Connected Community Classification (C3): Development, Validation, and Geospatial Application for Population Health Promotion and Equity.

CONTEXT: Social determinants of health (SDOH) impact population health. Leveraging community-level strengths related to SDOH through a social infrastructure perspective can optimize health behaviors and health outcomes to promote health equity. OBJECTIVE: Our aims were to develop, validate, and apply the Connected Community Classification (C3) as comprehensive community-level measure of protective SDOH and structural factors in the Four Corners states region of the United States. DESIGN: C3 was developed using an iterative principal component analysis of publicly available data mapped to 5 SDOH domains. Regional clustering of C3 by zip code tabulation area (ZCTA) was identified using spatial autocorrelation methods. MAIN OUTCOMES: In adjusted spatial autoregressive models, we analyzed the association of C3 with high-risk health behaviors and chronic disease prevalence using publicly available data for population-level estimates of fruit and vegetable intake, physical activity, obesity, smoking, alcohol use, coronary heart disease (CHD), diabetes, and cancer. RESULTS: C3 was found to be reliable and valid; a C3 value of 10 indicates communities with greater connection (high), while a value of 1 indicates communities with greater separation (low) to social infrastructure. Lower connection, as measured by C3, was significantly inversely associated with lower fruit and vegetable intake, lower physical activity, and higher rates of obesity, smoking, CHD, diabetes, and cancer. C3 was significantly positively associated with heavy alcohol use. CONCLUSIONS: These findings demonstrate that communities connected to social infrastructure have better population health outcomes. C3 captures protective community attributes and can be used in future applications to assist health researchers, practitioners, nonprofits, and policymakers to advance social connection and health equity in geographically diverse underserved regions.

Co-designing a dashboard of predictive analytics and decision support to drive care quality and client outcomes in aged care: a mixed-method study protocol.

INTRODUCTION: There is a clear need for improved care quality and quality monitoring in aged care. Aged care providers collect an abundance of data, yet rarely are these data integrated and transformed in real-time into actionable information to support evidence-based care, nor are they shared with older people and informal caregivers. This protocol describes the co-design and testing of a dashboard in residential aged care facilities (nursing or care homes) and community-based aged care settings (formal care provided at home or in the community). The dashboard will comprise integrated data to provide an 'at-a-glance' overview of aged care clients, indicators to identify clients at risk of fall-related hospitalisations and poor quality of life, and evidence-based decision support to minimise these risks. Longer term plans for dashboard implementation and evaluation are also outlined. METHODS: This mixed-method study will involve (1) co-designing dashboard features with aged care staff, clients, informal caregivers and general practitioners (GPs), (2) integrating aged care data silos and developing risk models, and (3) testing dashboard prototypes with users. The dashboard features will be informed by direct observations of routine work, interviews, focus groups and co-design groups with users, and a community forum. Multivariable discrete time survival models will be used to develop risk indicators, using predictors from linked historical aged care and hospital data. Dashboard prototype testing will comprise interviews, focus groups and walk-through scenarios using a think-aloud approach with staff members, clients and informal caregivers, and a GP workshop. ETHICS AND DISSEMINATION: This study has received ethical approval from the New South Wales (NSW) Population & Health Services Research Ethics Committee and Macquarie University's Human Research Ethics Committee. The research findings will be presented to the aged care provider who will share results with staff members, clients, residents and informal caregivers. Findings will be disseminated as peer-reviewed journal articles, policy briefs and conference presentations.

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates.

OBJECTIVE: To evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race. DATA SOURCES: Medicare Limited Data Set 5% sample claims 2003-2014 and the HRSA Area Health Resources Files. STUDY DESIGN: Instrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county-level Welcome to Medicare Visit rates as an instrument. DATA COLLECTION/EXTRACTION METHODS: Three hundred twenty-four thousand three hundred and eighty-five fee-for-service Medicare beneficiaries without dementia when the AWV was introduced in 2011. PRINCIPAL FINDINGS: Annual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6 months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P < .001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses. CONCLUSIONS: Dementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.

Persistent Disparities in Medicare's Annual Wellness Visit Utilization.

