Trends in Diabetes Medication Taking and Incidence of Depression in Patients with Type 2 Diabetes: A Retrospective Cohort Study from 2010 to 2018.

BACKGROUND: This study examined the trends in diabetes medication taking and its association with the incidence of depression in patients with type 2 diabetes (T2D). METHOD: A retrospective cohort of Medicare enrollees with regular care in 2010 was defined from 100% Texas Medicare claims. The impact of medication taking on incident depression was evaluated from 2010 to 2018. Cox proportional hazards regressions were used to estimate the association between medication taking and depression. RESULTS: A total of 72,461 patients with T2D and with regular care were analyzed. Among 60,216 treated patients, the regular medication taking rate slightly increased from 60.8 to 63.2% during the study period. Patients with regular medication taking at baseline had a 9% lower risk of developing depression (hazard ratio [HR]: 0.91, 95% confidence interval [CI]: 0.89-0.94), and the magnitude of the association increased after adjustment of the model for time-varied medication taking (HR: 0.82, 95% CI: 0.79-0.85). The presence of nephropathy had the greatest mediating effect (23.2%) on the association of medication taking and depression. CONCLUSION: We demonstrated a steady but modest increase in regular diabetes medication taking over a 9-year period and a significant relationship between medication taking and incident depression in patients with T2D.

Life-space mobility and post-hospitalization outcomes among older Mexican American Medicare beneficiaries.

BACKGROUND: Older adults with limited mobility are at an increased risk of adverse health outcomes, an outcome inadequately investigated in older Mexican Americans. We explored whether pre-admission life-space mobility predicts post-hospitalization outcomes among hospitalized Mexican American Medicare beneficiaries. METHODS: Life-space mobility, using the Life-Space Assessment (LSA), was analyzed using quartiles and 5-point intervals. Using the Hispanic Established Populations for the Epidemiologic Study of the Elderly (HEPESE) Waves 7 and 8 data linked to Medicare claims data, 426 older Mexican Americans with at least 2 months of Medicare coverage who were hospitalized within 2 years of completing the LSA were included. Logistic and Cox Proportional regression analyses estimated the association of pre-admission LSA with post-hospitalization outcomes. RESULTS: Prior to hospitalization, 85.4% reported limited life-space mobility. Most patients (n = 322, 75.6%) were hospitalized for medical reasons. About 65% were discharged to the community. Pre-admission LSA scores were not associated with community discharge (Odds Ratio [OR] = 1.02, 0.95-1.10). Higher pre-admission LSA scores were associated with 30-day readmission (OR = 1.11, 1.01-1.22). Patients in the highest pre-admission LSA quartile (i.e., greatest life-space mobility) were less likely to die within 2 years after hospital discharge (OR = 0.61, 0.39-0.97) compared to those with lower pre-admission LSA scores. CONCLUSIONS: Among older Mexican American Medicare beneficiaries, greater pre-admission LSA scores were associated with an increased risk of 30-day readmission and a decreased risk of mortality within 2 years following hospitalization. Future work should further investigate the relationship between LSA and post-hospitalization outcomes in a larger sample of Mexican American older adults.

Signal Detection of Adverse Events Associated with Trastuzumab in a Cohort of Elderly Patients with Breast Cancer.

AIM: Utilization of signal detection methods in longitudinal claims data can improve post-marketing drug surveillance, but to date there has been limited application. The aim of this study is to use 3 approaches, the proportional reporting ratio, Gamma Poisson Shrinker, and tree-based scan statistic in detecting adverse drug events (ADEs) attributed to trastuzumab using an administrative claims dataset. METHODS: Using data from the Texas Cancer Registry and SEER linked to Medicare from 2010 to 2013, we conducted 1:2 propensity score matching. Breast cancer HER2+ patients treated with trastuzumab in addition to standard chemotherapy were matched to HER2- patients treated with standard chemotherapy. Inpatient and outpatient encounters up to 6 months from start of therapy were used to identify adverse events. RESULTS: A total of 4191 patients were included in the study. Across all methods, use of trastuzumab generated signals on 9 distinct body systems. Cardiomyopathy and heart valve disease were the most consistently detected signals. Clinical review determined that most signals represented known ADEs. CONCLUSIONS: We showed that claims data can be used to complement current ADE monitoring using common data mining methods with propensity score matching. Our analysis identified all expected ADEs associated with trastuzumab, and additional signals of valvular heart disorders.

