Better Nurse Practitioner Primary Care Practice Environments Reduce Hospitalization Disparities Among Dually-Enrolled Patients.

BACKGROUND: Over 12 million Americans are dually enrolled in Medicare and Medicaid. These individuals experience over twice as many hospitalizations for chronic diseases such as coronary artery disease and diabetes compared with Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address the care needs of dually-enrolled patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and hospitalization disparities between dually-enrolled and Medicare-only patients with chronic diseases. METHODS: Using secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire and Medicare claims files, we examined 135,648 patients with coronary artery disease and/or diabetes (20.0% dually-eligible, 80.0% Medicare-only), cared for in 450 practices employing NPs across 4 states (PA, NJ, CA, FL) in 2015. We compared dually-enrolled patients' odds of being hospitalized when cared for in practice environments characterized as poor, mixed, and good based on practice-level Nurse Practitioner Primary Care Organizational Climate Questionnaire scores. RESULTS: After adjusting for patient and practice characteristics, dually-enrolled patients in poor practice environments had the highest odds of being hospitalized compared with their Medicare-only counterparts [odds ratio (OR): 1.48, CI: 1.37, 1.60]. In mixed environments, dually-enrolled patients had 27% higher odds of a hospitalization (OR: 1.27, CI: 1.12, 1.45). However, in the best practice environments, hospitalization differences were nonsignificant (OR: 1.02, CI: 0.85, 1.23). CONCLUSIONS: As policymakers look to improve outcomes for dually-enrolled patients, addressing a modifiable aspect of care delivery in NPs' clinical practice environment is a key opportunity to reduce hospitalization disparities.

Segregation Predicts COVID-19 Fatalities in Less Densely Populated Counties.

Aim It is well known that social determinants of health (SDoH) have affected COVID-19 outcomes, but these determinants are broad and complex. Identifying essential determinants is a prerequisite to address widening health disparities during the evolving COVID-19 pandemic. Methods County-specific COVID-19 fatality data from California, Illinois, and New York, three US states with the highest county-cevel COVID-19 fatalities as of June 15, 2020, were analyzed. Twenty-three county-level SDoH, collected from County Health Rankings & Roadmaps (CHRR), were considered. A median split on the population-adjusted COVID-19 fatality rate created an indicator for high or low fatality. The decision tree method, which employs machine learning techniques, analyzed and visualized associations between SDoH and high COVID-19 fatality rate at the county level. Results Of the 23 county-level SDoH considered, population density, residential segregation (between white and non-white populations), and preventable hospitalization rates were key predictors of COVID-19 fatalities. Segregation was an important predictor of COVID-19 fatalities in counties of low population density. The model area under the curve (AUC) was 0.79, with a sensitivity of 74% and specificity of 76%. Conclusion Our findings, using a novel analytical lens, suggest that COVID-19 fatality is high in areas of high population density. While population density correlates to COVID-19 fatality, our study also finds that segregation predicts COVID-19 fatality in less densely populated counties. These findings have implications for COVID-19 resource planning and require appropriate attention.

Access to post-acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study.

AIMS AND OBJECTIVES: We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30 days post-hospitalisation. BACKGROUND: Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use post-hospitalisation for individuals insured by Medicaid. DESIGN: We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study. METHODS: Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August-31 October 2017 (n = 785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit. RESULTS: Post-hospitalisation, 12% (n = 59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n = 13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR = 3.24). Having a home care visit or specialty care visit within 30 days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR = 0.01). CONCLUSIONS: Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid. RELEVANCE TO CLINICAL PRACTICE: Hospital-based nurses, including those in direct care, case management and discharge planning, play an important role in facilitating referrals and scheduling appointments prior to discharge. Individuals insured by Medicaid may require additional support in accessing these services and nurses are well-positioned to facilitate care continuity.

Disparities in Nurse Job Dissatisfaction and Intent to Leave: Implications for Retaining a Diverse Workforce.

