Treatment Complications Associated With Hospital Admission in Oropharyngeal Cancer Patients.

BACKGROUND: Oropharyngeal cancer (OPC) survivorship is a nursing priority because patients are living longer while significant short-term and long-term treatment complications that require nursing care are increasing. Hospital readmission is costly and reflects the quality of care patients receive. OBJECTIVES: This secondary analysis aimed to determine the prevalence of treatment complications resulting in hospital admissions among persons with OPC and examine the relationship between treatment complications resulting in hospital admission among persons with OPC and all other persons with head and neck cancer. METHODS: Using the National Inpatient Survey 2008-2019 database, we identified persons with relevant head and neck cancer diagnoses using specific International Classification of Disease ICD-9 and ICD-10 codes. Complications were operationalized by diagnosis-related codes; persons with codes for major elective surgery were excluded as our focus was posttreatment symptoms requiring hospitalization. Descriptive statistics were used to characterize persons with OPC hospitalized between 2008 and 2019. Binary logistic regression was used to assess complications using crude comparisons. The Elixhauser Comorbidity Index was used for controlling for comorbidities. RESULTS: The final analysis samples included 751,533: 164,770 persons with OPC and 586,763 with other head and cancers. The most prevalent diagnoses observed in those with OPC were esophagitis, nutrition disorder, hematological disorder, and renal failure; the least common diagnoses were sepsis, respiratory tract infection, and pneumonia. Binary regression revealed that persons with OPC experienced significantly more esophagitis, nutrition disorders, hematological disorders, and renal failure compared to persons with other head and neck cancers. DISCUSSION: Treatment of survivors of OPC requires more intensive monitoring for early symptoms associated with treatment, including esophagitis, nutrition disorders, bleeding disorders, and renal failure, than persons with other head and neck cancers. Monitoring laboratory values and clinical manifestations of these conditions is imperative. Nurses may encounter persons with OPC in emergency departments, outpatient radiology, or inpatient general medicine floors to manage swallowing difficulties, dehydration, malnutrition, and bleeding. Delayed or ineffective treatment of these conditions contributes to readmission, financial burden, and impairment of patient's quality of life. Future research should investigate the relationship between targeted treatment for expected complications and readmission rates in persons with OPC.

A Preliminary Study of Stress, Mental Health, and Pain Related to the COVID-19 Pandemic and Odds of Persistent Prescription Opioid Use.

BACKGROUND: The COVID-19 pandemic has been associated with increased opioid prescribing. It is not known if perceived COVID-19 related stress is associated with increased odds of long-term opioid use. OBJECTIVE: To determine if greater COVID-19-related stress and worsening pain attributed to the pandemic was associated with LTOT over a 6-month observation period. DESIGN: Longitudinal cohort. PARTICIPANTS: Patients (n=477) from two midwestern health care systems, with any acute or chronic non-cancer pain, starting a new period of 30-90-day prescription opioid use, were invited to participate in the Prescription Opioids and Depression Pathways Cohort Study, a longitudinal survey study of pain, opioid use, and mental health outcomes. MAIN MEASURES: Baseline and 6-month follow-up assessments were used to measure the association between perceived COVID-19 stressors, the perception that pain was made worse by the pandemic and the odds of persistent opioid use, i.e., remaining a prescription opioid user at 6-month follow-up. Multivariate models controlled for demographics, opioid dose, and change in pain characteristics, mental health measures, and social support. KEY RESULTS: Participants were, on average, 53.9 (±11.4) years of age, 67.1% White race, and 70.9% female. The most frequently endorsed COVID-19 stressor was "worry about health of self/others" (85.7% endorsed) and the least endorsed was "worsened pain due to pandemic" (26.2%). After adjusting for all covariates, "worsened pain due to pandemic" (OR=2.88; 95%CI: 1.33-6.22), change in pain interference (OR=1.20; 95%CI: 1.04-1.38), and change in vital exhaustion (OR=0.90; 95%CI: 0.82-0.99) remained significantly associated with persistent opioid use. CONCLUSIONS: Patients who attribute worsening pain to the COVID-19 pandemic are more likely to be persistent opioid users. Further research is warranted to identify mechanisms underlying this association. Clinicians may consider discussing pain in the context of the pandemic to identify patients at high risk for persistent opioid use.