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries.

OBJECTIVES: To examine Medicare health care spending and health services utilization among high-need population segments in older Mexican Americans, and to examine the association of frailty on health care spending and utilization. METHODS: Retrospective cohort study of the innovative linkage of Medicare data with the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) were used. There were 863 participants, which contributed 1,629 person years of information. Frailty, cognition, and social risk factors were identified from the H-EPESE, and chronic conditions were identified from the Medicare file. The Cost and Use file was used to calculate four categories of Medicare spending on: hospital services, physician services, post-acute care services, and other services. Generalized estimating equations (GEE) with a log link gamma distribution and first order autoregressive, correlation matrix was used to estimate cost ratios (CR) of population segments, and GEE with a logit link binomial distribution was applied to estimate odds ratios (OR) of healthcare use. RESULTS: Participants in the major complex chronic illness segment who were also pre-frail or frail had higher total costs and utilization compared to the healthy segment. The CR for total Medicare spending was 3.05 (95% CI, 2.48-3.75). Similarly, this group had higher odds of being classified in the high-cost category 5.86 (95% CI, 3.35-10.25), nursing home care utilization 11.32 (95% CI, 3.88-33.02), hospitalizations 4.12 (95% CI, 2.88-5.90) and emergency room admissions 4.24 (95% CI, 3.04-5.91). DISCUSSION: Our findings highlight that frailty assessment is an important consideration when identifying high-need and high-cost patients.

Impact of State Nurse Practitioner Regulations on Potentially Inappropriate Medication Prescribing Between Physicians and Nurse Practitioners: A National Study in the United States.

BACKGROUND: The American Geriatrics Society regularly updates the Beers Criteria for Potentially Inappropriate Medication (PIM) to improve prescribing safety. PURPOSE: This study assessed the impact of nurse practitioner (NP) practices on PIM prescribing across states in the United States and compared the change in PIM prescribing rates between 2016 and 2018. METHODS: We used data from a random selection of 20% of Medicare beneficiaries (66 years or older) from 2015 to 2018 to perform multilevel logistic regression. A PIM prescription was classified as initial or refill on the basis of medication history 1 year before a visit. PIM use after an outpatient visit was the primary study outcome. RESULTS: We included 9 000 224 visits in 2016 and 9 310 261 in 2018. The PIM prescription rate was lower in states with full NP practice and lower among NPs than among physicians; these rates for both physicians and NPs decreased from 2016 to 2018. CONCLUSIONS: Changes could be due to individual state practices.

Comprehensive Assessment of Fetal Bilateral Ventriculomegaly Based on Genetic Disorders, Cytomegalovirus Infection, Extra Prenatal Imaging and Pregnancy Outcomes in a Tertiary Referral Center.

