Effect of Telemedicine Education and Telemonitoring on Continuous Positive Airway Pressure Adherence. The Tele-OSA Randomized Trial.

RATIONALE: Automated telemedicine interventions could potentially improve adherence to continuous positive airway pressure (CPAP) therapy. OBJECTIVES: Examining the effects of telemedicine-delivered obstructive sleep apnea (OSA) education and CPAP telemonitoring with automated patient feedback messaging on CPAP adherence. METHODS: This four-arm, randomized, factorial design clinical trial enrolled 1,455 patients (51.0% women; age, 49.1 ± 12.5 yr [mean ± SD]) referred for suspected OSA. Nine hundred and fifty-six underwent home sleep apnea testing, and 556 were prescribed CPAP. Two telemedicine interventions were implemented: 1) web-based OSA education (Tel-Ed) and 2) CPAP telemonitoring with automated patient feedback (Tel-TM). Patients were randomized to 1) usual care, 2) Tel-Ed added, 3) Tel-TM added, or 4) Tel-Ed and Tel-TM added (Tel-both). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was 90-day CPAP usage. Secondary endpoints included attendance to OSA evaluation, and change in Epworth Sleepiness Scale score. CPAP average daily use at 90 days was 3.8 ± 2.5, 4.0 ± 2.4, 4.4 ± 2.2, and 4.8 ± 2.3 hours in usual care, Tel-Ed, Tel-TM, and Tel-both groups. Usage was significantly higher in the Tel-TM and Tel-both groups versus usual care (P = 0.0002 for both) but not for Tel-Ed (P = 0.10). Medicare adherence rates were 53.5, 61.0, 65.6, and 73.2% in usual care, Tel-Ed, Tel-TM, and Tel-both groups (Tel-both vs. usual care, P = 0.001; Tel-TM vs. usual care, P = 0.003; Tel-Ed vs. usual care, P = 0.07), respectively. Telemedicine education improved clinic attendance compared with no telemedicine education (show rate, 68.5 vs. 62.7%; P = 0.02). CONCLUSIONS: The use of CPAP telemonitoring with automated feedback messaging improved 90-day adherence in patients with OSA. Telemedicine-based education did not significantly improve CPAP adherence but did increase clinic attendance for OSA evaluation. Clinical trial registered with www.clinicaltrials.gov (NCT02279901).

Does Providing Positive Airway Pressure for Sleep Apnea Change Health Care Utilization?

BACKGROUND: Sleep apnea is underdiagnosed and thus undertreated. If therapy for sleep apnea results in reduced health care utilization in an entire treated population, then decision-makers will have key information for allocating limited health care resources. OBJECTIVES: To determine whether positive airway pressure (PAP) for sleep apnea was associated with reduced health care utilization in an entire treated population. RESEARCH DESIGN: This was a retrospective cohort; propensity score-matched cases and noncases; pre-post analyses of individual subject utilization. SUBJECTS: Electronic health records were used to identify adult subjects diagnosed with sleep apnea and dispensed PAP therapy (cases) and those without either diagnosed sleep apnea or dispensed PAP therapy (noncases). MEASURES: Acute care hospital days and dispensed medication days supply were compared in cases and noncases. Negative binomial regression was used to model utilization for up to 5 years before and 7 years after PAP dispensation (cases) or a random date (noncases). The association of PAP with changing annual utilization was estimated. RESULTS: There were 13,271 cases and 13,271 matched noncases from 2008 to 2012 for analyses. Trends in the annual rate of acute care utilization were no different between cases and noncases (rate ratio, 0.98, P=0.543). Trends in the annual rate of medication utilization were no different between cases and noncases (rate ratio, 1.008, P=0.112). CONCLUSIONS: PAP dispensation for sleep apnea did not appear to reduce the rate of acute care and medication utilization over several years of follow-up in a large integrated health care system.

Association of Serum Lipids and Coronary Heart Disease in Contemporary Observational Studies.

