized that exposure to ROR and other variables such as reading as part of a bedtime routine positively correlate with caregiver-child reading frequency. METHODS: This is a cross-sectional study based on a convenience sample of caregivers at 8 ROR-Milwaukee sites, which serve predominantly low-income populations in Milwaukee. On the basis of results of previously validated questionnaires, odds ratios were calculated to determine which variables are significantly associated with caregivers' reading to children 0 to 2 (rarely), 3 to 6 (often), and 7 (daily) days per week. Random forest analysis was performed to examine relative importance of variables in predicting caregivers' reading frequency. RESULTS: A total of 256 caregivers were eligible for analysis; those who reported receiving ≥4 books from pediatricians read to children more days per week compared to those receiving fewer books (5.07 vs 3.61, P < .001) and were more likely to read daily (odds ratio 3.07, 95% confidence interval 1.80-5.23). Caregivers' interest in reading, number of children's books in the home, reading as part of a bedtime routine, and number of books received from pediatricians were among the most important variables in distinguishing rarely, often, and daily reading caregivers. CONCLUSIONS: Exposure to ROR-Milwaukee's intervention is associated with increased reading frequency. Identified variables such as reading as a bedtime routine and number of children's books in the home should be targets for future literacy-promoting interventions.

Social support mediates the association of health literacy and depression among racially/ethnically diverse smokers with low socioeconomic status.

Nearly half of U.S. adults have health literacy (HL) difficulties, and lack the ability to effectively obtain, process, and understand health information. Poor HL is associated with depression, yet mechanisms of this relation are unclear. This study examined whether social support mediated the relation between HL and depressive symptoms in 200 low-socioeconomic status (SES), racially/ethnically diverse smokers enrolled in cessation treatment. Mediation analyses were conducted using bootstrapping and controlling for SES and nicotine dependence. In simple mediation models, social support [Interpersonal Support Evaluation List (ISEL) total, subscales (Appraisal, Belonging, Tangible)] mediated the effect of HL on depression, such that lower HL was associated with lower perceived support, which predicted higher depressive symptoms (ps < .05). A multiple mediation model, with ISEL subscales entered simultaneously as mediators, was significant (p < .05) but only the Belonging subscale demonstrating independent significance (p < .05). Thus, social support may be a critical factor underlying the HL-depression relationship in low-SES, racially/ethnically diverse smokers.

Subjective social status predicts quit-day abstinence among homeless smokers.

PURPOSE: Smoking prevalence is alarmingly high among the homeless. Few studies have focused on predictors of smoking abstinence in this population. Subjective social status, a person's ranking of their own social standing relative to others in the United States or in their own self-defined communities, has predicted smoking cessation among domiciled smokers in analyses adjusted for objective socioeconomic status and other demographic variables. This study examined if subjective social status predicted quit-day abstinence among homeless smokers making a quit attempt. DESIGN: Longitudinal study using self-reported survey data. SETTING: Transitional homeless shelter in Dallas, Texas. SUBJECTS: A total of 57 homeless smokers enrolled in a cessation program. MEASURES: Predictors were the Subjective Social Status-U.S (SSS-U.S.) and the Subjective Social Status-Community (SSS-Community) ladders measured 1 week pre quit. Covariates were sociodemographics and tobacco dependence measured 1 week pre quit. The outcome was self-reported and biochemically verified smoking abstinence on the quit day. Analysis . Covariate-adjusted logistic regression models. RESULTS: Higher rankings on the SSS-U.S. ladder, but not the SSS-Community ladder, predicted abstinence on the quit day (p = .005). CONCLUSION: Lower rankings on the SSS-U.S. ladder predicted increased risk of relapse on the quit day or the inability to quit at all. The SSS-U.S. ladder might be useful in identifying homeless smokers needing additional preparation and intervention before initiating a quit attempt.

Transposition of the great arteries--outcomes and time interval of early neonatal repair.

BACKGROUND: This study evaluates the relationship of morbidity and resource utilization with the timing of early neonatal repair of transposition of the great arteries and intact ventricular septum (d-TGA/IVS). METHODS: All patients with d-TGA/IVS who underwent arterial switch in the first 14 days of life, between January 2000 and May 2011, were reviewed. Patients undergoing repair at ≤ 4 days of age were categorized as group I, 5 to 7 days as group II, and 8 to 14 days as group III. Outcomes included mortality, morbidity, and resource utilization. RESULTS: Hospital survival was 69 (98.6%) of 70. The length of stay (LOS) and total charges were lowest in group I--15.5 days compared to group II--18.0 days and group III--23.5 days (P = .005); group I--US$128,219 compared to group II--US$141,729 and group III--US$217,427 (P = .0006). Using regression analysis to account for potentially confounding effects of multiple variables and treating time as a continuous variable demonstrated that age at surgery was significantly associated with total LOS (P = .029), hospital charges (P = .029) and intensive care unit charges (P = .002). Younger age at repair was not associated with worse outcomes for any measure of morbidity. CONCLUSIONS: Earlier repair of d-TGA/IVS was associated with decreased resource utilization and no detriment to clinical outcomes. Further analysis based on a larger cohort of patients is needed to verify these results that have important implications for improving the value of care.