OBJECTIVE: This retrospective study aimed to systematically evaluate the genetic disorders, cytomegalovirus (CMV) infection, extra ultrasound findings and outcomes of fetuses with bilateral ventriculomegaly (BVM). METHODS: Data from pregnancies with fetal BVM were obtained between 2014 and 2020. The cases were divided into groups of isolated bilateral ventriculomegaly (IBVM) and non-isolated bilateral ventriculomegaly (NIBVM) according to the presence of extra prenatal imaging. Subgroups of mild, moderate, and severe were determined according to lateral ventricle widths. The NIBVM group was further classified into pregnancies with soft markers, non-structural abnormalities, and structural abnormalities. RESULTS: A total of 353 pregnancies were enrolled, including 153 cases of IBVM and 200 cases of NIBVM. Conventional karyotyping was performed on 192 samples, and 15 cases of numerical abnormalities and 3 cases of unbalanced structural abnormalities were identified. Chromosomal microarray analysis (CMA) was concurrently performed on 108 of them and revealed additional 5 cases (4.7%) of copy number variants with clinical significance. CMV DNA testing was performed on 154 of the 192 cases that underwent invasive prenatal diagnosis, and a positive result was found in 2 (1.3%) cases. In the IBVM group, the percentage of favorable prognosis in the mild, moderate and severe pregnancies were 94.4%, 79.2%, and 4.8%, respectively, and the termination of pregnancy (TOP) rates were 4.6%, 20.8%, and 85.7%, respectively. In both the mild and moderate NIBVM, the TOP rates progressively increased and the favorable prognosis survival rates progressively decreased relative to the soft markers, non-structural abnormalities, and structural abnormalities, respectively. Approximately 94.1% of severe NIBVM ended in termination. CONCLUSION: Genetic disorders and fetal infection are important etiology of BVM. CMA is highly recommended for genetic disorders' evaluation. Pregnancies with severe BVM always ended in TOP, while in mild-to-moderate NIBVM, prenatal imaging by ultrasound and/or MRI plays important roles in the pregnancy outcomes.

General recommendation for assessment and management on the risk of glucocorticoid-induced osteonecrosis in patients with COVID-19.

BACKGROUND/OBJECTIVE: Coronavirus disease 2019 (COVID-19) is a disaster in human medical history and glucocorticoids remain the most promising therapy. Osteonecrosis is a disease caused by reduced intraosseous blood flow to bones in the joints, which will rapidly induce joint destruction. Approximately one-third patients with severe acute respiratory syndrome (SARS) who received high cumulative doses and long treatment durations of glucocorticoids occurred osteonecrosis. Considering the similarity of SARS and COVID-19 on their pathogen, clinical characteristics, and therapeutic strategies, it is particularly desirable to investigate whether osteonecrosis will become a common sequela among convalescent COVID-19 patients. METHODS: This multi-strategy study was designed by integrating different research methods, such as meta-analysis, systematic review, and cross-sectional investigations to address above study objectives. At first, two meta-analyses were performed on the osteonecrosis incidence among SARS patients and the clinical data of glucocorticoid exposure among COVID-19 patients. Then, a systematic review of low-dosage glucocorticoid associated osteonecrosis and a cross-sectional investigation of glucocorticoid exposure of COVID-19 patients in Wuhan city of China were also conducted. Moreover, the pathogenesis, diagnosis, prevention, and treatment options for osteonecrosis patients with COVID-19 infection were further presented and discussed. RESULTS: Our meta-analysis showed that 32% of SARS patients had developed osteonecrosis after receiving glucocorticoid treatment with high dose, and our system review supported that low level glucocorticoid exposure might also lead to the occurrence of osteonecrosis. Similarly, 40% of COVID-19 patients had undergone glucocorticoid treatment according to our meta-analysis. The cross-sectional investigation in Wuhan city of China found that the average of cumulative glucocorticoid exposure level was 504 â€‹mg calculated by the dosage of methylprednisolone. Notably, a confirmed osteonecrosis case was identified from 1406 patients with COVID-19 during our cross-sectional investigation, implying that preventive management of osteonecrosis should be better started with regular clinical follow-up observation. CONCLUSION: Growing evidence of the glucocorticoid therapy for COVID-19 patients prompts us to establish risk-classification-based early screening and to introduce early prevention protocol of its associated osteonecrosis that will be of clinical significance in favor of improved prognosis of this disease. THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE: To establish risk-classification-based early screening and to introduce early prevention protocol of glucocorticoid-induced osteonecrosis will be of clinical significance in favor of improved prognosis of COVID-19.

Documentation of Dementia as a Cause of Death Among Mexican-American Decedents Diagnosed with Dementia.