OBJECTIVE: To determine if Black nurses are more likely to report job dissatisfaction and whether factors related to dissatisfaction influence differences in intent to leave. BACKGROUND: Minority nurses report higher job dissatisfaction and intent to leave, yet little is known about factors associated with these differences in community settings. METHOD: Cross-sectional analysis of 11 778 nurses working in community-based settings was conducted. Logistic regression was used to estimate the association among race, job satisfaction, and intent to leave. RESULTS: Black nurses were more likely to report job dissatisfaction and intent to leave. Black nurses' intent to leave decreased in adjusted models that accounted for dissatisfaction with aspects of their jobs including salary, advancement opportunities, autonomy, and tuition benefits. CONCLUSION: Nurse administrators may find opportunities to decrease intent to leave among Black nurses through focused efforts to target areas of dissatisfaction.

Sociodemographic Indicators of Social Position and Self-care Maintenance in Adults with Heart Failure.

Social determinants of health (SDH) are known to influence health. Adequate self-care maintenance improves heart failure (HF) outcomes. However, the relationship between self-care maintenance and SDH remains unclear. Explore the relationship between sociodemographic indicators of social position and self-care maintenance in adults with HF. This was a secondary analysis of data from a cross-sectional descriptive study of 543 adults with HF. Participants completed the Self-Care of HF Index and a sociodemographic survey. We used multiple regression with backward elimination to determine which SDH variables were determinants of self-care maintenance. Marital status (p = .02) and race (p = .02) were significant determinants of self-care maintenance. Education (p = .06) was highest in Whites (35.6%). These variables explained only 3.8% of the variance in self-care maintenance. Race, education, and marital status were associated with HF self-care maintenance. SDH is complex and cannot be explained with simple sociodemographic characteristics.

Leveraging Electronic Health Records and Machine Learning to Tailor Nursing Care for Patients at High Risk for Readmissions.

BACKGROUND: Electronic health record-derived data and novel analytics, such as machine learning, offer promising approaches to identify high-risk patients and inform nursing practice. PURPOSE: The aim was to identify patients at risk for readmissions by applying a machine-learning technique, Classification and Regression Tree, to electronic health record data from our 300-bed hospital. METHODS: We conducted a retrospective analysis of 2165 clinical encounters from August to October 2017 using data from our health system's data store. Classification and Regression Tree was employed to determine patient profiles predicting 30-day readmission. RESULTS: The 30-day readmission rate was 11.2% (n = 242). Classification and Regression Tree analysis revealed highest risk for readmission among patients who visited the emergency department, had 9 or more comorbidities, were insured through Medicaid, and were 65 years of age and older. CONCLUSIONS: Leveraging information through the electronic health record and Classification and Regression Tree offers a useful way to identify high-risk patients. Findings from our algorithm may be used to improve the quality of nursing care delivery for patients at highest readmission risk.

Both Race and Insurance Type Independently Predict the Selection of Oral Opioids Prescribed to Cancer Outpatients.

BACKGROUND: Previous research suggests that racial disparities in patients' reported analgesic adverse effects are partially mediated by the type of opioid prescribed to African Americans despite the presence of certain comorbidities, such as renal disease. AIMS: We aimed to identify independent predictors of the type of opioid prescribed to cancer outpatients and determine if race and chronic kidney disease independently predict prescription type, adjusting for relevant sociodemographic and clinical confounders. DESIGN: We conducted a secondary analysis of a 3-month observational study. SETTING: Outpatient oncology clinics of an academic medical center. PARTICIPANTS/SUBJECTS: Patients were older than 18 years of age, self-identified as African American or White, and had an analgesic prescription for cancer pain. METHODS: Cancer patients (N = 241) were recruited from outpatient oncology clinics within a large mid-Atlantic healthcare system. RESULTS: Consistent with published literature, most patients (75.5%) were prescribed either morphine or oxycodone preparations as oral opioid therapy for cancer pain. When compared with Whites, African Americans were significantly more likely to be prescribed morphine (33% vs 14%) and less likely to be prescribed oxycodone (38% vs 64%) (p < .001). The estimated odds for African Americans to receive morphine were 2.573 times that for Whites (95% confidence interval 1.077-6.134) after controlling for insurance type, income, and pain levels. In addition, the presence of private health insurance was negatively associated with the prescription of morphine and positively associated with prescription of oxycodone in separate multivariable models. The presence of chronic kidney disease did not predict type of analgesic prescribed. CONCLUSIONS: Both race and insurance type independently predict type of opioid selection for cancer outpatients. Larger clinical studies are needed to fully understand the sources and clinical consequences of racial differences in opioid selection for cancer pain.