Advancing cessation research by integrating EMA and geospatial methodologies: associations between tobacco retail outlets and real-time smoking urges during a quit attempt.

INTRODUCTION: Residential tobacco retail outlet (TRO) density and proximity have been associated with smoking behaviors. More research is needed to understand the mechanisms underlying these relations and their potential relevance outside of the residential setting. This study integrates ecological momentary assessment (EMA) and geo-location tracking to explore real-time associations between exposure to TROs and smoking urges among 47 economically disadvantaged smokers in a cessation trial (59.6% female; 36.2% White). METHODS: EMA data were collected for 1 week postquit via smartphone, which recorded smoking urge strength ≤ 4 random times daily along with real-time participant location data. For each assessment, the participants' proximity to the closest TRO and the density of TROs surrounding the participant were calculated. Linear mixed model regressions examined associations between TRO variables and smoking urges and whether relations varied based on participants' distance from their home. Covariates included sociodemographics, prequit tobacco dependence, treatment group, and daily smoking status. RESULTS: Main effects were nonsignificant; however, the interaction between TRO proximity and distance from home was considered significant (p = .056). Specifically, closer proximity to TROs was associated with stronger smoking urges ≤ 1 mile of home (p = .001) but not >1 mile from home (p = .307). Significant associations were attributable to assessments completed at participants' home addresses. All density analyses were nonsignificant. CONCLUSIONS: Technological challenges encountered in this study resulted in a significant amount of missing data, highlighting the preliminary nature of these findings and limiting the inferences that can be drawn. However, results suggest that closer residential proximity to tobacco outlets may trigger stronger urges to smoke among economically disadvantaged smokers trying to quit, perhaps due to enhanced cigarette availability and accessibility. Therefore, limiting tobacco sales in close proximity to residential areas may complement existing tobacco control efforts and facilitate cessation.

The Ask-Advise-Connect approach for smokers in a safety net healthcare system: a group-randomized trial.

BACKGROUND: Because smoking has a profound impact on socioeconomic disparities in illness and death, it is crucial that vulnerable populations of smokers be targeted with treatment. The U.S. Public Health Service recommends that all patients be asked about their smoking at every visit and that smokers be given brief advice to quit and referred to treatment. PURPOSE: Initiatives to facilitate these practices include the 5A's (ask, advise, assess, assist, arrange) and Ask-Advise-Refer (AAR). Unfortunately, primary care referrals are low, and most smokers referred fail to enroll. This study evaluated the efficacy of the Ask-Advise-Connect (AAC) approach to linking smokers with treatment in a large, safety net public healthcare system. DESIGN: The study design was a pair-matched group-randomized trial with two treatment arms. SETTING/PARTICIPANTS: Ten safety net clinics in Houston TX. INTERVENTION: Clinics were randomized to AAC (n=5; intervention) or AAR (n=5; control). Licensed vocational nurses (LVNs) were trained to assess and record the smoking status of all patients at all visits in the electronic health record. Smokers were given brief advice to quit. In AAC, the names and phone numbers of smokers who agreed to be connected were sent electronically to the Texas quitline daily, and patients were proactively called by the quitline within 48 hours. In AAR, smokers were offered a quitline referral card and encouraged to call on their own. Data were collected between June 2010 and March 2012 and analyzed in 2012. MAIN OUTCOME MEASURES: The primary outcome was impact, defined here as the proportion of identified smokers that enrolled in treatment. RESULTS: The impact (proportion of identified smokers who enrolled in treatment) of AAC (14.7%) was significantly greater than the impact of AAR (0.5%), t(4)=14.61, p=0.0001, OR=32.10 (95% CI=16.60, 62.06). CONCLUSIONS: The AAC approach to aiding smoking cessation has tremendous potential to reduce tobacco-related health disparities.

Ask-Advise-Connect: a new approach to smoking treatment delivery in health care settings.

