Development of an interactive dashboard for gun violence pattern analysis and intervention design at the local level.

Introduction: Gun violence remains a concerning and persistent issue in our country. Novel dashboards may integrate and summarize important clinical and non-clinical data that can inform targeted interventions to address the underlying causes of gun violence. Methods: Data from various clinical and non-clinical sources were sourced, cleaned, and integrated into a customizable dashboard that summarizes and provides insight into the underlying factors that impact local gun violence episodes. Results: The dashboards contained data from 7786 encounters and 1152 distinct patients from our Emergency Department's Trauma Registry with various patterns noted by the team. A multidisciplinary executive team, including subject matter experts in community-based interventions, epidemiology, and social sciences, was formed to design targeted interventions based on these observations. Conclusion: Targeted interventions to reduce gun violence require a multimodal data sourcing and standardization approach, the inclusion of neighborhood-level data, and a dedicated multidisciplinary team to act on the generated insights.

Defining the Need for Causal Inference to Understand the Impact of Social Determinants of Health: A Primer on Behalf of the Consortium for the Holistic Assessment of Risk in Transplantation (CHART).

Objective: This study aims to introduce key concepts and methods that inform the design of studies that seek to quantify the causal effect of social determinants of health (SDOH) on access to and outcomes following organ transplant. Background: The causal pathways between SDOH and transplant outcomes are poorly understood. This is partially due to the unstandardized and incomplete capture of the complex interactions between patients, their neighborhood environments, the tertiary care system, and structural factors that impact access and outcomes. Designing studies to quantify the causal impact of these factors on transplant access and outcomes requires an understanding of the fundamental concepts of causal inference. Methods: We present an overview of fundamental concepts in causal inference, including the potential outcomes framework and direct acyclic graphs. We discuss how to conceptualize SDOH in a causal framework and provide applied examples to illustrate how bias is introduced. Results: There is a need for direct measures of SDOH, increased measurement of latent and mediating variables, and multi-level frameworks for research that examine health inequities across multiple health systems to generalize results. We illustrate that biases can arise due to socioeconomic status, race/ethnicity, and incongruencies in language between the patient and clinician. Conclusions: Progress towards an equitable transplant system requires establishing causal pathways between psychosocial risk factors, access, and outcomes. This is predicated on accurate and precise quantification of social risk, best facilitated by improved organization of health system data and multicenter efforts to collect and learn from it in ways relevant to specialties and service lines.

Do You PROMIS (Patient Reported Outcomes Measurement Information System)? Physical Function and Pain Interference Scores After Total Knee and Hip Arthroplasty.

Background: Physical function and pain outcomes vary after arthroplasty. We investigated differences in postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores for patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA). We aimed to identify preoperative factors that predict postoperative PROMIS scores. Methods: Patients who underwent TKA and THA from 2014-2020 were eligible. Preoperative variables including demographics, comorbidities, and pain scores were obtained from the medical record. Patients completed surveys measuring postoperative PF and PI. Descriptive statistics and separate linear regression models for each anatomical location were performed to examine factors predicting postoperative PROMIS PF and PI scores. Results: Surveys were completed by 2411 patients (19.5% response rate). Unadjusted mean PF postoperative scores were 47.2 for TKA and 48.8 for THA. Preoperative predictors of lower PF included female sex; body mass index and comorbidities for TKA and THA; and age, tobacco use, and non-White race for THA. Mean PI scores were 47.9 for THA and 49.0 for TKA. Preoperative predictors of increased PI included non-White race and increased body mass index for TKA and THA; higher preoperative pain for TKA; and female sex and increased comorbidity for THA. Conclusions: Postoperative PROMIS scores were similar for TKA and THA, with THA having slightly higher PF and lower PI scores. Regression models using preoperative variables showed similar performance for TKA compared with THA. These findings suggest areas for future development of clinical decision support tools.

Quantifying Associations Between Child Health and Neighborhood Social Vulnerability: Does the Choice of Index Matter?