INTRODUCTION: The Medicare Annual Wellness Visit (AWV) is a preventive care visit introduced in 2011 as part of the Affordable Care Act provided without cost to beneficiaries. The AWV is associated with higher preventive services utilization. Although AWV utilization increased during 2011-2013, utilization was lower among ethnoracial minority beneficiaries who may benefit the most. OBJECTIVES: To determine if AWV utilization disparities have persisted using the most recent data available. RESEARCH DESIGN: The authors analyzed AWV utilization in 2011-2013 and 2015-2016 by beneficiary-reported race and ethnicity, adjusting for potential confounders. SUBJECTS: Weighted sample of 78,639,501 fee-for-service Medicare beneficiaries aged 66 years and older who participated in the Medicare Current Beneficiary Survey 2011-2013 or 2015-2016. MEASURES: AWV utilization was identified using Medicare claims. RESULTS: AWV utilization increased from 8.1% to 23.0% of all beneficiaries between 2011 and 2016. Compared with non-Hispanic white beneficiaries, utilization was significantly lower among non-Hispanic Black and non-Hispanic other race beneficiaries in both the minimally and fully-adjusted models. Hispanic/Latino beneficiaries had lower utilization in the minimally adjusted model, but not in the fully-adjusted model. In 2016, compared with non-Hispanic white beneficiaries, AWV utilization was 10.2 points lower for non-Hispanic black, 11.6 points lower for Hispanic/Latino, and 8.6 points lower for non-Hispanic other race beneficiaries, and these differences were attenuated after adjusting for all covariates to 6.8 points lower, 9.4 points lower, and 7.2 points lower, respectively. CONCLUSIONS: The AWV has the potential to increase the use of preventive care, improve health, and reduce ethnoracial disparities among Medicare beneficiaries, but realizing these goals will require increasing utilization by minority groups. If ethnoracial minority beneficiaries had used the AWV at the same rate as non-Hispanic white beneficiaries during the study period, then ~1.6 million additional AWVs would have been used.

Sociodemographic Variation in the Use of Conservative Therapy Before MRI of the Lumbar Spine for Low Back Pain in the Era of Public Reporting.

PURPOSE: To evaluate the relationship between use of MRI of the lumbar spine for low back pain without prior conservative therapy and sociodemographic factors after the implementation of public reporting for Medicare's Hospital Outpatient Imaging Efficiency Measure for MRI Lumbar Spine for Low Back Pain (OP-8) metric. MATERIALS AND METHODS: We conducted a secondary data analysis using a nationally representative sample of 2009 to 2014 Medicare claims to evaluate trends in use of conservative therapy before MRI of the lumbar spine. Continuously enrolled fee-for-service Medicare beneficiaries were included. We applied the same criteria used by Medicare to generate a measure consistent with OP-8. Regression was used to evaluate trends in OP-8 by reporting status (outpatient hospital or clinic) and beneficiary characteristics. Age, sex, and race from the Medicare denominator and area-level socioeconomic measures from the Area Health Resource File were used as covariates. RESULTS: Use of conservative therapy before MRI increased regardless of OP-8 reporting status. Several sociodemographic characteristics were associated with the likelihood of receiving conservative therapy before MRI; beneficiaries were less likely to receive conservative therapy before MRI if they were male, older, black, Hispanic or Latino; if they lived in the West or in an area with more college graduates; or if they had low incomes. Beneficiaries were more likely to receive conservative therapy before MRI if they had poorer health or lived in areas with higher home values. CONCLUSION: Variations in use of conservative therapy according to factors other than clinically relevant factors, such as health status, are worrying. Further strategies are needed to improve appropriateness and equity in the provision of diagnostic imaging.

Assessment of PI-RADS v2 categories ≥ 3 for diagnosis of clinically significant prostate cancer.