Malnutrition Identified by Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition Is Associated With More 30-Day Readmissions, Greater Hospital Mortality, and Longer Hospital Stays: A Retrospective Analysis of Nutrition Assessment Data in a Major Medical Center.

BACKGROUND: Few studies have compared malnutrition identified by the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) consensus criteria with clinical outcomes. Our goal was to compare 30-day readmissions (primary outcome), hospital mortality, length of stay (LOS) in survivors, and time to discharge alive (TDA) in all patients assessed as malnourished or not malnourished using these criteria in fiscal year 2015. We hypothesized more frequent admissions, greater mortality, longer LOS, and less likely shorter TDA in the malnourished patients. METHODS: Demographic variables, clinical outcomes, and malnutrition diagnosis for all initial patient admissions were obtained retrospectively from the electronic medical record. Logistic regression was used to compare categorical and Cox proportional hazards for TDA in unadjusted and adjusted (age, sex, race, medical/surgical admission, Charlson Comorbidity Index) models. RESULTS: Of the 3907 patients referred for nutrition assessment, 66.88% met criteria for moderate or severe malnutrition. Malnourished patients were older (61 vs 58 years, P < .0001), and survivors had longer LOS (15 vs 12 days, P = .0067) and were more likely to be readmitted within 30 days (40% vs 23%, P < .0001). In adjusted models, 30-day readmissions (odds ratio [OR] 2.13, 95% confidence interval [CI] 1.82-2.48) and hospital mortality (OR 1.47, 95% CI 1.0-1.99) were increased, and the likelihood of earlier TDA was reduced (hazard ratio [HR] 0.55, 95% CI 0.44-0.77) in those who had >2-day stay. CONCLUSION: The AND/ASPEN criteria identified malnourished patients in a high-risk population who had more adverse clinical outcomes. Further studies are needed to determine whether optimal provision of nutrition support can improve these outcomes.

Growth in retail-based clinics after nurse practitioner scope of practice reform.

BACKGROUND: Retail clinics are largely staffed by nurse practitioners (NPs) and are a popular destination for nonemergent care. PURPOSE: We examined if there was a relationship between NP practice regulations and retail clinic growth after the passage of a scope of practice (SOP) reform bill in Pennsylvania. METHODS: General linear regression models were used to compare retail clinic openings in Pennsylvania, New Jersey, and Maryland between 2006 and 2013. DISCUSSION: From 2006 to 2008, Pennsylvania experienced a significant growth rate in net retail clinic openings per capita (p = .046), whereas New Jersey and Maryland experienced no significant increase (p = .109 and .053, respectively). From 2009 to 2013, Pennsylvania opened 0.20 clinics (p = .129), New Jersey opened 0.23 clinics (p = .086), and Maryland opened 0.34 clinics per capita per year (p = .017). CONCLUSIONS: Our study of three states with varying levels of SOP restraint reveals an association between relaxation of practice regulations and retail clinic growth.

Risk Factors for All-Cause Rehospitalization Among Medicare Recipients with Heart Failure Receiving Telehomecare.