Importance: Policymakers have increasingly utilized place-based social disadvantage indices to quantify the impacts of place on health and inform equitable resource allocation. Indices vary in design, content, and purpose but are often used interchangeably, potentially resulting in differential assignments of relative disadvantage depending on index choice. Objective: To compare associations between three commonly used disadvantage indices (Social Vulnerability Index (SVI), Area Deprivation Index (ADI), and Child Opportunity Index (COI)) and two epidemiologically distinct child health outcomes-infant well-child check (WCC) attendance and adolescent obesity. Design: Cross-sectional analysis of Duke University Health System electronic health record (EHR) data from January 2014 to December 2019. Participants: Children ≤18 years of age with outpatient encounters between January 2014 and December 2019, and who were Durham County residents were eligible. WCC attendance was assessed for infants ages 0-15 months; obesity was assessed for children ages 11-17 years. Exposures: 2014 Social Vulnerability Index (SVI), 2015 Area Deprivation Index (ADI), and 2015 Child Opportunity Index (COI) 2.0. Main Outcomes: 1) Infant WCC attendance: attending less than the minimum recommended six WCCs in the first 15 months of life, and 2) Adolescent obesity: BMI ≥ the 95th percentile at both the most recent encounter and an encounter within the prior 9-36 months. Results: Of 10175 patients in the WCC cohort, 20% (n = 2073) had less than six WCCs. Of 14961 patients in the obesity cohort, 20% (n = 2933) had obesity. All three indices were associated with both WCCs (OR for SVI 1.10, 95% CI 1.08-1.12; OR for ADI 1.10, 95% CI 1.08-1.12; OR for COI 1.12, 95% CI 1.10-1.14) and obesity (OR for SVI 1.05, 95% CI 1.04-1.08; OR for ADI 1.08, 95% CI 1.06-1.10; OR for COI 1.07, 95% CI 1.05-1.08). Conclusions and relevance: Higher social disadvantage as defined by all three indices was similarly associated with both adolescent obesity and decreased infant WCC attendance. While the COI incorporates a broader set of child-specific variables, the SVI and ADI may often be just as suitable for pediatric research. Users should consider population and outcome characteristics when selecting an index.

Association of Perceived Neighborhood Health With Hypertension Self-care.

Importance: Hypertension self-management is recommended for optimal blood pressure (BP) control, but self-identified residential contextual factors that hinder hypertension self-care are understudied. Objective: To quantify perceived neighborhood health and hypertension self-care and assess interactions with the area deprivation index (ADI) and healthy food availability at home. Design, Setting, and Participants: A cross-sectional study was conducted in Baltimore, Maryland, including primary care adults enrolled in the Achieving Blood Pressure Control Together trial between September 1, 2013, and June 30, 2014. Participants were Black and had at least 2 BP readings greater than or equal to 140/90 mm Hg in the 6 months before enrollment. Analyses were conducted from August 5, 2021, to January 28, 2022. Exposures: Participants' perceived neighborhood health, defined as the mean standardized score across 4 subdomains of aesthetic quality, walkability, safety, and violence, with a higher score signifying better neighborhood health. Main Outcomes and Measures: Hypertension self-care behavior and self-efficacy. Multivariable generalized linear models were fit regressing each outcome on perceived neighborhood health (higher scores on each domain signify better perceived neighborhood health), adjusted for confounders, and interaction terms between neighborhood health and potential modifiers (ADI [higher percentiles correspond to more deprivation] and healthy food availability [higher scores indicate greater availability]) of the primary association were included. Results: Among 159 participants (median [IQR] age, 57 [49-64] years; mean [SD] age, 57 (11) years; 117 women [74%]), median (IQR) hypertension self-care behavior was 50 (45-56) and self-efficacy was 64 (57-72). Better perceived neighborhood health was associated with greater hypertension self-care behavior (ß, 2.48; 95% CI, 0.63-4.33) and self-efficacy (ß, 4.42; 95% CI, 2.25-6.59); these associations persisted for all neighborhood health subdomains except aesthetic quality. There were no statistically significant interactions between perceived neighborhood health or its subdomains with ADI on self-care behavior (P = .74 for interaction) or self-efficacy (P = .85 for interaction). However, better perceived neighborhood aesthetic quality had associations with greater self-care behavior specifically at higher healthy food availability at home scores: ß at -1 SD, -0.29; 95% CI, -2.89 to 2.30 vs ß at 1 SD, 2.97; 95% CI, 0.46-5.47; P = .09 for interaction). Likewise, associations of perceived worse neighborhood violence with lower self-care behavior were attenuated at higher healthy food availability at home scores (ß for -1 SD, 3.69; 95% CI, 1.31-6.08 vs ß for 1 SD, 0.01; 95% CI, -2.53 to 2.54; P = .04 for interaction). Conclusions and Relevance: In this cross-sectional study, better perceived neighborhood health was associated with greater hypertension self-care among Black individuals with hypertension, particularly among those with greater in-home food availability. Thus, optimizing hypertension self-management may require multifaceted interventions targeting both the patients' perceived contextual neighborhood barriers to self-care and availability of healthy food resources in the home.