BACKGROUND: The use of statins increased among US adults with high coronary heart disease (CHD) risk after publication of the 2001 cholesterol treatment guidelines. METHODS AND RESULTS: We analyzed the association between lipids and CHD among 9578 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants and 346,595 Kaiser Permanente Southern California (KPSC) members with baseline lipid measurements in 2003 to 2007. We performed the same analyses among 14,590 Atherosclerosis Risk In Communities (ARIC) study participants with lipid measurements in 1987 to 1989. Analyses were restricted to blacks and whites 45 to 64 years of age without CHD who were not taking statins at baseline. Total cholesterol, high-density lipoprotein cholesterol, and triglycerides were measured at baseline. Low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and ratios of total to high-density lipoprotein cholesterol and triglycerides to high-density lipoprotein cholesterol were calculated. The prevalence of diabetes mellitus, history of stroke, and antihypertensive medication use increased at higher low-density lipoprotein cholesterol in ARIC but not in REGARDS or KPSC. Over 8.9 years of follow-up, 225 CHD events occurred in REGARDS, 6547 events in KPSC, and 583 events in ARIC. After multivariable adjustment, less favorable lipid levels were associated with higher hazard ratios for CHD in ARIC. These associations were attenuated in REGARDS and KPSC. For example, the hazard ratio associated with the highest versus lowest quartile of low-density lipoprotein cholesterol (≥ 146 versus ≤ 102 mg/dL) was 1.89 (95% confidence interval, 1.42-2.51) in ARIC, 1.25 (95% confidence interval, 0.81-1.92) in REGARDS, and 1.49 (95% confidence interval, 1.38-1.61) in KPSC. CONCLUSION: The association between lipids and CHD in contemporary studies may be attenuated by the preferential use of statins by high-risk individuals.

Estimated GFR Before and After Bariatric Surgery in CKD.

BACKGROUND: Several reviews have recently detailed the beneficial effects of weight loss surgery for kidney function. However, these studies have a number of limitations, including small sample size, few done in chronic kidney disease (CKD) stages 3 and 4, and many not including the main bariatric surgery procedures used in the United States today. STUDY DESIGN: This was an observational retrospective cohort study comparing propensity score-matched bariatric surgery patients and nonsurgery control patients who were referred for, but did not have, surgery. Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy were also compared using propensity matching. SETTING & PARTICIPANTS: Patients (714 surgery patients; 714 controls) were from a large integrated health care system, a mean of 58±8 (SD) years old, and mostly women (77%) and non-Hispanic whites (56%) and had diabetes mellitus (66%) and/or hypertension (91%). PREDICTOR: Predictors at the time of surgery or referral to surgery were age, sex, race/ethnicity, weight, and presence of diabetes and/or hypertension. OUTCOMES: The primary outcome for this study was change in estimated glomerular filtration rate (eGFR) from serum creatinine level over a median 3-year follow-up period. MEASUREMENTS: Serum creatinine was used to calculate eGFR using the CKD-EPI (CKD Epidemiology Collaboration) creatinine equation. RESULTS: Surgery patients had 9.84 (95% CI, 8.05-11.62) mL/min/1.73m2 greater eGFRs than controls at a median 3 years' follow-up and RYGB patients had 6.60 (95% CI, 3.42-9.78) mL/min/1.73m2 greater eGFRs than sleeve gastrectomy patients during the same period. LIMITATIONS: This study is limited by its nonrandomized observational study design, estimation of GFR, and large changes in muscle mass, which may affect serum creatinine level independent of changes in kidney function. CONCLUSIONS: Bariatric surgery, especially the RYGB procedure, results in significant improvements for up to 3 years in eGFRs for patients with CKD stages 3 and 4.

Comparisons of sleep apnoea rate and outcomes among patients with resistant and non-resistant hypertension.

