Effects of Social Determinants and Pharmacogenetic Medication Interactions on 90-Day Hospital Readmissions.

Context: The present study builds on our prior work that demonstrated an association between pharmacogenetic interactions and 90-day readmission. Objective: Evaluate aggregate contribution of social determinants, comorbidity, and gene-x-drug interactions to moderate 90-day hospital readmission. Study Design and Analysis: Non-concurrent cohort study; Multivariable logistic regression Setting: Hospital/integrated healthcare delivery system in northern Illinois Population Studied: 19,999 adults tracked from 2010 through 2020 who underwent testing with a 13-gene pharmacogenetic panel Outcome Measure: 90-day hospital readmission (primary outcome) Results: Univariate logistic regression analyses demonstrated that strongest associations with 90 day hospital readmissions were the number of medications prescribed within 30 days of a first hospital admission that had Clinical Pharmacogenomics Implementation Consortium (CPIC) guidance (CPIC medications) (5+ CPIC medications, odds ratio (OR) = 7.66, 95% confidence interval 5.45-10.77) (p < 0.0001), major comorbidities (5+ comorbidities, OR 3.36, 2.61-4.32) (p < 0.0001), age (65 + years, OR = 2.35, 1.77-3.12) (p < 0.0001), unemployment (OR = 2.19, 1.88-2.64) (p < 0.0001), Black/African-American race (OR 2.12, 1.47-3.07) (p < 0.0001), median household income (OR = 1.63, 1.03-2.58) (p = 0.035), male gender (OR = 1.47, 1.21-1.80) (p = 0.0001), and one or more gene-x-drug interaction (defined as a prescribed CPIC medication for a patient with a corresponding actionable pharmacogenetic variant) (OR = 1.41, 1.18-1.70). Health insurance was not associated with risk of 90-day readmission. Race, income, employment status, and gene-x-drug interactions were robust in a multivariable logistic regression model. The odds of 90-day readmission for patients with one or more identified gene-x-drug interactions after adjustment for these covariates was attenuated by 10% (OR = 1.31, 1.08-1.59) (p = 0.006). Although the interaction between race and gene-x-drug interactions was not statistically significant, White patients were more likely to have a gene-x-drug interaction (35.2%) than Black/African-American patients (25.9%) who were not readmitted (p < 0.0001). Conclusions: These results highlight the major contribution of social determinants and medical complexity to risk for hospital readmission, and that these determinants may modify the effect of gene-x-drug interactions on rehospitalization risk.

Costs Associated With Imaging Surveillance After Treatment for Head and Neck Cancer.

Importance: The National Comprehensive Cancer Network recommends imaging within 6 months after treatment for head and neck cancer (HNC). Further imaging is recommended only if the patient has symptoms or abnormal findings on physical examination. However, in many instances, asymptomatic patients continue to have imaging evaluations. Objectives: To assess practice patterns in surveillance imaging in patients with HNC and evaluate the costs associated with these imaging practices. Design, Setting, and Participants: This single-institution retrospective economic evaluation study screened 435 patients to identify patients newly diagnosed with head and neck mucosal and salivary gland malignant tumors between January 1, 2010, and December 31, 2016. Data analyses were performed from October 25, 2018, to November 24, 2020. Exposure: Imaging practice patterns. Main Outcomes and Measures: Number and costs of imaging studies during the surveillance period for all patients, patients who remained disease free, and patients who developed recurrence. Results: A total of 136 patients (mean [SD] age at diagnosis, 62 [14] years; 84 [61.8%] male; 106 [77.9%] White) with HNC were included in the study. The oropharynx was the most common subsite (64 [47.1%]), most HNCs were stage IVA (62 [45.6%]), and most patients received definitive radiation-based treatment (71 [52.2%]). During the median surveillance period of 3.2 years (range, 0.3-6.8 years), a mean (SD) of 14 (10) imaging studies were performed for all patients, with a mean (SD) total cost of $36 800 ($24 500). In patients who remained disease free, a mean (SD) of 13 (10) imaging studies were performed during the surveillance period, with a mean (SD) total cost of $35 000 ($21 700). Patients who lacked symptoms had a mean (SD) of 4 (3) studies performed per year, resulting in a mean cost of $9600 ($5900) per year. Patients who developed recurrence had more studies per year of follow-up (mean difference, 5.0; 95% CI, 3.4-6.6) and higher associated mean costs (mean difference, $10 600; 95% CI, $6100-$15 000) than patients who remained disease free. Conclusions and Relevance: In this economic evaluation study, many patients treated for HNCs received imaging studies beyond what is recommended by National Comprehensive Cancer Network guidelines. These findings suggest that the cost burden of imaging in the asymptomatic patient needs to be considered against the value obtained from routine imaging in this current health care environment.