Endoscopic retrograde cholangiopancreatography outcomes in inflammatory bowel disease patients: a 12-year analysis of a national database.

BACKGROUND: Despite inflammatory bowel disease's (IBD) association with hepatobiliary disorders and the use of endoscopic retrograde cholangiopancreatography (ERCP) for both diagnostic and therapeutic evaluation of these diseases, it remains a poorly studied area within the literature. The purpose of this study is to examine the effect of IBD on the occurrence of adverse events (AE) pertaining to ERCP. METHODS: This project utilized the National Inpatient Sample (NIS) database, the largest inpatient database in the USA. All patients 18 years or older with and without IBD undergoing ERCP were identified from 2008 to 2019. Post-ERCP AEs were analyzed using multivariate logistic or linear regression controlling for age, race, and existing comorbidities using the Charlson comorbidity index (CCI). RESULTS: There was no difference in post-ERCP pancreatitis (PEP) or mortality. IBD patients were also found to have a lower risk of bleeding and decreased length of stay (LOS) despite adjustment for comorbidities. They also underwent less sphincterotomies when compared to the non-IBD cohort. Subgroup analysis between ulcerative colitis (UC) and Crohn's disease (CD) did not find any significant differences in outcomes. CONCLUSION: To our knowledge, this is the largest study to date evaluating ERCP outcomes in IBD patients. After adjustment of co-variates, there was no difference in the occurrence of PEP, infections, and perforation. IBD patients were less likely to experience post-ERCP bleeding and mortality and had shorter LOS which may be due to the decreased frequency of sphincterotomy in this population.

Prescription opioid analgesics increase the risk of depression.

BACKGROUND: Prescription opioid analgesic use has quintupled recently. Evidence linking opioid use with depression emanates from animal models and studies of persons with co-occurring substance use and major depression. Little is known about depressogenic effects of opioid use in other populations. OBJECTIVE: The purpose of this study was to determine whether prescription opioids are associated with increased risk of diagnosed depression. DESIGN: Retrospective cohort study, new user design. PATIENTS: Medical record data from 49,770 US Department of Veterans Affairs (VA) health care system patients with no recent (24-month) history of opioid use or a diagnosis of depression in 1999 and 2000. MAIN MEASURES: Propensity scores were used to control for bias by indication, and the data were weighted to balance the distribution of covariates by duration of incident opioid exposure. Cox proportional hazard models with adjustment for painful conditions were used to estimate the association between duration of prescription opioid use and the subsequent risk of development of depression between 2001 and 2007. KEY RESULTS: Of 49,770 patients who were prescribed an opioid analgesic, 91 % had a prescription for < 90 days, 4 % for 90-180 days, and 5 % for > 180 days. Compared to patients whose prescription was for < 90 days, the risk of depression increased significantly as the duration of opioid prescription increased (HR = 1.25; 95 % CI: 1.05-1.46 for 90-180 days, and HR = 1.51; 95 % CI:1.31-1.74 for > 180 days). CONCLUSIONS: In this sample of veterans with no recent (24-month) history of depression or opioid analgesic use, the risk of development of depression increased as the duration of opioid analgesic exposure increased. The potential for depressogenic effect should be considered in risk-benefit discussions, and patients initiating opioid treatment should be monitored for development of depression.

Association between facility characteristics and the process of care delivered to patients with hepatitis C virus infection.