BACKGROUND AND OBJECTIVE: We directly compared sleep apnoea (SA) rates and risk of cardiovascular and mortality outcomes among SA patients with resistant hypertension (RH) and non-RH within a large diverse hypertension population. METHODS: A retrospective cohort study between 1 January 2006 and 31 December 2010 among hypertensive adults (age ≥ 18 years) was performed within an integrated health system. Rates of SA in RH and non-RH were determined. Multivariable logistic regression analyses were used to calculate OR for SA. Cox proportional hazard modelling was used to estimate hazard ratios (HRs) for cardiovascular and mortality outcomes between SA in RH versus SA in non-RH adjusting for age, gender, race, BMI, chronic kidney disease and other comorbidities. RESULTS: SA was identified in 33 682 (7.2%) from 470 386 hypertensive individuals. SA in RH accounted for 5806 (9.6%) compared to SA in non-RH 27 876 individuals (6.8%). Multivariable OR (95% CI) for SA was 1.16 (1.12, 1.19), 3.57 (3.47, 3.66) and 2.20 (2.15, 2.25) for RH versus non-RH, BMI ≥ 30, and males, respectively. Compared to SA in non-RH individuals, SA in RH had a multivariable adjusted HR (95% CI) of 1.24 (1.13, 1.36), 1.43 (1.28, 1.61), 0.98 (0.85, 1.12) and 1.04 (0.95, 1.14) for ischaemic heart event (IHE), congestive heart failure (CHF), stroke and mortality, respectively. CONCLUSION: We observed a modest increase in likelihood for SA among RH compared to non-RH patients. Risks for IHE and CHF were higher for SA in RH compared to SA in non-RH patients; however, there were no differences in risk for stroke and mortality.

Emergency Department Crowding and Outcomes After Emergency Department Discharge.

STUDY OBJECTIVE: We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge. METHODS: We conducted a retrospective cohort study of ED discharges, using data from an integrated health system for 2008 to 2010. We assessed patient transit-level (n=3) and ED system-level (n=6) measures of crowding, using multivariable logistic regression models. The outcome measures were inpatient admission or death within 7 days of ED discharge. We defined a clinically important association by assessing the relative risk ratio and 95% confidence interval (CI) difference and also compared risks at the 99th percentile and median value of each measure. RESULTS: The study cohort contained a total of 625,096 visits to 12 EDs. There were 16,957 (2.7%) admissions and 328 (0.05%) deaths within 7 days. Only 2 measures, both of which were patient transit measures, were associated with the outcome. Compared with a median evaluation time of 2.2 hours, the evaluation time of 10.8 hours (99th percentile) was associated with a relative risk of 3.9 (95% CI 3.7 to 4.1) of an admission. Compared with a median ED length of stay (a CMS measure) of 2.8 hours, the 99th percentile ED length of stay of 11.6 hours was associated with a relative risk of 3.5 (95% CI 3.3 to 3.7) of admission. No system measure of ED crowding was associated with outcomes. CONCLUSION: Our findings suggest that ED length of stay is a proxy for unmeasured differences in case mix and challenge the validity of the CMS metric as a safety measure for discharged patients.

Emergency department crowding predicts admission length-of-stay but not mortality in a large health system.

BACKGROUND: Emergency department (ED) crowding has been identified as a major threat to public health. OBJECTIVES: We assessed patient transit times and ED system crowding measures based on their associations with outcomes. RESEARCH DESIGN: Retrospective cohort study. SUBJECTS: We accessed electronic health record data on 136,740 adults with a visit to any of 13 health system EDs from January 2008 to December 2010. MEASURES: Patient transit times (waiting, evaluation and treatment, boarding) and ED system crowding [nonindex patient length-of-stay (LOS) and boarding, bed occupancy] were determined. Outcomes included individual inpatient mortality and admission LOS. Covariates included demographic characteristics, past comorbidities, severity of illness, arrival time, and admission diagnoses. RESULTS: No patient transit time or ED system crowding measure predicted increased mortality after control for patient characteristics. Index patient boarding time and lower bed occupancy were associated with admission LOS (based on nonoverlapping 95% CI vs. the median value). As boarding time increased from none to 14 hours, admission LOS increased an additional 6 hours. As mean occupancy decreased below the median (80% occupancy), admission LOS decreased as much as 9 hours. CONCLUSIONS: Measures indicating crowded ED conditions were not predictive of mortality after case-mix adjustment. The first half-day of boarding added to admission LOS rather than substituted for it. Our findings support the use of boarding time as a measure of ED crowding based on robust prediction of admission LOS. Interpretation of measures based on other patient ED transit times may be limited to the timeliness of care.