BACKGROUND: Hispanic older adults are a high-risk population for Alzheimer's disease and related dementias (ADRD) but are less likely than non-Hispanic White older adults to have ADRD documented as a cause of death on a death certificate. OBJECTIVE: To investigate characteristics associated with ADRD as a cause of death among Mexican-American decedents diagnosed with ADRD. METHODS: Data came from the Hispanic Established Populations for the Epidemiologic Study of the Elderly, Medicare claims, and National Death Index. RESULTS: The final sample included 853 decedents diagnosed with ADRD of which 242 had ADRD documented as a cause of death. More health comorbidities (OR = 0.40, 95% CI = 0.28-0.58), older age at death (OR = 1.18, 95% CI = 1.03-1.36), and longer ADRD duration (OR = 1.08, 95% CI = 1.03-1.14) were associated with ADRD as a cause of death. In the last year of life, any ER admission without a hospitalization (OR = 0.45, 95% CI = 0.22-0.92), more physician visits (OR = 0.96, 95% CI = 0.93-0.98), and seeing a medical specialist (OR = 0.46, 95% CI = 0.29-0.75) were associated with lower odds for ADRD as a cause of death. In the last 30 days of life, any hospitalization with an ICU stay (OR = 0.55, 95% CI = 0.36-0.82) and ER admission with a hospitalization (OR = 0.67, 95% CI = 0.48-0.94) were associated with lower odds for ADRD as a cause of death. Receiving hospice care in the last 30 days of life was associated with 1.98 (95% CI = 1.37-2.87) higher odds for ADRD as a cause of death. CONCLUSION: Under-documentation of ADRD as a cause of death may reflect an underestimation of resource needs for Mexican-Americans with ADRD.

Potentially inappropriate medication prescribing by nurse practitioners and physicians.

BACKGROUND: Potentially inappropriate medication (PIM) use is a risk factor for hospitalization and mortality. However, there were few studies focusing on the impact of provider type on PIM use. OBJECTIVE: We aimed to estimate the initial and refill PIM prescribing rate for physician visits and nurse practitioner (NP) visits and the impact of provider type on PIM prescribing. RESEARCH DESIGN: We used 100% Texas Medicare data to define physician visits and NP visits in 2016. The rate of visits with a PIM prescription from the same provider was measured, distinguishing between initial and refill prescription to estimate the PIM rate and adjusted odds ratio (OR) by provider type. RESULTS: There were 24.1 per 1000 visits with a prescription for a PIM: 9.0 per 1000 visits for an initial PIM and 15.1 per 1000 visits for a refill PIM. A visit to an NP was less likely to result in an initial (OR = 0.74, 95% confidence interval [CI] = 0.70-0.79) or refill (OR = 0.54, 95% CI = 0.51-0.57) PIM. The association of lower odds of receiving a prescription for an initial PIM from an NP was substantially stronger among black enrollees than white enrollees (OR = 0.44, 95%CI = 0.30-0.65 for blacks and OR = 0.73, 95%CI = 0.68-0.78 for white enrollees). The association of an NP provider with lower odds of receiving a PIM refill was more pronounced in older patients and in those with more comorbidities. CONCLUSIONS: NPs prescribed fewer initial PIMs and were less likely to refill a PIM after an outpatient visit than physicians. The lower odds of receiving PIMs during an NP visit varied by age, race/ethnicity, rurality, and number of comorbidities.

Association of Occupational and Physical Therapy With Duration of Prescription Opioid Use After Hip or Knee Arthroplasty: A Retrospective Cohort Study of Medicare Enrollees.