BACKGROUND: Available data suggest problems in the process of care provided to patients with chronic hepatitis C (HCV). However, the solutions to these problems are less obvious. Healthcare facility factors are potentially modifiable and may enhance process quality in HCV treatment. METHODS: We evaluated the relationship between the process of HCV care and facility factors including number of weekly half-day HCV clinics per 1,000 HCV patients, HCV-specific quality-improvement initiatives, and administrative service of the HCV clinic (gastroenterology, infectious disease, primary care) for a cohort of 34,258 patients who sought care in 126 Veterans Affairs facilities during 2003-2006. We measured HCV care on the basis of 23 HCV-specific process measures capturing pretreatment (seven measures), preventive and/or comorbid (seven measures), and treatment and treatment monitoring care (nine measures). RESULTS: Patients seen at a facility with >8 half-day clinics were 52 % more likely to receive overall indicated care (OR 1.52, 95 % CI 1.13-2.05). Patients seen at a facility with >3 HCV quality improvement initiatives were more likely to receive better preventive and/or comorbid care (OR 1.32, 95 % CI 1.00-1.74). Compared with patients in facilities with no dedicated HCV clinic, patients at facilities with gastroenterology-based clinics received better pretreatment care (OR 1.36, 95 % CI 1.01-1.85) and more antiviral treatment (OR 1.45, 95 % CI 1.06-1.97) whereas those at facilities with infectious disease-based or primary care-based clinics received better preventive and/or comorbid care (OR 1.59, 95 % CI 1.06-2.39 and 1.84, 95 % CI 1.21-2.79 respectively). CONCLUSION: Several facility factors affected the process of HCV care. These factors may serve as targets for quality-improvement efforts.

Long-term clinical outcomes in patients with hypertrophic cardiomyopathy versus hypertensive heart disease.

Background: For most patients with hypertrophic cardiomyopathy (HCM), the clinical course is considered relatively benign, similar to hypertensive heart disease (HHD). We compared the long-term outcomes in patients with HCM versus HHD from a large healthcare system database. Methods: Data from SSM Virtual Data Warehouse were used to identify patients with a new diagnosis of either HCM or HHD who followed up in our system for at least 6 months. HCM patients were matched 1:1 to HHD patients based on age, sex, and race. Outcomes examined included heart failure (HF) admission, ventricular tachyarrhythmia (ventricular fibrillation or sustained ventricular tachycardia), and need for pacemaker or defibrillator implantation. We identified 1904 HCM patients along with HHD controls. Results: After adjusting for demographic characteristics and relevant comorbidities, HCM had higher odds of HF admission (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 1.43-2.10), ventricular tachyarrhythmias (OR: 2.31, CI: 1.60-3.33), pacemaker implantation (OR: 2.14, CI: 1.29-3.57), and defibrillator implantation (OR: 3.77, CI: 1.82-7.83). Survival analysis confirmed the difference in outcomes early on from the time of diagnosis. Conclusion: In this retrospective study from a large healthcare system database, HCM patients had significantly higher incidences of HF admission, ventricular tachyarrhythmias, and pacemaker or defibrillator implantation compared to HHD patients.

Baseline Characteristics From a New Longitudinal Cohort of Patients With Noncancer Pain and Chronic Opioid Use in the United States.

Retrospective cohort studies have consistently observed that long-term prescription opioid use is a risk factor for new major depressive episodes. However, prospective studies are needed to confirm these findings and establish evidence for causation. The Prescription Opioids and Depression Pathways cohort study is designed for this purpose. The present report describes the baseline sample and associations between participant characteristics and odds of daily versus nondaily opioid use. Second, we report associations between participant characteristics and odds of depression, dysthymia, anhedonia, and vital exhaustion. Patients with noncancer pain were eligible if they started a new period of prescription opioid use lasting 30 to 90 days. Participants were 54.8 (standard deviation ± 11.3) years of age, 57.3% female and 73% White race. Less than college education was more common among daily versus nondaily opioid users (32.4% vs 27.3%; P = .0008), as was back pain (64.2% vs 51.3%; P < .0001), any nonopioid substance use disorder (12.8% vs 4.8%; P < .0001), and current smoking (30.7% vs 18.4% P < .0001). High pain interference (50.9% vs 28.4%; P < .0001) was significantly associated with depression, as was having more pain sites (6.9 ± 3.6 vs 5.7 ± 3.6; P < .0001), and benzodiazepine comedication (38.2% vs 23.4%; P < .0001). High pain interference was significantly more common among those with anhedonia (46.8% vs 27.4%; P < .0001), and more pain sites (7.0 ± 3.7 vs 5.6 ± 3.6; P < .0001) were associated with anhedonia. Having more pain sites (7.9 ± 3.6 vs 5.5 ± 3.50; P < .0001) was associated with vital exhaustion, as was back pain (71.9% vs 56.8%; P = .0001) and benzodiazepine comedication (42.8% vs 22.8%; P < .0001). Patients using prescription opioids for noncancer pain have complex pain, psychiatric, and substance use disorder comorbidities. Longitudinal data will reveal whether long-term opioid therapy leads to depression or other mood disturbances such as anhedonia and vital exhaustion. PERSPECTIVE: This study reports baseline characteristics of a new prospective, noncancer pain cohort study. Risk factors for adverse opioid outcomes were most common in those with depression and vital exhaustion and less common in dysthymia and anhedonia. Baseline data highlight the complexity of patients receiving long-term opioid therapy for noncancer pain.