Racial differences in estimated GFR decline, ESRD, and mortality in an integrated health system.

BACKGROUND: Current evidence does not clearly identify the contribution of kidney function decline and mortality to racial disparities in end-stage renal disease (ESRD) incidence. We used observed estimated glomerular filtration rate (eGFR) to project the time of onset of kidney failure and examined mortality to better understand these racial disparities. STUDY DESIGN: Retrospective cohort. SETTING & PARTICIPANTS: Adult members of Kaiser Permanente Southern California in 2003-2009 with more than 2 serum creatinine tests and more than 180 days between tests: 526,498 whites, 350,919 Hispanics, 136,923 blacks, and 105,476 Asians. PREDICTOR: Race/ethnicity. OUTCOMES: ESRD (dialysis or transplantation); mortality. MEASUREMENTS: eGFR decline was modeled using linear regression. Kidney failure was projected based on predicted eGFR <15 mL/min/1.73 m² at specified times. Racial differences in projected kidney failure and mortality in those with projected kidney failure were estimated with adjustment for age, sex, and entry eGFR. RESULTS: Blacks had more extreme rates of eGFR decline (1st percentile, -23.6 mL/min/1.73 m² per year), followed by Hispanics (-20.9 mL/min/1.73 m² per year), whites (-20.1 mL/min/1.73 m² per year), and Asians (-17.6 mL/min/1.73 m² per year; P < 0.001). There were 25,065 whites, 11,368 Hispanics, 6,785 blacks, and 3,176 Asians with projected kidney failure during the study period. The ORs for projected kidney failure versus whites during CKD stages 3 and 4 were 1.54 (95% CI, 1.46-1.62) in blacks, 1.49 (95% CI, 1.42-1.56) in Hispanics, and 1.41 (95% CI, 1.32-1.51) in Asians. For those with projected kidney failure, the HRs of death versus whites during CKD stages 3 and 4 were 0.82 (95% CI, 0.77-0.88) in blacks, 0.67 (95% CI, 0.63-0.72) in Hispanics, and 0.58 (95% CI, 0.52-0.65) in Asians. LIMITATIONS: Results may not generalize to the uninsured or subgroups within a race. Projected kidney failure was based on linear trends from clinically obtained eGFR. CONCLUSIONS: We found more extreme rates of eGFR decline in blacks. Projected kidney failure during CKD stages 3 and 4 was high in blacks, Hispanics, and Asians relative to whites. Mortality for those with projected kidney failure was highest in whites. Differences in eGFR decline and mortality contributed to racial disparities in ESRD incidence.

Patterns and predictors of short-term death after emergency department discharge.

STUDY OBJECTIVE: The emergency department (ED) is an inherently high-risk setting. Early death after an ED evaluation is a rare and devastating outcome; understanding it can potentially help improve patient care and outcomes. Using administrative data from an integrated health system, we describe characteristics and predictors of patients who experienced 7-day death after ED discharge. METHODS: Administrative data from 12 hospitals were used to identify death after discharge in adults aged 18 year or older within 7 days of ED presentation from January 1, 2007, to December 31, 2008. Patients who were nonmembers of the health system, in hospice care, or treated at out-of-network EDs were excluded. Predictors of 7-day postdischarge death were identified with multivariable logistic regression. RESULTS: The study cohort contained a total of 475,829 members, with 728,312 discharges from Kaiser Permanente Southern California EDs in 2007 and 2008. Death within 7 days of discharge occurred in 357 cases (0.05%). Increasing age, male sex, and number of preexisting comorbidities were associated with increased risk of death. The top 3 primary discharge diagnoses predictive of 7-day death after discharge included noninfectious lung disease (odds ratio [OR] 7.1; 95% confidence interval [CI] 2.9 to 17.4), renal disease (OR 5.6; 95% CI 2.2 to 14.2), and ischemic heart disease (OR 3.8; 95% CI 1.0 to 13.6). CONCLUSION: Our study suggests that 50 in 100,000 patients in the United States die within 7 days of discharge from an ED. To our knowledge, our study is the first to identify potentially "high-risk" discharge diagnoses in patients who experience a short-term death after discharge.