A comparison of deprivation indices and application to transplant populations.

The choice of deprivation index can influence conclusions drawn regarding the extent of deprivation within a community and the identification of the most deprived communities in the United States. This study aimed to determine the degree of correlation among deprivation indices commonly used to characterize transplant populations. We used a retrospective cohort consisting of adults listed for liver or kidney transplants between 2008 and 2018 to compare 4 deprivation indices: neighborhood deprivation index, social deprivation index (SDI), area deprivation index, and social vulnerability index. Pairwise correlation between deprivation indices by transplant referral regions was measured using Spearman correlations of population-weighted medians and upper quartiles. In total, 52 individual variables were used among the 4 deprivation indices with 25% overlap. For both organs, the correlation between the population-weighted 75th percentile of the deprivation indices by transplant referral region was highest between SDI and social vulnerability index (liver and kidney, 0.93) and lowest between area deprivation index and SDI (liver, 0.19 and kidney, 0.15). The choice of deprivation index affects the applicability of research findings across studies examining the relationship between social risk and clinical outcomes. Appropriate application of these measures to transplant populations requires careful index selection based on the intended use and included variable relevance.

Assessment of Population-Level Disadvantage Indices to Inform Equitable Health Policy.

Policy Points The rapid uptake of disadvantage indices during the pandemic highlights investment in implementing tools that address health equity to inform policy. Existing indices differ in their design, including data elements, social determinants of health domains, and geographic unit of analysis. These differences can lead to stark discrepancies in place-based social risk scores depending on the index utilized. Disadvantage indices are useful tools for identifying geographic patterns of social risk; however, indiscriminate use of indices can have varied policy implications and unintentionally worsen equity. Implementers should consider which indices are suitable for specific communities, objectives, potential interventions, and outcomes of interest. CONTEXT: There has been unprecedented uptake of disadvantage indices such as the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to identify place-based patterns of social risk and guide equitable health policy during the COVID-19 pandemic. However, limited evidence around data elements, interoperability, and implementation leaves unanswered questions regarding the utility of indices to prioritize health equity. METHODS: We identified disadvantage indices that were (a) used three or more times from 2018 to 2021, (b) designed using national-level data, and (c) available at the census-tract or block-group level. We used a network visualization to compare social determinants of health (SDOH) domains across indices. We then used geospatial analyses to compare disadvantage profiles across indices and geographic areas. FINDINGS: We identified 14 indices. All incorporated data from public sources, with half using only American Community Survey data (n = 7) and the other half combining multiple sources (n = 7). Indices differed in geographic granularity, with county level (n = 5) and census-tract level (n = 5) being the most common. Most states used the SVI during the pandemic. The SVI, the Area Deprivation Index (ADI), the COVID-19 Community Vulnerability Index (CCVI), and the Child Opportunity Index (COI) met criteria for further analysis. Selected indices shared five indicators (income, poverty, English proficiency, no high school diploma, unemployment) but varied in other metrics and construction method. While mapping of social risk scores in Durham County, North Carolina; Cook County, Illinois; and Orleans Parish, Louisiana, showed differing patterns within the same locations depending on choice of disadvantage index, risk scores across indices showed moderate to high correlation (rs 0.7-1). However, spatial autocorrelation analyses revealed clustering, with discrepant distributions of social risk scores between different indices. CONCLUSIONS: Existing disadvantage indices use varied metrics to represent place-based social risk. Within the same geographic area, different indices can provide differences in social risk values and interpretations, potentially leading to varied public health or policy responses.

Association between Gentrification and Health and Healthcare Utilization.