Neighborhood Characteristics & Walking Behavior Among Adults with Arthritis: An NHIS Study.

OBJECTIVE: This study investigated the association of perceived neighborhood qualities with likelihood of transit walking, leisure walking, neighborhood walking, and meeting physical activity (PA) recommendations among US adults with arthritis. METHODS: This cross-sectional study utilized 2020 National Health Interview Survey data. Included participants were adults reporting clinician-diagnosed arthritis and who reported the ability to walk. Exposures of interest were perceived neighborhood attributes. Outcomes were transit walking, leisure walking, neighborhood walking, and meeting PA recommendations. Standardized mean difference percent (SMD%) was used to assess relationships between exposures and outcomes with SMD% >10% resulting in inclusion in final adjusted multivariate logistic regression models for odds of outcomes. All analyses were weighted to account for complex survey methodology. RESULTS: The analytic sample included 7,322 adults with arthritis. Fully adjusted logistic regression models showed presence of roads to walk on was associated with meeting PA recommendations (OR=1.26[95%CI=1.07-1.49]). Three attributes were positively associated with transit walking, while safety from crime was negatively associated (OR=2.33[95%CI=1.75-3.10], OR=1.49[95%CI=1.17-1.91], OR=1.67[95%CI=1.34-2.08]), OR=0.70[95%CI=0.53-0.92]). Roads to walk and places to walk and relax were associated with leisure and neighborhood walking (OR=1.46[95%CI=1.21-1.76], OR=1.56[95%CI=1.34-1.82], OR=1.58[95%CI=1.29-1.93], OR=1.63[95%CI=1.40-1.90], respectively). CONCLUSION: This study identified several neighborhood characteristics associated with higher likelihood of walking behaviors among adults with arthritis. Factors associated with walking behavior varied by type of walking. The shared correlates between leisure and neighborhood walking imply they occur in the same setting. Patients with arthritis may benefit from exercise recommendations that are informed by the presence or absence of facilitating infrastructure in their neighborhoods.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management.

OBJECTIVE: Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids. METHODS: Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management. RESULTS: There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant. DISCUSSION: The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

Social support and the association between post-traumatic stress disorder and risk for long-term prescription opioid use.

ABSTRACT: Post-traumatic stress disorder (PTSD) is common in patients with chronic pain, adversely affects chronic pain outcomes, and is associated with opioid use and adverse opioid outcomes. Social support is a robust predictor of PTSD incidence and course as well as chronic pain outcome. We determined whether the association between PTSD and persistent opioid use was modified by emotional support in a cohort of patients receiving opioids for noncancer pain. Eligible participants were ≥18 years and had completed a new period of prescription opioid use lasting 30 to 90 days. Bivariate associations between cohort characteristics and each key variable was assessed using χ 2 tests for categorical variables and t -tests for continuous variables. Interaction between PTSD and emotional support was assessed by a priori stratification on low vs high emotional support. Participants (n = 808) were 53.6 (SD ± 11.6) years of age, 69.8% female, 69.6% White, and 26.4% African American. Overall, 17.2% had probable PTSD. High emotional support was significantly ( P < 0.0001) more common among those without probable PTSD. Prescription opioid use at 6-month follow-up was significantly ( P = 0.0368) more common among patients with vs without probable PTSD. In fully adjusted models, PTSD was no longer associated with opioid use at 6-month follow-up among participants with high emotional support. Among those with lower emotional support, PTSD was significantly associated with opioid use at 6-month follow-up in unadjusted (odds ratio = 2.40; 95% confidence interval: 1.24-4.64) and adjusted models (odds ratio = 2.39; 95% confidence interval: 1.14-4.99). Results point to the hypothesis that improvement of emotional support in vulnerable patients with chronic pain and PTSD may help reduce sustained opioid use.

