Renoprotective Effects of Metabolic Surgery Versus GLP1 Receptor Agonists on Progression of Kidney Impairment in Patients with Established Kidney Disease.

OBJECTIVE: To examine the renoprotective effects of metabolic surgery in patients with established chronic kidney disease (CKD). BACKGROUND: The impact of metabolic surgery compared with glucagon-like peptide-1 receptor agonists (GLP-1RA) in patients with established CKD has not been fully characterized. METHODS: Patients with obesity (BMI ≥30 kg/m2), type 2 diabetes (T2DM), and baseline estimated glomerular filtration rate (eGFR) 20-60 mL/min/1.73 m² who underwent metabolic bariatric surgery at a large U.S. health system (2010-2017) were compared with nonsurgical patients who continuously received GLP-1RA. The primary end point was CKD progression, defined as decline of eGFR by ≥50% or to <15 mL/min/1.73 m2, initiation of dialysis, or kidney transplant. The secondary end point was the incident kidney failure (eGFR <15 mL/min/1.73 m2, dialysis, or kidney transplant) or all-cause mortality. RESULTS: 425 patients, including 183 patients in the metabolic surgery group and 242 patients in the GLP-1RA group, with a median follow-up of 5.8 years (IQR, 4.4-7.6) were analyzed. The cumulative incidence of the primary end point at 8-years was 21.7% (95% CI, 12.2-30.6) in the surgical group and 45.1% (95% CI, 27.7-58.4) in the nonsurgical group, with an adjusted hazard ratio of 0.40 (95% CI, 0.21-0.76), P=0.006. The cumulative incidence of the secondary composite end point at 8-years was 24.0% (95% CI, 14.1-33.2) in the surgical group and 43.8% (95% CI, 28.1-56.1) in the nonsurgical group, with an adjusted HR of 0.56 (95% CI, 0.31-0.99), P=0.048. CONCLUSIONS: Among patients with T2DM, obesity, and established CKD, metabolic surgery, compared with GLP-1RA, was significantly associated with a 60% lower risk of progression of kidney impairment and a 44% lower risk of kidney failure or death. Metabolic surgery should be considered as a therapeutic option for patients with CKD and obesity.

Development and Internal Validation of the Cleveland Clinic Bleeding Model to Predict Major Bleeding Risk at Admission in Medical Inpatients.

BACKGROUND: Guidelines recommend pharmacological VTE prophylaxis for acutely ill medical patients at acceptable bleeding risk, but only the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model has been validated for bleeding risk assessment. OBJECTIVE: We developed and internally validated a risk assessment model (RAM) to predict major in-hospital bleeding using risk factors at admission and compared our model to IMPROVE. METHODS: We selected patients admitted to medical services at 10 hospitals in the Cleveland Clinic Health System from 2017 to 2020. We identified major bleeding according to the International Society on Thrombosis and Hemostasis criteria, using a combination of diagnostic codes and laboratory values, and confirmed events with chart review. We fit a LASSO logistic regression model in the training set and compared the discrimination and calibration of our model and IMPROVE in the validation set. RESULTS: Among 46,314 admissions, 268 (0.58%) had a major bleed. The final RAM included 16 risk factors, of which prior bleeding (OR = 4.83), peptic ulcer (OR = 3.82), history of sepsis (OR = 3.26), and steroid use (OR = 2.59) were the strongest. The Cleveland Clinic Bleeding Model (CCBM) had better discrimination than IMPROVE (AUC = 0.85 vs. 0.70, p < .001) and, at equivalent sensitivity (52%), categorized fewer patients as high-risk (7.2% vs. 11.8%, p < .001). Calibration was adequate (Brier score = 0.0057). CONCLUSION: Using a large population of medical inpatients with verified major bleeding events, we developed and internally validated a RAM for major bleeding whose performance surpassed the IMPROVE model.

Role of Patient Characteristics and Insurance Type in Newly Diagnosed Multiple Myeloma Care Disparities.