There is tremendous interest in understanding how neighborhoods impact health by linking extant social and environmental drivers of health (SDOH) data with electronic health record (EHR) data. Studies quantifying such associations often use static neighborhood measures. Little research examines the impact of gentrification-a measure of neighborhood change-on the health of long-term neighborhood residents using EHR data, which may have a more generalizable population than traditional approaches. We quantified associations between gentrification and health and healthcare utilization by linking longitudinal socioeconomic data from the American Community Survey with EHR data across two health systems accessed by long-term residents of Durham County, NC, from 2007 to 2017. Census block group-level neighborhoods were eligible to be gentrified if they had low socioeconomic status relative to the county average. Gentrification was defined using socioeconomic data from 2006 to 2010 and 2011-2015, with the Steinmetz-Wood definition. Multivariable logistic and Poisson regression models estimated associations between gentrification and development of health indicators (cardiovascular disease, hypertension, diabetes, obesity, asthma, depression) or healthcare encounters (emergency department [ED], inpatient, or outpatient). Sensitivity analyses examined two alternative gentrification measures. Of the 99 block groups within the city of Durham, 28 were eligible (N = 10,807; median age = 42; 83% Black; 55% female) and 5 gentrified. Individuals in gentrifying neighborhoods had lower odds of obesity (odds ratio [OR] = 0.89; 95% confidence interval [CI]: 0.81-0.99), higher odds of an ED encounter (OR = 1.10; 95% CI: 1.01-1.20), and lower risk for outpatient encounters (incidence rate ratio = 0.93; 95% CI: 0.87-1.00) compared with non-gentrifying neighborhoods. The association between gentrification and health and healthcare utilization was sensitive to gentrification definition.

Social determinants of health data in solid organ transplantation: National data sources and future directions.

Health equity research in transplantation has largely relied on national data sources, yet the availability of social determinants of health (SDOH) data varies widely among these sources. We sought to characterize the extent to which national data sources contain SDOH data applicable to end-stage organ disease (ESOD) and transplant patients. We reviewed 10 active national data sources based in the United States. For each data source, we examined patient inclusion criteria and explored strengths and limitations regarding SDOH data, using the National Institutes of Health PhenX toolkit of SDOH as a data collection instrument. Of the 28 SDOH variables reviewed, eight-core demographic variables were included in ≥80% of the data sources, and seven variables that described elements of social status ranged between 30 and 60% inclusion. Variables regarding identity, healthcare access, and social need were poorly represented (≤20%) across the data sources, and five of these variables were included in none of the data sources. The results of our review highlight the need for improved SDOH data collection systems in ESOD and transplant patients via: enhanced inter-registry collaboration, incorporation of standardized SDOH variables into existing data sources, and transplant center and consortium-based investigation and innovation.

Chronic Pain Prevalence and Factors Associated With High Impact Chronic Pain following Total Joint Arthroplasty: An Observational Study.

Hip, knee, and shoulder arthroplasty are among the most frequently performed orthopaedic procedures in the United States. High impact and bothersome chronic pain rates following total joint arthroplasty (TJA) are unknown; as are factors that predict these chronic pain outcomes. This retrospective observational study included individuals that had a TJA from January 2014 to January 2020 (n = 2,638). Pre-operative and clinical encounter information was extracted from the electronic health record and chronic pain state was determined by email survey. Predictor variables included TJA location, number of surgeries, comorbidities, tobacco use, BMI, and pre-operative pain intensity. Primary outcomes were high impact and bothersome chronic pain. Rates of high impact pain (95% CI) were comparable for knee (9.8-13.3%), hip (8.3-11.8%) and shoulder (7.6-16.3%). Increased risk of high impact pain included non-white race, two or more comorbidities, age less than 65 years, pre-operative pain scores 5/10 or higher, knee arthroplasty, and post-operative survey completion 24 months or less. Rates of bothersome chronic pain (95% CI) were also comparable for knee (24.9-29.9%) and hip (21.3-26.3%) arthroplasty; but higher for shoulder (26.9-39.6%). Increased risk of bothersome chronic pain included non-white race, shoulder arthroplasty, knee arthroplasty, current or past tobacco use, and being female. PERSPECTIVE: In this cohort more than 1/3rd of individuals reported high impact or bothersome chronic pain following TJA. Non-white race and knee arthroplasty were the only two variables associated with both chronic pain outcomes.

A Prospective Multicenter Evaluation of Initial Treatment Choice in Metastatic Renal Cell Carcinoma Prior to the Immunotherapy Era: The MaRCC Registry Experience.