Alcohol, Tobacco, and Marijuana use Among Individuals Receiving Prescription Opioids for Pain Management.

OBJECTIVE: Substance use among individuals receiving prescription opioids for pain may be associated with poorer functioning. The purpose was to examine whether use of substances (i.e., alcohol, marijuana, or tobacco) among individuals prescribed opioids for pain management was associated with pain, psychiatric disorders, and opioid misuse. METHODS: Patients with non-cancer pain and a new opioid prescription were recruited from two health systems. Participants (N= 827) completed measures regarding pain severity, pain interference, psychiatric symptoms, and substance use. RESULTS: Substance use was common with 58.0%, 26.2%, and 28.9% reporting alcohol, tobacco, and marijuana use, respectively. Use of tobacco or marijuana was associated with poorer functioning. Those with tobacco use had greater pain severity, interference, number of pain sites, and concern for opioid misuse, and were more likely to have probable depression, anxiety, and PTSD. Participants reporting marijuana use were more likely to have higher concern for opioid misuse scores and probable depression, anxiety, and PTSD. Use of alcohol was associated with lower pain severity and interference and fewer number of pain sites. DISCUSSION: Substance use is common among individuals receiving prescription opioids. Some types of substance use may be related to poorer opioid, pain, and psychiatric functioning. Clinicians prescribing opioids for pain management should assess for substance use, including tobacco, and be aware of the association with poorer functioning. Interventions could target pain, psychiatric symptoms, and substance use simultaneously to optimize outcomes for individuals with pain and substance use.

Characteristics of patients with non-cancer pain and long-term prescription opioid use who have used medical versus recreational marijuana.

OBJECTIVE: Marijuana use is increasingly common among patients with chronic non-cancer pain (CNCP) and long-term opioid therapy (LTOT). We determined if lifetime recreational and medical marijuana use were associated with more frequent and higher dose prescription opioid use. DESIGN: Cross-sectional SUBJECTS: Eligible patients (n=1,037), who had a new period of prescription opioid use lasting 30-90 days, were recruited from two midwestern health care systems to a study of long-term prescription opioid use and mental health outcomes. The present cross-sectional analyses uses baseline data from this on-going cohort study. METHODS: Primary exposures were participant reported lifetime recreational and medical marijuana use versus no lifetime marijuana use. Prescription opioid characteristics included daily versus non-daily opioid use and ≥50 morphine milligram equivalent (MME) dose per day vs. <50 MME. Multivariate, logistic regression models estimated the association between lifetime recreational and medical marijuana use vs. no use and odds of daily and higher dose prescription opioid use, before and after adjusting for confounding. RESULTS: The sample was an average of 54.9 (SD±11.3) years of age, 57.3% identified as female gender, 75.2% identified as White, and 22.5% identified as Black race. Among all participants, 44.4% were never marijuana users, 21.3% were recreational only, 7.7% medical only and 26.6% were both recreational and medical marijuana users. After controlling for all confounders, lifetime recreational marijuana use, as compared to no use, was significantly associated with increased odds of daily prescription opioid use (OR=1.61; 95%CI:1.02-2.54). There was no association between lifetime recreational or medical marijuana use and daily opioid dose. CONCLUSION: Lifetime medical marijuana use is not linked to current opioid dose, but lifetime recreational use is associated with more than a 60% odds of being a daily prescription opioid user. Screening for lifetime recreational marijuana use may identify patients with chronic pain who are vulnerable to daily opioid use which increases risk for adverse opioid outcomes. Prospective data is needed to determine how marijuana use influences the course of LTOT and vice versa.

Pre-pregnancy weight loss associations with prenatal and postpartum mental health conditions: A retrospective cohort study.