A population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia.

STUDY OBJECTIVES: To determine if a population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia (ICBT-I) affects dispensed medications and provider encounters compared with usual care. METHODS: A pragmatic hybrid study design was used to evaluate both the implementation strategy and the long-term effects of ICBT-I on health care utilization in an integrated health system. Adult members with insomnia (a diagnosis or insomnia medication dispensation) or at high risk of insomnia (a diagnosis of depression or anxiety) were randomized to receive information on either an ICBT-I program (intervention arm) or in-person classes on insomnia (usual-care arm). Outcomes included dispensed insomnia medications and provider encounters over 12 months. The effectiveness of our implementation of ICBT-I on the target population was determined by an intention-to-treat analysis and by regression models comparing those who engaged in ICBT-I with matched usual-care arm controls. RESULTS: A total of 136,630 participants were randomized. Six hundred thirty-eight (0.96%) accessed the ICBT-I program while 431 (0.66%) attended 1 or more usual-care insomnia classes. Dispensed insomnia medications and provider encounters were no different in the ICBT-I arm vs the usual-care arm (intention-to-treat) or among those who engaged in ICBT-I vs matched usual-care arm controls. CONCLUSIONS: Since ICBT-I program engagement was low, additional strategies to improve engagement should be explored. ICBT-I did not result in a reduction in several measures of health care utilization; nevertheless, it offers an alternative and accessible approach to managing population insomnia. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Trial of Internet-Based Cognitive Behavioral Therapy for Insomnia in Patients Prescribed Insomnia Medications; URL: https://clinicaltrials.gov/ct2/show/NCT03313466; Identifier: NCT03313466. CITATION: Derose SF, Rozema E, Chen A, Shen E, Hwang D, Manthena P. A population health approach to insomnia using internet-based cognitive behavioral therapy for insomnia. J Clin Sleep Med. 2021;17(8):1675-1684.

Review article: Managing sleep apnoea in kidney diseases.

A higher prevalence of sleep apnoea (SA) has been observed in the chronic kidney disease (CKD) population compared with estimates in the general population. Increased rates of SA have been described in patients with various renal-related diagnoses including dialysis, renal transplant, early-stage CKD and proteinuria. The mechanism or underlying aetiology for this association is different for each type of kidney disease. The extracellular fluid volume and metabolic derangements that characterize the uremic state likely contributes to SA in the dialysis population. SA causing direct renal insults from haemodynamic changes, ischaemic stress, or an intermediary condition such as hypertension, can lead to early CKD and proteinuria. While renal transplantation has cured SA in some patients, the post-transplant state is itself a risk factor for SA. The high prevalence of SA in kidney disease and the associated clinical implications warrant vigilance in diagnosis and treatment of SA in the CKD patient. This review focuses on the prevalence of SA in patients with CKD including dialysis and transplant patients, and those with early-stage CKD and proteinuria. SA may vary in form and aetiology depending on type or stage of CKD. Based on these associations, we discuss our rationale for recommendations on screening and management of SA specific to the CKD population.

Health plan administrative records versus birth certificate records: quality of race and ethnicity information in children.

BACKGROUND: To understand racial and ethnic disparities in health care utilization and their potential underlying causes, valid information on race and ethnicity is necessary. However, the validity of pediatric race and ethnicity information in administrative records from large integrated health care systems using electronic medical records is largely unknown. METHODS: Information on race and ethnicity of 325,810 children born between 1998-2008 was extracted from health plan administrative records and compared to birth certificate records. Positive predictive values (PPV) were calculated for correct classification of race and ethnicity in administrative records compared to birth certificate records. RESULTS: Misclassification of ethnicity and race in administrative records occurred in 23.1% and 33.6% children, respectively; the majority due to missing ethnicity (48.3%) and race (40.9%) information. Misclassification was most common in children of minority groups. PPV for White, Black, Asian/Pacific Islander, American Indian/Alaskan Native, multiple and other was 89.3%, 86.6%, 73.8%, 18.2%, 51.8% and 1.2%, respectively. PPV for Hispanic ethnicity was 95.6%. Racial and ethnic information improved with increasing number of medical visits. Subgroup analyses comparing racial classification between non-Hispanics and Hispanics showed White, Black and Asian race was more accurate among non-Hispanics than Hispanics. CONCLUSIONS: In children, race and ethnicity information from administrative records has significant limitations in accurately identifying small minority groups. These results suggest that the quality of racial information obtained from administrative records may benefit from additional supplementation by birth certificate data.