INTRODUCTION: The Metastatic Renal Cell Carcinoma (MaRCC) Registry provides prospective data on real-world treatment patterns and outcomes in patients with metastatic renal cell carcinoma (mRCC). METHODS AND MATERIALS: Patients with mRCC and no prior systemic therapy were enrolled at academic and community sites. End of study data collection was in March 2019. Outcomes included overall survival (OS). A survey of treating physicians assessed reasons for treatment initiations and discontinuations. RESULTS: Overall, 376 patients with mRCC initiated first-line therapy; 171 (45.5%) received pazopanib, 75 (19.9%) sunitinib, and 74 (19.7%) participated in a clinical trial. Median (95% confidence interval) OS was longest in the clinical trial group (50.3 [35.8-not reached] months) versus pazopanib (39.0 [29.7-50.9] months) and sunitinib 26.2 [19.9-61.5] months). Non-clear cell RCC (21.5% of patients) was associated with worse median OS than clear cell RCC (18.0 vs. 47.3 months). Differences in baseline characteristics, treatment starting dose, and relative dose exposure among treatment groups suggest selection bias. Survey results revealed a de-emphasis on quality of life, toxicity, and patient preference compared with efficacy in treatment selection. CONCLUSION: The MaRCC Registry gives insights into real-world first-line treatment selection, outcomes, and physician rationale regarding initial treatment selection prior to the immunotherapy era. Differences in outcomes between clinical trial and off-study patients reflect the difficulty in translating trial results to real-world patients, and emphasize the need to broaden clinical trial eligibility. Physician emphasis on efficacy over quality of life and toxicity suggests more data and education are needed regarding these endpoints.

Psychosocial determinants of cardiovascular events among black Americans with chronic kidney disease or associated risk factors in the Jackson heart study.

BACKGROUND: Individuals with chronic kidney disease (CKD), hypertension (HTN), or diabetes mellitus (DM) are at increased risk for cardiovascular disease (CVD). The extent to which psychosocial factors are associated with increased CVD risk within these individuals is unclear. Black individuals experience a high degree of psychosocial stressors due to socioeconomic factors, environment, racism, and discrimination. We examined the association between psychosocial factors and risk of CVD events among Black men and women with CKD and CKD risk factors in the Jackson Heart Study. METHODS AND RESULTS: We identified 1919 participants with prevalent CKD or CKD risk factors at baseline. We used rotated principal component analysis - a form of unsupervised machine learning that may identify constructs not intuitively identified by a person - to describe five groups of psychosocial components (including negative moods, religiosity, discrimination, negative outlooks, and negative coping resources) based on a battery of questionnaires. Multiple imputation by chained equation (MICE) was used to impute missing covariate data. Cox models were used to quantify the association between psychosocial components and incident CVD, defined as a fatal coronary heart disease event, myocardial infarction, cardiac procedure (angiography or revascularization procedure), or stroke. Of the 929 participants in the analysis, 67% were female, 28% were current/former smokers with mean age of 56 years and mean BMI of 33 kg/m2. Over a median follow-up of 8 years, 6% had an incident CVD event. In multivariable models, each standard deviation (SD) increase in the religiosity component was associated with an increased hazard for CVD event (hazard ratio [HR] = 1.52, 95% CI: 1.09-2.13). CONCLUSIONS: Religiosity was associated with CVD among participants with prevalent CKD or CKD risk factors. Studies to better understand the mechanisms of this relationship are needed.

A prospective study of multiple sleep dimensions and hypertension risk among white, black and Hispanic/Latina women: findings from the Sister Study.

BACKGROUND: Poor sleep is associated with increased hypertension risk, but few studies have evaluated multiple sleep dimensions or investigated racial/ethnic disparities in this association among women. METHOD: We investigated multiple sleep dimensions (sleep duration, inconsistent weekly sleep patterns, sleep debt, frequent napping and difficulty falling or staying asleep) and hypertension risk among women, and determined modification by age, race/ethnicity and menopausal status. We used data from the Sister Study, a national cohort of 50 884 women who had sisters diagnosed with breast cancer in the United States enrolled in 2003-2009 and followed through September 2018. RESULTS: Of 33 497 women without diagnosed hypertension at baseline (mean age ±â€Šstandard deviation: 53.9 ±â€Š8.8 years; 88.7% White, 6.4% Black and 4.9% Hispanic/Latina), 23% (n = 7686) developed hypertension over a median follow-up of 10.1 years [interquartile range: 8.2-11.9 years]. Very short, short or long sleep duration, inconsistent weekly sleep patterns, sleep debt, frequent napping, insomnia, insomnia symptoms as well as short sleep and exploratory cumulative poor sleep score were associated with incident hypertension after adjustment for demographics factors. After additional adjustment for lifestyle and clinical factors, insomnia [hazard ratio = 1.09, 95% confidence interval (95% CI): 1.03-1.15] and insomnia symptoms plus short sleep (hazard ratio = 1.13, 95% CI: 1.05-1.21) remained associated with incident hypertension. These associations were stronger in younger (age<54 vs. ≥54 years) and premenopausal vs. postmenopausal women (all P-interaction < 0.05). Associations did not differ by race/ethnicity (all P-interaction > 0.05). CONCLUSION: Thus, screening for multiple sleep dimensions and prioritizing younger and premenopausal women may help identify individuals at high risk for hypertension.