Background: Obesity is a risk factor for adverse outcomes during and following pregnancy. Most women are advised to lose weight prior to becoming pregnant, to help alleviate complications including prenatal and postpartum depression and anxiety. Yet, no studies have examined how the process of losing weight prior to pregnancy interacts with the development of prenatal and postpartum mental health disorders.The objective of the study was to determine if women with pre-pregnancy weight loss (≥10%) vs. those who do not, in the two years prior to pregnancy, have a lower risk for new onset prenatal and postpartum mental health conditions. Methods: This retrospective cohort study used data from the Virtual Data Warehouse of a large Midwestern, U.S. based hospital system. The final sample consisted of 6,085 female patients of reproductive age that had given birth between 10/1/2011-6/30/2020 and had two recorded weights in the year prior to conception. Univariate analysis between weight loss and outcome variables (pre-natal and post-partum depression and anxiety) and multivariate analysis using logistic regression was conducted for variable significant on univariate analysis. Results: On univariate analysis, women with pre-pregnancy weight loss had increased odds of post-partum depression (OR=1.47, 95%CI=1.03-2.10), though decreased odds of prenatal anxiety (OR=0.59, 95% CI 0.33-0.90). After controlling for confounders in the multivariate analysis, there was not a significant difference in the odds of post-partum depression; however, women who lost weight had approximately half the odds of having prenatal anxiety than those who did not lose weight (OR=0.54, 95%CI=0.33-0.90). Discussion: The experience of achieving weight loss prior to pregnancy may foster a sense of agency within pregnant women, helping them to reduce their experience of pre-natal anxiety. Providers could engage in patient conversations around weight loss and mental health management in a strengths-based framework to continue to foster this sense of agency. Conclusion: Anxiety and depression were uniquely related to pre-pregnancy weight loss. Pre-pregnancy weight loss was associated with lower odds of prenatal anxiety and higher odds of postpartum depression. These results highlight the need for real world examination of pre-conception treatment recommendations and their association with non-physical health-based outcomes.

Process of care for hepatitis C infection is linked to treatment outcome and virologic response.

BACKGROUND & AIMS: Process of care-based measures are used commonly to assess the quality of medical care provided to patients with chronic hepatitis C virus (HCV) infection. However, the links between these processes and patient outcomes are not clear. METHODS: We conducted a large retrospective cohort study of 34,749 patients with HCV infection identified from the national Veterans Administration HCV Clinical Case Registry between 2003 and 2006. We examined the relationship between meeting process-based measures of HCV care (categorized into pretreatment, preventive or comorbid care, and treatment monitoring domains) and antiviral treatment-related outcomes. For each domain, we defined optimum care as receipt of all indicated care processes in that domain. Study end points were rates of antiviral treatment, treatment completion, and sustained virologic response (SVR), adjusted for patient demographics, comorbidities, use of health services, and intrafacility clustering. RESULTS: Patients who received optimum pretreatment care were significantly more likely to receive antiviral treatment (odds ratio [OR], 3.2; 95% confidence interval [CI], 2.9-3.5), complete treatment (OR, 1.26; 95% CI, 1.13-1.43), and achieve an SVR (OR, 1.29; 95% CI, 1.01-1.65), than those with suboptimum pretreatment care. Optimum preventive or comorbidity care also independently was associated with receipt of antiviral treatment (OR, 1.36; 95% CI, 1.23-1.51), but not with completion of treatment or SVR. Optimum treatment monitoring was associated with a nonsignificant trend toward achieving an SVR (OR, 1.22; 95% CI, 0.95-1.56). CONCLUSIONS: Optimum care for HCV infection-particularly the care delivered before treatment-is associated with increased rates of treatment and SVR. These data could be used to guide clinical policy as newer, more-effective treatments become available.

The performance of process measures in hepatitis C.

OBJECTIVES: Previous evaluations regarding the extent to which standard chronic hepatitis C virus (HCV) care processes are delivered during routine clinical care are scant and have primarily relied on automated data--the validity of which is unknown. METHODS: We examined adherence to 24 explicit modified Delphi panel-derived HCV-specific process measures in a cohort of 122,744 patients enrolled in the automated Veterans Administration HCV Clinical Case Registry between 2000 and 2006. We reviewed medical charts of 717 patients to compare the agreement between Registry and charts. We also estimated the effect of justifiable exceptions on measured performance in HCV by determining the proportion of patients who failed a measure but met a valid exception (i.e., patient refusal, outside care, or treatment contraindications). RESULTS: The percentage of patients who met the individual measures varied. For example, 74% of patients received HCV genotype testing, 23% received antiviral treatment, 28% received liver biopsy, and 16% received hepatitis A vaccination. We found excellent agreement between the Registry and charts in all measures (agreement coefficients >0.75). However, exceptions to indicated care documented in charts were common for genotype testing, liver biopsy, and antiviral treatment. After accounting for these exceptions, the measure rates increased from 75 to 93% for genotype testing, 31 to 50% for liver biopsy, and from 26 to 64% for antiviral treatment. Treatment contraindications were the most common reasons for not meeting indicated care. CONCLUSIONS: Automated data missed several exceptions to care that are documented only in providers' notes, thus underestimating process of care. These results have implications for future quality assessment initiatives-most of which will likely rely on automated data for process-based quality reporting. After accounting for automated data and medical record reviews, vaccinations and antiviral treatment rates in the Veterans Administration left room for improvement.