PURPOSE: To assess the diagnostic accuracy of PI-RADS v2 categories ≥ 3 to detect clinically significant prostate cancer (csPCa) against histopathology of Transperineal Mapping Biopsy (TPMB). MATERIALS AND METHODS: IRB-approved retrospective cohort study included 47 men who had 3.0 T multi-parametric MRI (mpMRI) and TPMB of prostate. Two radiologists independently evaluated T2, DWI, ADC map, and DCE images using PI-RADS v2 categories. A third radiologist served as tie-breaker. PI-RADS v2 score (PS) ≥ 3 lesions were correlated with 3D model of TPMB (3DTPMB) results based on prostate sectors. Two groups of csPCa status were separately analyzed for accuracy measures at lesion and person levels: Group 1 with GS (Gleason Score) ≥ 7 and group 2 with tumor volume ≥ 0.5 cc. Inter-rater reliability for PS and MR lexicon was calculated. RESULTS: Forty-seven patients with 3DTPMB had at least one lesion with PS ≥ 3 on mpMRI. PS of 5 had high PPV and high specificity of 100% at the lesion and person levels. Sensitivity of a PS ≥ 3 was 68.27% for group 1 and was 48.39% for group 2. Specificity was 93.56% for group 1 and was 95.53% for group 2. At the person level, sensitivity of PS ≥ 3 was 81.25% for group 1 and was 82.35% for group 2. Specificity was 32.26% for group 1 and was 53.85% for group 2. CONCLUSION: PI-RADS v2 category of 5 had high PPV and specificity; however, combined PS ≥ 3 had mixed performance in detection of csPCa.

Effect of Medicare Part D on Ethnoracial Disparities in Antidementia Medication Use.

OBJECTIVES: To examine ethnoracial disparities in antidementia medication use, accounting for implementation of Part D, and to evaluate the role of prescription drug coverage as a cause of antidementia medication disparities. DESIGN: Rotating panel of Medicare beneficiaries who participated in the Medicare Current Beneficiary Survey from 2003 to 2013. SETTING: Nationally representative sample of Medicare fee-for-service (FFS) beneficiaries with dementia. PARTICIPANTS: Community-dwelling FFS Medicare beneficiaries with dementia (N=4,304). MEASUREMENTS: Antidementia medication use, defined as at least one prescription fill in a given year. RESULTS: Unadjusted antidementia medication use was 10-percentage points lower for ethnoracial minority beneficiaries before Part D was implemented in 2006 (p=.01). This difference was attenuated after adjusting for demographic and socioeconomic factors (6-percentage points; p=.10). Part D was associated with a 6-percentage point increase in use (p<.01). The increase in use associated with Part D was higher although not statistically significantly so in ethnoracial minority beneficiaries (8-percentage points, p=.08). Analyses of each ethnoracial group found a significant effect of Part D only in Hispanic/Latino beneficiaries (18-percentage points; p<.01, adjusted). CONCLUSION: Antidementia medication disparities were reduced with expanded prescription drug coverage through Medicare Part D. Increases in antidementia medication use for minority beneficiaries started after Part D was implemented, with the largest increases in use observed in Hispanic/Latino beneficiaries.

Ethnoracial Disparities in Medicare Annual Wellness Visit Utilization: Evidence From a Nationally Representative Database.

INTRODUCTION: In 2011, Medicare began offering annual preventive care visits (annual wellness visit; AWV) to beneficiaries at no charge. Providing free preventive care supports primary and secondary prevention of chronic disease and may reduce ethnoracial disparities in health outcomes. OBJECTIVES: To estimate AWV utilization trends by ethnoracial group in a nationally representative sample of the Medicare population. RESEARCH DESIGN: We estimated the probability of AWV utilization using probit regression models with beneficiary-reported ethnoracial group as the primary predictor and demographics, socioeconomic indicators, and factors related to access and utilization of health care as covariates. SUBJECTS: In total, 14,687 fee-for-service Medicare beneficiaries aged 66 years or older who participated in the Medicare Current Beneficiary Survey 2011-2013. MEASURES: AWV utilization was identified using procedure codes. RESULTS: Overall AWV utilization increased from 8.1% (2011) to 13.4% (2013). In 2011, utilization was highest in non-Hispanic white (8.5%) and lowest in non-Hispanic black (4.5%) beneficiaries. Utilization increased the most in non-Hispanic black beneficiaries, to 15.4% in 2013. Significant differences in AWV utilization by non-Hispanic black and Hispanic/Latino beneficiaries were found in unadjusted models, but did not persist after controlling for income and education. Having a usual (nonemergent) place of care and a nonrural residence were strong predictors of utilization. CONCLUSIONS: Utilization of the AWV has increased modestly since its introduction, but remains low. Utilization varies by ethnoracial group, with disparities largely explained by differences in income and education. Further efforts are needed to evaluate AWV utilization and effectiveness, especially among low socioeconomic status ethnoracial minorities.