OBJECTIVE: To establish whether nonpharmacologic interventions, such as occupational and physical therapy, were associated with a shorter duration of prescription opioid use after hip or knee arthroplasty. DESIGN: This retrospective cohort study used data from a national 5% Medicare sample database between January 1, 2010 and December 31, 2015. SETTING: Home health or outpatient. PARTICIPANTS: Adults 66 years or older with an inpatient total hip (n=4272) or knee (n=9796) arthroplasty (N=14,068). INTERVENTIONS: We dichotomized patients according to whether they had received any nonpharmacologic pain intervention within 1 year after hospital discharge (eg, occupational or physical therapy evaluation). Using Cox proportional hazards, we treated exposure to nonpharmacologic interventions as time dependent to determine if skilled therapy was associated with duration of opioid use. MAIN OUTCOME MEASURES: Duration of prescription opioid use. RESULTS: Median time to begin nonpharmacologic interventions was 91 days (95% confidence interval [CI], 74-118d) for hip and 27 days (95% CI, 27-28d) for knee arthroplasty. Median time to discontinue prescription opioids was 16 days (hip: 95% CI, 15-16d) and 30 days (knee: 95% CI, 29-31d). Nonpharmacologic interventions delivered with home health increased the likelihood of discontinuing opioids after hip (hazard ratio [HR], 1.15; 95% CI, 1.01-1.30) and knee (HR, 1.10; 95% CI, 1.03-1.17) arthroplasty. A sensitivity analysis found these estimates to be robust and conservative. CONCLUSIONS: Occupational and physical therapy with home health was associated with a shorter duration of prescription opioid use after hip and knee arthroplasty. Occupational and physical therapy can address pain and sociobehavioral factors associated with postsurgical opioid use.

SNP Array as a Tool for Prenatal Diagnosis of Congenital Heart Disease Screened by Echocardiography: Implications for Precision Assessment of Fetal Prognosis.

OBJECTIVE: This study aimed to examine the effectiveness of the SNP array for the prenatal diagnosis of congenital heart disease (CHD) screened by echocardiography. PATIENTS AND METHODS: A total of 356 pregnant women with fetal congenital heart malformations revealed by echocardiography at the Center for Prenatal Diagnosis of Fujian Maternal and Children Hospital during the period from November 2016 through July 2019 were recruited. The fetuses were assigned into three cohorts, including 142 with a single cardiac malformation, 106 with multiple cardiac malformations and 108 with cardiac and extracardiac malformations. All fetuses underwent chromosomal karyotyping and SNP array simultaneously, and the effectiveness of the SNP array for the prenatal diagnosis of CHD was evaluated. RESULTS: The overall prevalence of abnormal karyotypes was 9.3% among the 356 fetuses with CHD, and a higher proportion was found in fetuses with cardiac and extracardiac malformations (18.5%) than in those with single (5.6%) or multiple cardiac malformations (4.7%) (P<0.05). Consistent with karyotype analysis, SNP array detected an additional 25 fetuses with pathogenic copy number variations (CNVs), seven with variant of unknown significance (VOUS) and seven with benign CNVs, and a lower proportion of abnormal CNV was found in fetuses with a single cardiac malformation (4.2%) than in those with multiple cardiac malformations (9.4%) or cardiac and extracardiac malformations (14.8%) (P<0.05). Among the 33 fetuses with chromosomal abnormality, postnatal follow-up showed termination of pregnancy in 25 with pathogenic CNVs, one with VOUS, and six with normal karyotypes and SNP array findings but severe multiple malformations by ultrasonography. CONCLUSION: SNP array increases the overall detection of abnormal CNVs by 9%, which improves the detection of CNVs associated with CHD. SNP array may serve as a tool for prenatal diagnosis of CHD that facilitates the discovery of pathogenic genes associated with CHD and provide valuable insights into the precision assessment of fetal prognosis during the prenatal counseling.

Nurse Practitioner Involvement in Medicare Accountable Care Organizations: Association With Quality of Care.