Treatment-resistant and insufficiently treated depression and all-cause mortality following myocardial infarction.

BACKGROUND: Depression is a known risk factor for mortality after an acute myocardial infarction. Patients with treatment-responsive depression may have a better prognosis than those with treatment-resistant depression. AIMS: We sought to determine whether mortality following acute myocardial infarction was associated with treatment-resistant depression. METHOD: Follow-up began after myocardial infarction and continued until death or censorship. Depression was counted as present if diagnosed any time during the study period. Treatment for depression was defined as receipt of 12 or more weeks of continuous antidepressant therapy at a therapeutic dose during follow-up. Treatment-resistant depression was defined as use of two or more antidepressants plus augmentation therapy, receipt of electroconvulsive therapy or use of monoamine oxidase inhibitors. Mean duration of follow-up was 39 months. RESULTS: During follow-up of 4037 patients with major depressive disorder who had had a myocardial infarction, 6.9% of those with insufficiently treated depression, 2.4% of those with treated depression and 5.0% of those with treatment-resistant depression died. A multivariable survival model that adjusted for sociodemographics, anxiety disorders, beta-blocker use, mortality risk factors and health service utilisation indicated that compared with treated patients, insufficiently treated patients were 3.04 (95% CI 2.12-4.35) times more likely and patients with treatment-resistant depression were 1.71 (95% CI 1.05-2.79) times more likely to die. CONCLUSIONS: All-cause mortality following an acute myocardial infarction is greatest in patients with depression who are insufficiently treated and is a risk in patients with treatment-resistant depression. However, the risk of mortality associated with treatment-resistant depression is partly explained by comorbid disorders. Further studies are warranted to determine whether changes in depression independently predict all-cause mortality.

Construction of an Administrative Osteoarthritis Severity Index.

OBJECTIVE: Electronic health record (EHR) databases are a powerful resource to investigate clinical trajectories of osteoarthritis (OA). There are no existing EHR tools to evaluate risk for knee arthroplasty (KA). We developed an OA severity index (OASI) using EHR data and demonstrate the index's association with time to KA. METHODS: This retrospective cohort study used 2010-2018 nationally distributed Optum EHR data. Eligible patients were 45 to 80 years old with a new diagnosis of knee OA in 2011-2012 and no prior KA. The OASI was a sum of first instance of x-ray imaging, advanced imaging, intra-articular injection, nonsteroidal anti-inflammatory drugs, and opioids. Principal components analysis index (PCI) score was also explored. Extended Cox proportional hazard models assessed time-dependent OASI and time to KA. RESULTS: Among 16,675 eligible patients, 12.7% underwent KA. Median follow-up time was 72 months. Adjusted OASI models showed each additional event almost doubled the risk for KA (adjusted hazard ratio = 1.80, 95% confidence interval: 1.75-1.86). Similar results were observed for PCI. CONCLUSION: The sum OASI performs well identifying patients who would undergo KA and offers simplicity versus the PCI. Although replication in other cohorts is recommended, the OASI appears to be a novel and valid means to measure clinical OA severity in research studies using large EHR-based cohorts.

Disparities Exist in Physical Therapy Utilization and Time to Utilization Between Black and White Patients With Musculoskeletal Pain.