Race and Sex Disparities in Outcomes of Dialysis Access Maintenance Interventions.

PURPOSE: To determine whether utilization and outcomes of dialysis access maintenance interventions vary by patient race or sex. MATERIALS AND METHODS: Data for this retrospective cohort study of first-time arteriovenous (AV) access recipients were drawn from a 5% sample of Medicare beneficiaries, containing claims from all clinical settings (2009-2014) in 2,693 patients who received their first AV fistula/graft in 2009. Maintenance interventions-angiography, angioplasty, thrombolysis, stent placement, and venous embolization-were identified by corresponding Current Procedural Terminology codes. Outcomes of primary patency (PP), postinterventional primary patency (PIPP), and postinterventional secondary patency (PISP) were calculated with utilization records. Associations between demographic data and patency times were evaluated by a multivariate survival approach, controlling for baseline differences in patient age, comorbid disease, type of dialysis access, and interventionist specialty. RESULTS: AV grafts (AVGs) were created with greater frequency in women (32% vs 23% in men; P < .001) and minority patients (39% in black, 32% in Hispanic, and 29% in Asian patients vs 21% in white patients; P < .001). Women were at greater hazards for loss of PP (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.09-2.14) and PIPP (HR, 1.42; 95% CI, 1.01-2.00). Black patients were at greater hazards for loss of PP (HR, 1.37; 95% CI, 1.23-1.54) and PISP (HR, 1.29; 95% CI, 1.01-1.65). AVG creation predisposed patients to patency loss in all models (P < .001). CONCLUSIONS: Dialysis access patency rates are lower for women and black patients. More frequent primary AVG creation in women and minority patients additionally predisposes these patients to patency loss.

Public Reporting of MRI of the Lumbar Spine for Low Back Pain and Changes in Clinical Documentation.

OBJECTIVE: OP-8 is the Medicare imaging efficiency metric for MRI of the lumbar spine for low back pain in the outpatient hospital. We studied trends in exclusion criteria coding over time by site of service after implementation of OP-8 to evaluate provider's response to public reporting. MATERIALS AND METHODS: We conducted a secondary data analysis using the Medicare Limited Data Set 5% sample for beneficiaries with MRI lumbar spine and lower back pain during 2009 to 2014. We evaluated the association between excluding condition prevalence and site by using generalized estimating equations regression. We produced model-based estimates of excluding condition prevalence by site and year. As a sensitivity analysis, we repeated the analysis while including additional conditions in the outcome measure. RESULTS: We included 285,911 MRIs of the lumbar spine for low back pain. Generalized estimating equations regression found that outpatient hospitals had a higher proportion of MRIs with at least one excluding condition documented compared with outpatient clinics (P < .05), but increases in excluding condition prevalence were similar across all sites during 2009 to 2014. Our results were not sensitive to the inclusion of additional conditions. CONCLUSION: Documentation of excluding conditions and other clinically reasonable exclusions for OP-8 increased over time for outpatient hospitals and clinics. Increases in documentation of comorbidities may not translate to actual improvement in imaging appropriateness for low back pain. When accounting for all relevant conditions, the proportion of patients with low back pain considered uncomplicated and being measured by OP-8 would be small, reflecting a small proportion of patients with low back pain.

Caregiver reported oral health-related quality of life in young American Indian children.

American Indian/Alaska Native (AI/AN) children experience high rates of dental decay, yet their pediatric oral health-related quality of life (POQL) has not been described. We measured POQL in AI children and compared it in children with reported excellent/very good/good versus fair/poor oral health status (OHS) and assessed association of OHS, child's age, dental service utilization, and dental insurance on POQL scores. Caregivers of 143 AI (100 %), young (mean age 25.1 months) children reported their POQL score as 4.2 (scale 0-100, lower score indicates better POQL); OHS as excellent (35 %), very good (27 %), good (21 %), fair (14 %), and poor (3 %); and utilization of urgent dental services (12 %). Worse POQL was associated with worse OHS (p = 0.01). After adjustment, worse POQL was associated with increased reported use of urgent dental services (p = 0.004). POQL of young AI children was generally favorable but worsened with increased utilization of urgent dental services.