OBJECTIVE: To identify potential risk factors associated with rehospitalization among Medicare recipients with heart failure (HF) receiving telehomecare. MATERIALS AND METHODS: This study is a nonexperimental, cross-sectional secondary data analysis of the Centers for Medicare and Medicaid (CMS) mandated assessment called the Outcome and Assessment Information Set (OASIS)-C, provided by a large home care company. A total of 526 patients who received telehomecare from January 1, 2011 to August 31, 2013 were included in the analyses, which used multiple logistic regression. RESULTS: The overall rate of rehospitalization was 36% while patients were receiving telehomecare. Moderately frail health status (p = 0.01), the presence of severe pain (p = 0.01), the presence of dermatologic problems (p = 0.03), and independence in dressing one's lower body (compared to slightly dependent [p = 0.01] or mostly dependent patient groups [p = 0.02]) were identified as risk factors for rehospitalization. CONCLUSIONS: The risk factors identified from this study may be used to drive more effective telehomecare placements, and referrals for additional services among telehomecare patients with HF.

Measuring fear of falling among high-risk, urban, community-dwelling older adults.

Fear of falling (FOF) creates a psychological barrier to performing activities for many older adults. The negative impact of fear of falling increases risk of curtailment of activities, future falls, and injury. The specific aim for this study was to investigate the relationship between two fear of falling measures used in clinical research, the FOF Likert scale and Falls Self Efficacy Scale-International (FES-I). The study included a convenience sample of 107 high-risk, community-dwelling, mostly Black (94%) members from one Program for All-Inclusive Care for the Elderly program. The FOF scale is one-item asking to rate overall concern about falling, while the FES-I is 16-items rating concern about falling during physical and social activities. One-way ANOVA and Kruskal-Wallis were highly significant (F-value = 22.25, R-squared = 0.39, p < 0.0001). The Graded Response Model statistics demonstrated one underlying latent factor, fear of falling. This study supports the use of both tools for thorough FOF measurement.

Utilizing Home Healthcare Electronic Health Records for Telehomecare Patients With Heart Failure: A Decision Tree Approach to Detect Associations With Rehospitalizations.

Heart failure is a complex condition with a significant impact on patients' lives. A few studies have identified risk factors associated with rehospitalization among telehomecare patients with heart failure using logistic regression or survival analysis models. To date, there are no published studies that have used data mining techniques to detect associations with rehospitalizations among telehomecare patients with heart failure. This study is a secondary analysis of the home healthcare electronic medical record called the Outcome and Assessment Information Set-C for 552 telemonitored heart failure patients. Bivariate analyses using SAS and a decision tree technique using Waikato Environment for Knowledge Analysis were used. From the decision tree technique, the presence of skin issues was identified as the top predictor of rehospitalization that could be identified during the start of care assessment, followed by patient's living situation, patient's overall health status, severe pain experiences, frequency of activity-limiting pain, and total number of anticipated therapy visits combined. Examining risk factors for rehospitalization from the Outcome and Assessment Information Set-C database using a decision tree approach among a cohort of telehomecare patients provided a broad understanding of the characteristics of patients who are appropriate for the use of telehomecare or who need additional supports.

Conducting Research with Vulnerable Populations: Cautions and Considerations in Interpreting Outliers in Disparities Research.

Addressing the needs of understudied and vulnerable populations first and foremost necessitate correct application and interpretation of research that is designed to understand sources of disparities in healthcare or health systems outcomes. In this brief research report, we discuss some important concerns and considerations in handling "outliers" when conducting disparities-related research. To illustrate these concerns, we use data from our recently completed study that investigated sources of disparities in cancer pain outcomes between African Americans and Whites with cancer-related pain. A choice-based conjoint (CBC) study was conducted to compare preferences for analgesic treatment for cancer pain between African Americans and Whites. Compared to Whites, African Americans were both disproportionately more likely to make pain treatment decisions based on analgesic side-effects and were more likely to have extreme values for the CBC-elicited utilities for analgesic "side-effects." Our findings raise conceptual and methodological consideration in handling extreme values when conducting disparities-related research. Extreme values or outliers can be caused by random variations, measurement errors, or true heterogeneity in a clinical phenomenon. The researchers should consider: 1) whether systematic patterns of extreme values exist and 2) if systematic patterns of extreme values are consistent with a clinical pattern (e.g., poor management of cancer pain and side-effects in racial/ethnic subgroups as documented by many previous studies). As may be evident, these considerations are particularly important in health disparities research where extreme values may actually represent a clinical reality, such as unequal treatment or disproportionate burden of symptoms in certain subgroups. Approaches to handling outliers, such as non-parametric analyses, log transforming clinically important extreme values, or removing outliers may represent a missed opportunity in understanding a potentially targetable area of intervention.