The objective was to examine trend and care quality outcomes associated with nurse practitioner (NP) involvement in Accountable Care Organizations (ACOs) via a cross-sectional study of 521 Medicare Shared Savings Program ACOs during 2014 to 2016. Data include ACO provider/beneficiary files, Medicare claims, and ACO performance data with a focus on Medicare beneficiaries with diabetes, chronic obstructive pulmonary disease, or heart failure. ACO care quality measures were stratified by NP involvement and adjusted for patient, provider, and ACO factors. NP involvement was highest in larger ACOs, states that allow NPs full scope of practice, and rural areas. Greater involvement was associated with fewer readmissions and higher scores on measures of preventive care but not chronic disease and medication management. Greater NP involvement in ACOs was associated with improvement in some care quality measures. With NPs' increasing involvement in ACOs, more research is needed to understand the NP role in processes and outcomes of care.

Changes in Health Care Use by Mexican American Medicare Beneficiaries Before and After a Diagnosis of Dementia.

BACKGROUND: Evidence from predominantly non-Hispanic White cohorts indicates health care utilization increases before Alzheimer's disease and related dementias (ADRD) is diagnosed. We investigated trends in health care utilization by Mexican American Medicare beneficiaries before and after an incident diagnosis of ADRD. METHODS: Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare claims files from 1999 to 2016 (n = 558 matched cases and controls). Piecewise regression and generalized linear mixed models were used to compare the quarterly trends in any (ie, one or more) hospitalizations, emergency room (ER) admissions, and physician visits for 1 year before and 1 year after ADRD diagnosis. RESULTS: The piecewise regression models showed that the per-quarter odds for any hospitalizations (odds ratio [OR] = 1.62, 95% CI = 1.43-1.84) and any ER admissions (OR = 1.40, 95% CI = 1.27-1.54) increased before ADRD was diagnosed. Compared to participants without ADRD, the percentage of participants with ADRD who experienced any hospitalizations (27.2% vs 14.0%) and any ER admissions (19.0% vs 11.7%) was significantly higher at 1 quarter and 3 quarters before ADRD diagnosis, respectively. The per-quarter odds for any hospitalizations (OR = 0.88, 95% CI = 0.80-0.97) and any ER admissions (OR = 0.89, 95% CI = 0.82-0.97) decreased after ADRD was diagnosed. Trends for any physician visits before or after ADRD diagnosis were not statistically significant. CONCLUSIONS: Older Mexican Americans show an increase in hospitalizations and ER admissions before ADRD is diagnosed, which is followed by a decrease after ADRD diagnosis. These findings support the importance of a timely diagnosis of ADRD for older Mexican Americans.

Concentration, spatial distribution, and health risk assessment of PFASs in serum of teenagers, tap water and soil near a Chinese fluorochemical industrial plant.

Discharges released from fluorochemical industrial plants lead to severe contamination of the environment with per- and polyfluoroalkyl substances (PFASs), which may pose risks to human health. In this study, 187 serum samples from teenagers (age = 14 years), 22 tap water samples and 40 soil samples were collected in areas within 0-11 km of a fluorochemical industrial plant in Huantai County, Shandong Province, and concentrations of 18 PFASs were quantified by UPLC-MS/MS. Perfluorooctanoic acid (PFOA) was found to be predominant, concentrations of which ranged from 40.4 to 845 ng/mL in serum, from 2.88 to 19.3 ng/L in tap water, from 4.40 to 189 ng/g in soil, and accounting for 84.1-98.6%, 15.9-79.8%, and 73.8-96.7% of the total PFASs, respectively. Statistical analysis demonstrated that concentrations of perfluorinated carboxylic acids (PFCAs) in soil (C5-C9) and serum (C8-C10) were associated with the industrial plant. And PFOA concentrations in tap water were not relevant to the industrial plant, which were comparable with the non-contaminated area and lower than the threshold value recommended by U.S. EPA (70 ng/mL), indicating that the contribution to the high concentration of serum PFOA of local teenagers by drinking water was limited. Moreover, PFCAs in soil only made a limited contribution to the serum PFCAs of local residents by direct inhalation and dermal exposure, but the potential health risk by the soil via food chain should be paid attention to. Furthermore, health risk assessment demonstrated that high concentrations of PFOA in serum could pose potential health risk to local teenagers. Therefore, effective measures should be taken to attenuate the health risks caused by the industrial plant to local residents, and further epidemiological studies should be carried out in the future.