IMPORTANCE: Several national health care-based smoking cessation initiatives have been recommended to facilitate the delivery of evidence-based treatments, such as quitline (telephone-based tobacco cessation services) assistance. The most notable examples are the 5 As (Ask, Advise, Assess, Assist, Arrange) and Ask. Advise. Refer. (AAR) programs. Unfortunately, rates of primary care referrals to quitlines are low, and most referred smokers fail to call for assistance. OBJECTIVE: To evaluate a new approach--Ask-Advise-Connect (AAC)--designed to address barriers to linking smokers with treatment. DESIGN: A pair-matched, 2-treatment-arm, group-randomized design in 10 family practice clinics in a single metropolitan area. Five clinics were randomized to the AAC (intervention) and 5 to the AAR (control) conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the AAC clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the AAR clinics, smokers were offered a quitline referral card and encouraged to call on their own. All data were collected from February 8 through December 27, 2011. SETTING: Ten clinics in Houston, Texas. PARTICIPANTS: Smoking status assessments were completed for 42,277 patients; 2052 unique smokers were identified at AAC clinics, and 1611 smokers were identified at AAR clinics. INTERVENTIONS: Linking smokers with quitline-delivered treatment. MAIN OUTCOME MEASURE: Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment. RESULTS: In the AAC clinics, 7.8% of all identified smokers enrolled in treatment vs 0.6% in the AAR clinics (t4 = 9.19 [P < .001]; odds ratio, 11.60 [95% CI, 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment. CONCLUSIONS AND RELEVANCE: The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality.

The relation between social cohesion and smoking cessation among Black smokers, and the potential role of psychosocial mediators.

BACKGROUND: Social cohesion, the self-reported trust and connectedness between neighbors, may affect health behaviors via psychosocial mechanisms. PURPOSE: Relations between individual perceptions of social cohesion and smoking cessation were examined among 397 Black treatment-seeking smokers. METHODS: Continuation ratio logit models examined the relation of social cohesion and biochemically verified continuous smoking abstinence through 6 months post-quit. Indirect effects were examined in single mediator models using a nonparametric bootstrapping procedure. All analyses controlled for sociodemographics, tobacco dependence, and treatment. RESULTS: The total effect of social cohesion on continuous abstinence was non-significant (ß = 0.05, p = 0.10). However, social cohesion was associated with social support, positive affect, negative affect, and stress, which, in turn, were each associated with abstinence in adjusted models (ps < 0.05). CONCLUSIONS: Results suggest that social cohesion may facilitate smoking cessation among Black smokers through desirable effects on psychosocial mechanisms that can result from living in a community with strong interpersonal connections.

Individual- and area-level unemployment influence smoking cessation among African Americans participating in a randomized clinical trial.

African Americans suffer disproportionately from the adverse health consequences of smoking, and also report substantially lower socioeconomic status than Whites and other racial/ethnic groups in the U.S. Although socioeconomic disadvantage is known to have a negative influence on smoking cessation rates and overall health, little is known about the influence of socioeconomic status on smoking cessation specifically among African Americans. Thus, the purpose of the current study was to characterize the impact of several individual- and area-level indicators of socioeconomic status on smoking cessation among African Americans. Data were collected as part of a smoking cessation intervention study for African American smokers (N = 379) recruited from the Houston, Texas, metropolitan area, who participated in the study between 2005 and 2007. The separate and combined influences of individual-level (insurance status, unemployment, education, and income) and area-level (neighborhood unemployment, education, income, and poverty) indicators of socioeconomic status on continuous smoking abstinence were examined across time intervals using continuation ratio logit modeling. Individual-level analyses indicated that unemployment was significantly associated with reduced odds of smoking abstinence, while higher income was associated with greater odds of abstinence. However, only unemployment remained a significant predictor of abstinence when unemployment and income were included in the model together. Area-level analyses indicated that greater neighborhood unemployment and poverty were associated with reduced odds of smoking abstinence, while greater neighborhood education was associated with higher odds of abstinence. However, only neighborhood unemployment remained significantly associated with abstinence status when individual-level income and unemployment were included in the model. Overall, findings suggest that individual- and area-level unemployment have a negative impact on smoking cessation among African Americans. Addressing unemployment through public policy and within smoking cessation interventions, and providing smoking cessation treatment for the unemployed may have a beneficial impact on tobacco-related health disparities.

Subjective social status predicts long-term smoking abstinence.