Multisite validation of a simple electronic health record algorithm for identifying diagnosed obstructive sleep apnea.

STUDY OBJECTIVES: We examined the performance of a simple algorithm to accurately distinguish cases of diagnosed obstructive sleep apnea (OSA) and noncases using the electronic health record (EHR) across six health systems in the United States. METHODS: Retrospective analysis of EHR data was performed. The algorithm defined cases as individuals with ≥ 2 instances of specific International Classification of Diseases (ICD)-9 and/or ICD-10 diagnostic codes (327.20, 327.23, 327.29, 780.51, 780.53, 780.57, G4730, G4733 and G4739) related to sleep apnea on separate dates in their EHR. Noncases were defined by the absence of these codes. Using chart reviews on 120 cases and 100 noncases at each site (n = 1,320 total), positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: The algorithm showed excellent performance across sites, with a PPV (95% confidence interval) of 97.1 (95.6, 98.2) and NPV of 95.5 (93.5, 97.0). Similar performance was seen at each site, with all NPV and PPV estimates ≥ 90% apart from a somewhat lower PPV of 87.5 (80.2, 92.8) at one site. A modified algorithm of ≥ 3 instances improved PPV to 94.9 (88.5, 98.3) at this site, but excluded an additional 18.3% of cases. Thus, performance may be further improved by requiring additional codes, but this reduces the number of determinate cases. CONCLUSIONS: A simple EHR-based case-identification algorithm for diagnosed OSA showed excellent predictive characteristics in a multisite sample from the United States. Future analyses should be performed to understand the effect of undiagnosed disease in EHR-defined noncases. This algorithm has wide-ranging applications for EHR-based OSA research.

Incidence of end-stage renal disease and death among insured African Americans with chronic kidney disease.

African Americans have the highest incidence of end-stage renal disease (ESRD) in the United States. To understand the basis of this disparity, we examined data from a prepaid, integrated health system for this retrospective cohort study of members who had one or more serum creatinine tests performed over a 9-year period. The cohort included 182,959 adults (8% black) with stage 3 or 4 chronic kidney disease based on their estimated glomerular filtration rate (eGFR). Competing-risk methods were used to determine the incidence of ESRD and death prior to ESRD. At all follow-up times and from any entry eGFR, the cumulative incidence of ESRD was significantly greater in blacks. The age and gender-adjusted hazard ratios for ESRD and death prior to ESRD in blacks compared to non-blacks were 1.83 and 1.15, respectively. Increased survival free of ESRD was found in blacks 70 years and older with eGFR stage 4. The hazard ratio for the combined outcomes of ESRD or death was 1.31 in blacks as compared to non-blacks. Despite equivalent health insurance benefits, blacks with chronic kidney disease were at increased risk for ESRD and death prior to ESRD. Compared to non-blacks, blacks with chronic kidney disease were twice as likely to enter into ESRD as to die prior to ESRD.

Predictors of 30-day serious events in older patients with syncope.