Objective and subjective assessment of physician labor and resource utilization in maintenance percutaneous transluminal angioplasty of nonthrombosed hemodialysis arteriovenous fistulas versus arteriovenous grafts.

PURPOSE: To complement prior studies that have shown that arteriovenous fistula (AVF) thrombectomies require more time and equipment than arteriovenous graft (AVG) thrombectomies by measuring work via established instruments to determine whether there is also a difference in maintenance percutaneous transluminal angioplasty (PTA) of nonthrombosed AVFs versus AVGs. MATERIALS AND METHODS: PTA procedures performed on a consecutive cohort of 42 patients with AVFs and 27 patients with AVGs were prospectively compared. To quantify resource utilization, procedure time and disposable equipment were measured. Established instruments developed by the American Medical Association for Current Procedural Terminology code valuation were used to measure subjective "physician work," including mental effort and judgment, technical skill, physical effort, and psychological stress. These items were scored by 1 of 12 attending interventional radiology physicians performing the procedure. RESULTS: Mean PTA procedure time was 74 minutes (range, 18-183 minutes) for AVFs and 71 minutes (range, 28-204 minutes) for AVGs; hemostasis time was 12 minutes for AVFs and 11 minutes for AVGs. There was no significant difference in equipment use between groups. "Physician work" for AVFs scored significantly higher in four categories (P≤ .05). CONCLUSIONS: Using established subjective instruments, maintenance PTA of AVFs was scored as more cognitively, physically, and psychologically demanding than maintenance PTA of AVGs. However, there was no significant difference in resource utilization between maintenance PTA of AVFs versus AVGs, as has been previously shown with thrombectomy of thrombosed AVFs and AVGs.

Condom use with serious and casual heterosexual partners: findings from a community venue-based survey of young adults.

Given the racial/ethnic disparities that characterize STI trends and recent increases in heterosexually transmitted HIV infection in the US, an understanding of factors underlying condom use among young adults in minority communities is vitally important. To this end, this paper presents findings from a community venue-based survey examining the influence of motivations, heuristics, and relationship factors on condom behaviors with serious and casual heterosexual partners in a sample of urban African American and Puerto Rican males and females ages 18-25 (n = 380). Condom use rates at time of last sex were considerably higher with casual partners (n = 87) than with serious (n = 313) partners, 77.9% vs. 38.7%. While dual pregnancy/STI prevention was the most frequently cited reason for use at last sex with casual partners, pregnancy prevention was the most frequently cited reason for use with serious partners. Bivariate conditional logistic regression analyses found two factors to be associated with condom use at last sex with casual partners: use at first sex with the partner and belief that neighborhood peers worried some/a lot about HIV. In contrast, such factors as condom heuristics (e.g., nonuse symbolizes trust), contraceptive status, and markers of emotional intimacy were associated with condom use with serious partners in both bivariate and multivariable analyses.

Incidence and management of percutaneous transluminal angioplasty-induced venous rupture in the "fistula first" era.