BACKGROUND: The relationship between subjective social status (SSS), a person's perception of his/her relative position in the social hierarchy, and the ability to achieve long-term smoking abstinence during a specific quit attempt is unknown. The purpose of this study was to examine the relationship between SSS and long-term smoking abstinence among 421 racially/ethnically diverse smokers undergoing a specific quit attempt, as well as the interactive effects of race/ethnicity and sex. METHODS: The main effects and moderated relationships of SSS on biochemically-confirmed, continuous smoking abstinence through 26 weeks post-quit were examined using continuation ratio logit models adjusted for sociodemographics and smoking characteristics. RESULTS: Even after adjusting for the influence of socioeconomic status and other covariates, smokers endorsing lower SSS were significantly less likely to maintain long-term smoking abstinence during a specific quit attempt than those with higher SSS (OR = 1.14, 95% CI: 1.00 - 1.28; p = 0.044). The statistical significance of this relationship, however, did not vary by race/ethnicity or sex. CONCLUSIONS: SSS independently predicts long-term smoking abstinence during a specific quit attempt. SSS may be a useful screener to identify smokers at elevated risk of relapse who may require additional attention to facilitate long-term abstinence. More research is needed to understand the mechanisms underlying the relationship between SSS and long-term smoking abstinence in order to appropriately tailor treatment to facilitate abstinence among lower SSS smokers.

The effect of tobacco outlet density and proximity on smoking cessation.

OBJECTIVES: We examined the influence of tobacco outlet density and residential proximity to tobacco outlets on continuous smoking abstinence 6 months after a quit attempt. METHODS: We used continuation ratio logit models to examine the relationships of tobacco outlet density and tobacco outlet proximity with biochemically verified continuous abstinence across weeks 1, 2, 4, and 26 after quitting among 414 adult smokers from Houston, Texas (33% non-Latino White, 34% non-Latino Black, and 33% Latino). Analyses controlled for age, race/ethnicity, partner status, education, gender, employment status, prequit smoking rate, and the number of years smoked. RESULTS: Residential proximity to tobacco outlets, but not tobacco outlet density, provided unique information in the prediction of long-term, continuous abstinence from smoking during a specific quit attempt. Participants residing less than 250 meters (P = .01) or less than 500 meters (P = .04) from the closest tobacco outlet were less likely to be abstinent than were those living 250 meters or farther or 500 meters or farther, respectively, from outlets. CONCLUSIONS: Because residential proximity to tobacco outlets influences smoking cessation, zoning restrictions to limit tobacco sales in residential areas may complement existing efforts to reduce tobacco use.

Subjective social status affects smoking abstinence during acute withdrawal through affective mediators.

OBJECTIVES: Direct and mediated associations between subjective social status (SSS), a subjective measure of socio-economic status, and smoking abstinence were examined during the period of acute withdrawal among a diverse sample of 421 smokers (33% Caucasian, 34% African American, 33% Latino) undergoing a quit attempt. METHODS: Logistic regressions examined relations between SSS and abstinence, controlling for socio-demographic variables. Depression, stress, positive affect and negative affect on the quit day were examined as potential affective mediators of the SSS-abstinence association, with and without adjusting for pre-quit mediator scores. RESULTS: SSS predicted abstinence to 2 weeks post-quit. Abstinence rates were 2.6 (postquit week 1) and 2.4 (postquit week 2) times higher in the highest versus the lowest SSS quartile. Depression and positive affect mediated the SSS-abstinence relationships, but only depression maintained significance when adjusting for the baseline mediator score. CONCLUSIONS: Among a diverse sample of quitting smokers, low SSS predicted relapse during acute withdrawal after controlling for numerous covariates, an effect accounted for partially by quit day affective symptomatology. Smokers endorsing lower SSS face significant hurdles in achieving cessation, highlighting the need for targeted interventions encompassing attention to quit day mood reactivity.

Acculturative and neighborhood influences on subjective social status among Spanish-speaking Latino immigrant smokers.

Subjective social status (SSS) reflects an individual's perception of her/his relative position in the social hierarchy. However, little is known about culturally-relevant, multilevel predictors of low SSS among low socioeconomic status (SES), minority populations. The goal of this study was to identify individual- and neighborhood-level variables predicting SSS among 297 Spanish-speaking Latino immigrant smokers living in several locations in Texas, with an emphasis on the association of SSS with acculturative and socioeconomic variables. Participants were recruited and enrolled through the National Cancer Institute's Cancer Information Service from August 2002 to March 2004. Determinants of SSS were explored using a series of linear regressions. In analyses adjusting for demographics (including objective indicators of SES), speaking Spanish at home and work and living in economically disadvantaged neighborhoods, respectively, were associated with low SSS. However, in analyses including demographics, acculturation, and neighborhood characteristics, only income, education, and acculturation remained associated with SSS. Consistent with results from a previous study in the area (Franzini & Fernandez-Esquer, 2006), less acculturation predicted low SSS among immigrant Latino smokers. However, unlike previous research, these associations were maintained after controlling for SES. Results suggest that the density of less acculturated Latinos within economically deprived neighborhoods might account for the disappearance of neighborhood effects in the final model.