PURPOSE: Little is known about the role of social determinants of health (SDOH) in the utilization of novel treatments among patients with newly diagnosed multiple myeloma (NDMM). METHODS: This retrospective cohort study used Taussig Cancer Center's Myeloma Patient Registry to identify adults with NDMM between January 1, 2017, and December 31, 2021. Electronic health records data captured treatment with (1) triplet or quadruplet regimen and (2) lenalidomide during the first year after NDMM, and (3) stem-cell transplant (SCT) through December 31, 2022. Multivariable logistic regression models examined associations of demographic/clinical characteristics and SDOH with care patterns. RESULTS: We identified 569 patients with median age at diagnosis of 66 years (IQR, 59-73); 55% were male, 76% White, 23% Black, 1.1% other races, insured by Medicare (51%), private payer (38%), Medicaid (8.3%), and self-pay/other (1.8%). In the multivariable models, self-pay/other payers (adjusted odds ratio [AOR], 0.15 [95% CI, 0.03 to 0.54]) was associated with lower odds of triplet or quadruplet regimen, compared with Medicare. Private insurance (AOR, 0.48 [95% CI, 0.27 to 0.86]) and self-pay/other payers (AOR, 0.16 [95% CI, 0.04 to 0.74]) had lower odds of lenalidomide. Black patients (v White; AOR, 0.47 [95% CI, 0.26 to 0.85]) and patients treated at regional hospitals (v Taussig Cancer Center; AOR, 0.27 [95% CI, 0.12 to 0.57]) had lower odds of SCT. The odds of receiving triplet or quadruplet regimen, lenalidomide, and SCT also varied by the year of NDMM. CONCLUSION: Care for NDMM varied based on race, insurance type, year of diagnosis, and treatment facility. It may be useful to examine the impact of insurance-related characteristics and recent policy initiatives on care disparities.

Association of Food Insecurity with Mental Health Outcomes in Parents and Children.

BACKGROUND: Food insecurity affects 13.7 million US households and is linked to poor mental health. Families shield children from food insecurity by sacrificing their nutritional needs, suggesting parents and children experience food insecurity differentially. OBJECTIVE: To identify the associations of food insecurity and mental health outcomes in parents and children DATA SOURCES: PubMed, Embase, Web of Science, and PsycInfo STUDY ELIGIBILITY CRITERIA: We included original research published in English from January 1990 to June 2020 that examined associations between food insecurity and mental health in children or parents/guardians in the United States. STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers screened studies for inclusion. Data extraction was completed by one reviewer and checked by a second. Bias and confounding were assessed using the Agency for Healthcare Research and Quality RTI Item Bank. Studies were synthesized qualitatively, grouped by mental health outcome, and patterns were assessed. Meta-analyses were not performed due to high variability between studies. RESULTS: We included 108 studies, assessing 250,553 parents and 203,822 children in total. Most studies showed a significant association between food insecurity and parental depression, anxiety, and stress, and between food insecurity and child depression, externalizing/internalizing behaviors, and hyperactivity. LIMITATIONS: Most studies were cross-sectional and many were medium- or high-risk for bias or confounding. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Food insecurity is significantly associated with various mental health outcomes in both parents and children. The rising prevalence of food insecurity and mental health problems make it imperative that effective public health and policy interventions address both problems.

Characteristics of Adult Primary Care Patients Who Use the Patient Portal: A Cross-Sectional Analysis.

BACKGROUND: The patient portal allows patients to engage with their health care team beyond the clinical encounter. While portals can improve patient outcomes, there may be disparities in which patients access the portal by sociodemographic factors. Understanding the characteristics of patients who use the portal could help design future interventions to expand portal adoption. OBJECTIVES: This study aimed to (1) examine the socioeconomic factors, comorbid conditions, and health care utilization among patients of a large academic primary care network who are users and non-users of the patient portal; and (2) describe the portal functions most frequently utilized. METHODS: We included all adult patients at Atrium Health Wake Forest Baptist who had at least two primary care visits between 2018 and 2019. Patients' demographics, comorbidities, health care utilization, and portal function usage were extracted from the electronic health record and merged with census data (income, education, and unemployment) from the American Community Survey. A myWakeHealth portal user was defined as a patient who used a bidirectional portal function at least once during the study period. We used multivariable logistic regression to determine which patient characteristics were independently associated with being a portal user. RESULTS: Of the 178,720 patients who met inclusion criteria, 32% (N = 57,122) were users of myWakeHealth. Compared to non-users, users were more likely to be 18 to 64 years of age, female, non-Hispanic White, married, commercially insured, have higher disease burden, and have lower health care utilization. Patients residing in areas with the highest educational attainment had 51% higher odds of being a portal user than the lowest (p <0.001). Among portal users, the most commonly used function was messaging clinic providers. CONCLUSION: We found that patient demographics and area socioeconomic factors were associated with patient portal adoption. These findings suggest that efforts to improve portal adoption should be targeted at vulnerable patients.