PURPOSE: Percutaneous transluminal angioplasty (PTA)-induced venous rupture is a common complication of hemodialysis access interventions. The authors sought to determine if venous rupture rates and management differed between grafts and fistulas, and in the fistula subset, between transposed and nontransposed fistulas. MATERIALS AND METHODS: Patients experiencing venous rupture during hemodialysis PTA over a 5-year period were identified. Of 1,985 hemodialysis interventions, 75 ruptures occurred in 69 patients (46 women) with a mean age of 63 years (range, 31-88 y). Rupture rates, proportion of successful treatments, and treatment type and number (ie, balloon tamponade, stent, covered stent) were determined. RESULTS: Rupture was more common in fistulas overall (5.6%, 39 of 693) compared with grafts (2.8%, 36 of 1,292; P = .002), in transposed (10.7%, 20 of 187) compared with nontransposed fistulas (3.8%, 19 of 506; P = .001), and in transposed fistulas compared with grafts (P = .0001). There was no significant difference between nontransposed fistulas and grafts. Treatment success (ie, resolution of extravasation) was the same among groups: 69% (27 of 39) in fistulas overall, 70% (14 of 20) in transposed fistulas, 68% (13 of 19) in nontransposed fistulas, and 72% (26 of 36) in grafts. There was a greater need for stents in grafts (38.9%, 14 of 36) compared with fistulas (12.8%, five of 39; P = .003). CONCLUSIONS: PTA-induced rupture is more common in fistulas than grafts, and this effect seems nearly entirely driven by transposed fistulas. Although rupture treatment in fistulas of all types yielded similar success to grafts, and graft ruptures were more difficult to treat than fistula ruptures, the high rupture rates in transposed fistulas attest to the increased difficulty of treating this subset of fistulas.

Pharmacy refill adherence compared with CD4 count changes for monitoring HIV-infected adults on antiretroviral therapy.

BACKGROUND: World Health Organization (WHO) guidelines for monitoring HIV-infected individuals taking combination antiretroviral therapy (cART) in resource-limited settings recommend using CD4(+) T cell (CD4) count changes to monitor treatment effectiveness. In practice, however, falling CD4 counts are a consequence, rather than a cause, of virologic failure. Adherence lapses precede virologic failure and, unlike CD4 counts, data on adherence are immediately available to all clinics dispensing cART. However, the accuracy of adherence assessments for predicting future or detecting current virologic failure has not been determined. The goal of this study therefore was to determine the accuracy of adherence assessments for predicting and detecting virologic failure and to compare the accuracy of adherence-based monitoring approaches with approaches monitoring CD4 count changes. METHODOLOGY AND FINDINGS: We conducted an observational cohort study among 1,982 of 4,984 (40%) HIV-infected adults initiating non-nucleoside reverse transcriptase inhibitor-based cART in the Aid for AIDS Disease Management Program, which serves nine countries in southern Africa. Pharmacy refill adherence was calculated as the number of months of cART claims submitted divided by the number of complete months between cART initiation and the last refill prior to the endpoint of interest, expressed as a percentage. The main outcome measure was virologic failure defined as a viral load > 1,000 copies/ml (1) at an initial assessment either 6 or 12 mo after cART initiation and (2) after a previous undetectable (i.e., < 400 copies/ml) viral load (breakthrough viremia). Adherence levels outperformed CD4 count changes when used to detect current virologic failure in the first year after cART initiation (area under the receiver operating characteristic [ROC] curves [AUC] were 0.79 and 0.68 [difference = 0.11; 95% CI 0.06 to 0.16; chi(2) = 20.1] respectively at 6 mo, and 0.85 and 0.75 [difference = 0.10; 95% CI 0.05 to 0.14; chi(2) = 20.2] respectively at 12 mo; p < 0.001 for both comparisons). When used to detect current breakthrough viremia, adherence and CD4 counts were equally accurate (AUCs of 0.68 versus 0.67, respectively [difference = 0.01; 95% CI -0.06 to 0.07]; chi(2) = 0.1, p > 0.5). In addition, adherence levels assessed 3 mo prior to viral load assessments were as accurate for virologic failure occurring approximately 3 mo later as were CD4 count changes calculated from cART initiation to the actual time of the viral load assessments, indicating the potential utility of adherence assessments for predicting future, rather than simply detecting current, virologic failure. Moreover, combinations of CD4 count and adherence data appeared useful in identifying patients at very low risk of virologic failure. CONCLUSIONS: Pharmacy refill adherence assessments were as accurate as CD4 counts for detecting current virologic failure in this cohort of patients on cART and have the potential to predict virologic failure before it occurs. Approaches to cART scale-up in resource-limited settings should include an adherence-based monitoring approach.