OBJECTIVE: Black patients are less likely than White patients to receive physical therapy for musculoskeletal pain conditions. Current evidence, however, is limited to self-reported conditions and health services use. The purpose of this study was to use a large electronic health record database to determine whether a race disparity existed in use of physical therapy within 90 days of a new musculoskeletal diagnosis. METHODS: Eligible patients (n = 52,384) were sampled from an Optum deidentified electronic health record database of 5 million adults distributed throughout the United States. In this database, patients were designated as "Black" and "White." Patients were eligible if they had a new diagnosis for musculoskeletal neck, shoulder, back, or knee pain between January 1, 2012, and December 31, 2017. Logistic regression and Cox proportional hazard models were computed before and after adjusting for covariates to estimate the association between race and receipt of physical therapy services within 90 days of musculoskeletal pain diagnoses. RESULTS: Patients were on average 47.5 (SD = 14.9) years of age, 12.8% were Black, 87.2% were White, and 52.7% were female. Ten percent of Black patients and 15.5% of White patients received physical therapy services within 90 days of musculoskeletal pain diagnoses. After adjusting for covariates, White patients were 57% more likely (odds ratio = 1.57; 95% CI = 1.44-1.71) to receive physical therapy compared with Black patients and had significantly shorter time to physical therapy than Black patients (hazard ratio = 1.53; 95% CI = 1.42-1.66). CONCLUSIONS: In a nationally distributed cohort, Black patients were less likely than White patients to utilize physical therapy and had a longer time to utilization of physical therapy for musculoskeletal pain. IMPACT: These findings highlight the need to determine the mechanisms underlying the observed disparities and how these disparities influence health outcomes.

Diversity, Inclusion, and Health Equity in Academic Family Medicine.

BACKGROUND AND OBJECTIVES: Diversity, inclusion, and health equity (DIHE) are integral to the practice of family medicine. Academic family medicine has been grappling with these issues in recent years, particularly with a focus on racism and health inequity. We studied the current state of DIHE activities in academic family medicine departments and suggest a framework for departments to become more diverse, inclusive, antiracist, and focused on health equity and racial justice. METHODS: As part of a larger annual membership survey, family medicine department chairs were asked for their assessment of departmental DIHE and antioppression activities, and infrastructure and resources committed to increasing DIHE. RESULTS: More than 60% of family medicine department chairs participating in this study rate their departments highly in promoting DIHE and antioppression, and 66% of chairs report an institutional infrastructure that is working well. Just over half of departments or institutions have had a climate survey in the past 3 years, 47.3% of departments have a diversity officer, and 26% of departments provide protected time or resources for a diversity officer. CONCLUSIONS: The majority of family medicine department chairs rate their departments highly on DIHE. However, only 50% of departments have formally assessed climate in the past 3 years, fewer have diversity officers, and even fewer invest resources in their diversity officers. This disconnect should motivate academic family medicine departments to undertake formal self-assessment and implement a strategic plan that includes resource investment in DIHE, measurable outcomes, and sustainability.

Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans Administration patients.

BACKGROUND: Depression is a risk factor for incident myocardial infarction (MI), but little is known about the independent or additive risk from anxiety disorders. METHODS: In a 7-year retrospective cohort design, we identified a cohort free of cardiovascular disease in fiscal years 1999 and 2000 that contained 96,612 patients between 25 and 80 years of age who had an International Classification of Diseases, Ninth Revision, Clinical Modification code indicating a diagnosis of depression in 2000 (baseline) and 259,387 patients without depression. Cox proportional hazards models stratified by depression were computed to test for a main effect of anxiety disorder unspecified, generalized anxiety disorder, panic disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder (PTSD) on risk of incident MI. The models were adjusted for multiple MI risk factors and sociodemographics. RESULTS: Depressed as compared to nondepressed Veterans Administration patients were at increased risk for incident MI (HR 1.39; 95% CI 1.34-1.45). In nondepressed patients those with anxiety disorder unspecified (HR 1.34; 95% CI 1.21-1.47), panic disorder (HR 1.43; 95% CI 1.11-1.83), and PTSD (HR 1.25; 95% CI 1.16-1.36) were at increased risk for incident MI. The independent risk associated with anxiety disorders was reduced in patients comorbid for depression. CONCLUSIONS: In Veterans Administration patients free of heart disease in 1999 and 2000, those with depression, anxiety disorder unspecified, panic disorder, and PTSD were at increased risk of incident MI. Anxiety disorders are independent risk factors for MI. Depression partially accounts for the effect of anxiety disorders on risk of MI in patients with both conditions.