STUDY OBJECTIVE: We identify predictors of 30-day serious events after syncope in older adults. METHODS: We reviewed the medical records of older adults (age > or =60 years) who presented with syncope or near syncope to one of 3 emergency departments (EDs) between 2002 and 2005. Our primary outcome was occurrence of a predefined serious event within 30 days after ED evaluation. We used multivariable logistic regression to identify predictors of 30-day serious events. RESULTS: Of 3,727 potentially eligible patients, 2,871 (77%) met all eligibility criteria. We excluded an additional 287 patients who received a diagnosis of a serious clinical condition while in the ED. In the final study cohort (n=2,584), we identified 173 (7%) patients who experienced a 30-day serious event. High-risk predictors included age greater than 90 years, male sex, history of an arrhythmia, triage systolic blood pressure greater than 160 mm Hg, abnormal ECG result, and abnormal troponin I level. A low-risk predictor was a complaint of near syncope rather than syncope. A risk score, generated by summing high-risk predictors and subtracting the low-risk predictor, can stratify patients into low- (event rate 2.5%; 95% confidence interval [CI] 1.4% to 3.6%), intermediate- (event rate 6.3%; 95% CI 5.1% to 7.5%), and high-risk (event rate 20%; 95% CI 15% to 25%) groups. CONCLUSION: We identified predictors of 30-day serious events after syncope in adults aged 60 years and greater. A simple score was able to stratify these patients into distinct risk groups and, if externally validated, might have the potential to aid ED decisionmaking.

Burnt-out diabetes: impact of chronic kidney disease progression on the natural course of diabetes mellitus.

Many individuals with diabetic nephropathy, the leading cause of chronic kidney disease (CKD) in the United States, progress to stage 5 of CKD and undergo maintenance dialysis treatment. Recent data indicate that in up to one third of diabetic dialysis patients with a presumptive diagnosis of diabetic nephropathy, glycemic control improves spontaneously with the progression of CKD, loss of residual renal function, and the initiation of dialysis therapy, leading to normal-to-low hemoglobin A1c (<6%) and glucose levels, requiring cessation of insulin or other anti-diabetic medications. Potential contributors to this so-called "burnt-out diabetes" include decreased renal and hepatic insulin clearance, a decline in renal gluconeogenesis, deficient catecholamine release, diminished food intake (because of anorexia or diabetic gastroparesis), protein-energy wasting (with resultant loss of weight and body fat), and the hypoglycemic effects of dialysis treatment. Although the concept of "burnt-out diabetes" appears in sharp contradistinction to the natural history of diabetes mellitus, studying this condition and its potential causes and consequences, including the role of genetic factors, may lead to a better understanding of the pathophysiology of metabolic syndrome and diabetes mellitus in the CKD population and in many other individuals with chronic disease states associated with wasting syndrome that can confound the natural history of diabetes.

Potential Effects Of Eliminating The Individual Mandate Penalty In California.

The tax penalty for noncompliance with the Affordable Care Act's individual mandate is to be eliminated starting in 2019. We investigated the potential impact of this change on enrollees' decisions to purchase insurance and on individual-market premiums. In a survey of enrollees in the individual market in California in 2017, 19 percent reported that they would not have purchased insurance had there been no penalty. We estimated that premiums would increase by 4-7 percent if these enrollees were not in the risk pool. The percentages of enrollees who would forgo insurance were higher among those with lower income and education, Hispanics, and those who had been uninsured in the prior year, relative to the comparison groups. Compared to older enrollees and those with two or more chronic conditions, respectively, younger enrollees and those with no chronic conditions were also more likely to say that they would not have purchased insurance. Eliminating the mandate penalty alone is unlikely to destabilize the California individual market but could erode coverage gains, especially among groups whose members have historically been less likely to be insured.

Sleep Apnea and Kidney Function Trajectory: Results From a 20-Year Longitudinal Study of Healthy Middle-Aged Adults.