Characteristics Associated with Feeding Tube Placement: Retrospective Cohort Study of Texas Nursing Home Residents with Advanced Dementia.

OBJECTIVES: To investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: NH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582). METHODS: This study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors. RESULTS: The prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50). CONCLUSIONS AND IMPLICATIONS: Regional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns.

Assessing Association Between Team Structure and Health Outcome and Cost by Social Network Analysis.

BACKGROUND/OBJECTIVE: To assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care. DESIGN: Cross-sectional study. SETTING: Data from 20% randomly selected primary care service areas in the 2015 Medicare claims were used to identify primary care practices. PARTICIPANTS: 449,460 patients with diabetes, heart failure, or chronic obstructive pulmonary disease cared for by the identified primary care practices. MEASUREMENTS: Social network analysis measures, including edge density, degree centralization, and betweenness centralization for each practice. RESULTS: When compared with practices with MDs and nurse practitioners (NPs) or/and physicians assistants (PAs), the practices with MDs had only lower degree of centralization and higher MD-to-MD connectedness. Within the primary care practices comprising MDs, NPs, or/and PAs, the nonphysician providers were more connected (measured as edge density) to all providers in the practice but with higher degree of centralization compared with the MDs in the practice. After adjusting for patient characteristics and type of practice, higher edge density was associated with lower odds of hospitalization (odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-0.99), emergency department (ER) admission (OR = 0.80, 95% CI = 0.70-0.92), and total spending (cost ratio (CR) = 0.86, standard error of the mean (SE) = 0.038). Conversely, higher degree centralization was associated with higher rates of hospitalization (OR = 1.15, 95% CI = 1.03-1.28), ER admission (OR = 1.23, 95% CI = 1.08-1.40), and total spending (CR = 1.14, SE = 0.037). However, higher degree centralization was associated with lower rates of potentially inappropriate medications (OR = 0.90, 95% CI = 0.81-0.99). Team leadership by an NP versus an MD was similar in the rate of ER admissions, hospitalizations, or total spending. CONCLUSION: Our findings showed that highly connected primary care practices with high collaborative care and less top-down MD-centered authority have lower odds of hospitalization, fewer ER admissions, and less total spending; findings likely reflecting better communication and more coordinated care of older patients.

Frailty transitions predict healthcare use and Medicare payments in older Mexican Americans: a longitudinal cohort study.

BACKGROUND: Little is known regarding the impact of transitions in frailty on healthcare use and payment in older Mexican Americans. We address this gap in knowledge by investigating the effect of early transitions in physical frailty on the use of healthcare services and Medicare payments involving older Mexican Americans. METHODS: Longitudinal analyses were conducted using the Hispanic Established Populations for the Epidemiological Study of the Elderly (Hispanic-EPESE) survey data from five Southwest states linked to the Medicare claims files from the Centers for Medicare and Medicaid Services. Seven hundred and eighty-eight community-dwelling Mexican Americans 72 years and older in 2000/01 were studied. We used a modified Frailty Phenotype (unintentional weight loss, weakness, self-reported exhaustion and slow walking speed) to classify frailty status (non-frail, pre-frail or frail). Each participant was placed into one of 5 frailty transition groups: 1) remain non-frail, 2) remain pre-frail, 3) remain frail, 4) improve (pre-frail to non-frail, frail to non-frail, frail to pre-frail) and 5) worse (non-frail to pre-frail, non-frail to frail, pre-frail to frail). The outcomes for the one-year follow-up period (2000-2001) were: (a) healthcare use (hospitalization, emergency room [ER] admission and physician visit); and (b) Medicare payments (total payment and outpatient payment). RESULTS: Mean age was 78.8 (SD = 5.1) years and 60.3% were female in 1998/99. Males who remained pre-frail (Odds Ratio [OR] = 3.49, 1.13-10.8, remained frail OR = 6.92, 1.61-29.7) and transitioned to worse frail status (OR = 4.49, 1.74-11.6) had significantly higher hospitalization risk compared to individuals who remained non-frail. Males in the 'worsened' groups, and females in the 'improved' groups, had significantly higher Medicare payments than individuals who remained non-frail (Cost Ratio [CR] = 2.00, 1.30-3.09; CR = 1.53, 1.12-2.09, respectively]. CONCLUSIONS: Healthcare use and Medicare payments differed by frailty transition status. The differences varied by sex. Research is necessary to elucidate the relationship between frailty transitions and outcomes, sex difference and Medicare payment for older Mexican Americans living in the community.