Study Objectives: To determine whether sleep apnea, defined by polysomnography, accelerates kidney function decline in generally healthy adults not selected for sleep apnea or kidney disease. Methods: We performed a retrospective cohort study in 855 participants from the Wisconsin Sleep Cohort Study, a large 20-year population-based study of sleep apnea, who had at least one polysomnogram and serial measurements of serum creatinine over time. Sleep apnea was defined as an apnea-hypopnea index ≥ 15 or positive airway pressure (PAP) use at baseline. We compared the slope of estimated glomerular filtration rate (eGFR) change and odds of rapid eGFR decline (>2.2 mL/minute/1.73 m2/year) for those with and without sleep apnea. Results: The mean follow-up was 13.9 ± 3.4 years. The cohort was 50.4 ± 7.6 years, 55% male, and 97% white. The mean eGFR was 89.3 ± 13.8 mL/minute/1.73 m2 and 11% had sleep apnea. Overall, the mean eGFR change was -0.88 ± 1.12 mL/minute/1.73 m2/year. Compared with those without sleep apnea, participants with sleep apnea had a 0.2 mL/minute/1.73 m2/year slower eGFR decline though this was not statistically significant (95% CI [-0.06-0.45], p = .134). When we excluded those on PAP therapy (n = 17), eGFR decline was even slower among those with sleep apnea (0.36 mL/minute/1.73 m2/year slower, 95% CI [0.08-063], p = .012). Those with sleep apnea had lower odds of rapid eGFR decline but this was not statistically significant, even after excluding PAP users. Conclusion: Among healthy middle-aged adults, the presence of sleep apnea at baseline did not accelerate kidney function decline compared with those without sleep apnea over time.

Kidney Function Decline in Patients with CKD and Untreated Hepatitis C Infection.

BACKGROUND AND OBJECTIVES: Studies evaluating the role of hepatitis C viral (HCV) infection on the progression of CKD are few and conflicting. Therefore, we evaluated the association of untreated HCV on kidney function decline in patients with stage 3-5 CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study included members of Kaiser Permanente Southern California and Kaiser Permanente Mid-Atlantic States aged ≥18 years, with incident HCV and CKD diagnoses from January 1, 2004 to December 31, 2014. We used generalized estimating equations to compare the rate of change in eGFR between those with HCV and CKD versus CKD alone, adjusting for covariates. Cox proportional hazards models compared the risk of 25% decrease in eGFR and ESKD (defined as progression to eGFR<15 ml/min per 1.73 m2 on two or more occasions, at least 90 days apart) in those with HCV and CKD versus CKD alone, adjusting for covariates. RESULTS: We identified 151,974 patients with CKD only and 1603 patients with HCV and CKD who met the study criteria. The adjusted annual decline of eGFR among patients with HCV and CKD was greater by 0.58 (95% confidence interval [95% CI], 0.31 to 0.84) ml/min per 1.73 m2, compared with that in the CKD-only population (HCV and CKD, -1.61; 95% CI, -1.87 to -1.35 ml/min; CKD only, -1.04; 95% CI, -1.06 to -1.01 ml/min). Adjusted for covariates, the hazard for a 25% decline in eGFR and for ESKD were 1.87 (95% CI, 1.75 to 2.00) and 1.93 (95% CI, 1.64 to 2.27) times higher among those with HCV and CKD, respectively, compared with those with CKD only. CONCLUSIONS: Untreated HCV infection was associated with greater kidney function decline in patients with stage 3-5 CKD.

Adverse Selection into and within the Individual Health Insurance Market in California in 2014.

OBJECTIVE: The Affordable Care Act (ACA) introduced reforms to mitigate adverse selection into and within the individual insurance market. We examined the traits and predicted medical spending of enrollees in California post-ACA. DATA SOURCES: Survey of 2,103 enrollees in individual market plans, on- and off-exchange, in 2014. STUDY DESIGN: We compared actual versus potential participants using data from the 2014 California Health Interview Survey on respondents who were individually insured or uninsured. We predicted annual medical spending for each group using age, sex, self-rated health, body mass index, smoking status, and income. PRINCIPAL FINDINGS: Average predicted spending was similar for actual ($3,377, 95 percent CI [$3,280-$3,474]) and potential participants ($3,257 [$3,060-$3,454]); however, some vulnerable subgroups were underrepresented. On- versus off-exchange enrollees differed in sociodemographic and health traits with modest differences in spending ($3,448 [$3,330-$3,565] vs. $3,175 [$3,012-$3,338]). CONCLUSIONS: We did not find evidence of selection into the overall insurance pool in 2014; however, differences by exchange status reflect the importance of including off-exchange enrollees in analyses and the pool for risk adjustment. California's post-ACA individual market has been a relative success, highlighting the importance of state policies and outreach efforts to encourage participation in the market.