Long-Molecule Sequencing: A New Approach for Identification of Clinically Significant DNA Variants in α-Thalassemia and ß-Thalassemia Carriers.

Multiple molecular tests are currently needed for accurate carrier testing for thalassemia. Therefore, long-molecule sequencing (LMS) was evaluated as an alternate on the PacBio Sequel platform for genotyping carriers of α-thalassemia or ß-thalassemia. Multiplex long PCR was used to generate representative amplicons for the α (HBA1/2) and ß (HBB) gene loci. Following LMS, circular consensus sequencing reads were aligned to the hg19 reference genome and variants called using FreeBayes software version 1.2.0. In a blinded study of 64 known carrier samples, all HBA1/2 and HBB variants detected by LMS were concordant with those independently assigned by targeted PCR assays. For HBA1/2 carrier samples, LMS accurately detected the common South East Asian, -α3.7, and -α4.2 deletions and four different rare single-nucleotide variants (SNVs). For HBB carrier samples, LMS accurately detected the most common Chinese insertion and deletion variant c.126_129delCTTT and 14 different SNVs/insertions and deletions and could discriminate compound heterozygous SNVs (trans configuration) and identify variants linked to benign SNPs (cis configuration). Overall, LMS displayed the hallmarks of a scalable, accurate, and cost-effective genotyping method. With further test coverage to additionally include detection of other clinically significant HBA1/2 copy number variations, such as the Thai, Mediterranean, and Filipino deletions, LMS may eventually serve as a comprehensive method for large-scale thalassemia carrier screening.

End-expiratory lung volume assessment using helium and carbon dioxide in an experimental model of pediatric capnoperitoneum.

BACKGROUND: Capnoperitoneum during laparoscopy leads to cranial shift of the diaphragm, loss in lung volume, and risk of impaired gas exchange. Infants are susceptible to these changes and bedside assessment of lung volume during laparoscopy might assist with optimizing the ventilation. Thus, the primary aim was to investigate the monitoring value of a continuous end-expiratory lung volume (EELV) assessment method based on CO2 dynamics ( EELV CO 2 ) in a pediatric capnoperitoneum model by evaluating the correlation and trending ability against helium washout (EELVHe ). METHODS: Intra-abdominal pressure (IAP) was randomly varied between 0, 6, and 12 mm Hg with CO2 insufflation, while positive end-expiratory pressure (PEEP) levels of 3, 6, and 9 cm H2 O were randomly applied in eight anesthetized and mechanically ventilated chinchilla rabbits. Concomitant EELV CO 2 and EELVHe and lung clearance index (LCI) were obtained under each experimental condition. RESULTS: Significant correlations were found between EELV CO 2 and EELVHe before capnoperitoneum (r = .85, P < .001), although increased IAP distorted this relationship. The negative influence of IAP was counteracted by the application of PEEP 9, which restored the correlation between EELV CO 2 and EELVHe and resulted in 100% concordance rate between the methods regarding changes in lung volume. EELVHe and LCI showed a curvilinear relationship, and an EELVHe of approximately 20 mL kg-1 , determined with a receiver operating characteristic curve, was associated with near-normal LCI values. CONCLUSION: In this animal model of pediatric capnoperitoneum, reliable assessment of changes in EELV based on EELV CO 2 requires an open lung strategy, defined as EELV above approximately 20 mL kg-1 .