Integrated Digital Health System Tools to Support Decision Making and Treatment Preparation in CKD: The PREPARE NOW Study.

RATIONALE & OBJECTIVE: Digital health system tools to support shared decision making and preparation for kidney replacement treatments for patients with chronic kidney disease (CKD) are needed. STUDY DESIGN: Descriptive study of the implementation of digital infrastructure to support a patient-centered health system intervention. SETTING & PARTICIPANTS: 4 CKD clinics within a large integrated health system. EXPOSURE: We developed an integrated suite of digital engagement tools to support patients' shared decision making and preparation for kidney failure treatments. Tools included an automated CKD patient registry and risk prediction algorithm within the electronic health record (EHR) to identify and prioritize patients in need of nurse case management to facilitate shared decision making and preparation for kidney replacement treatments, an electronic patient-facing values clarification tool, a tracking application to document patients' preparation for treatments, and an EHR work flow to broadcast patients' treatment preferences to all health care providers. OUTCOMES: Uptake and acceptability. ANALYTIC APPROACH: Mixed methods. RESULTS: From July 1, 2017, through June 30, 2018, the CKD registry identified 1,032 patients in 4 nephrology clinics, of whom 243 (24%) were identified as high risk for progressing to kidney failure within 2 years. Kidney Transitions Specialists enrolled 117 (48%) high-risk patients by the end of year 1. The values tool was completed by 30/33 (91%) patients who attended kidney modality education. Nurse case managers used the tracking application for 100% of patients to document 287 planning steps for kidney replacement therapy. Most (87%) high-risk patients had their preferred kidney replacement modality documented and displayed in the EHR. Nurse case managers reported that the tools facilitated their identification of patients needing support and their navigation activities. LIMITATIONS: Single institution, short duration. CONCLUSIONS: Digital health system tools facilitated rapid identification of patients needing shared and informed decision making and their preparation for kidney replacement treatments. FUNDING: This work was supported through a Patient-Centered Outcomes Research Institute (PCORI) Project Program Award (IHS-1409-20967). TRIAL REGISTRATION: ClinicalTrials.gov NCT02722382.

Prevalence and predictors of no-shows to physical therapy for musculoskeletal conditions.

OBJECTIVES: Chronic pain affects 50 million Americans and is often treated with non-pharmacologic approaches like physical therapy. Developing a no-show prediction model for individuals seeking physical therapy care for musculoskeletal conditions has several benefits including enhancement of workforce efficiency without growing the existing provider pool, delivering guideline adherent care, and identifying those that may benefit from telehealth. The objective of this paper was to quantify the national prevalence of no-shows for patients seeking physical therapy care and to identify individual and organizational factors predicting whether a patient will be a no-show when seeking physical therapy care. DESIGN: Retrospective cohort study. SETTING: Commercial provider of physical therapy within the United States with 828 clinics across 26 states. PARTICIPANTS: Adolescent and adult patients (age cutoffs: 14-117 years) seeking non-pharmacological treatment for musculoskeletal conditions from January 1, 2016, to December 31, 2017 (n = 542,685). Exclusion criteria were a primary complaint not considered an MSK condition or improbable values for height, weight, or body mass index values. The study included 444,995 individuals. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of no-shows for musculoskeletal conditions and predictors of patient no-show. RESULTS: In our population, 73% missed at least 1 appointment for a given physical therapy care episode. Our model had moderate discrimination for no-shows (c-statistic:0.72, all appointments; 0.73, first 7 appointments) and was well calibrated, with predicted and observed no-shows in good agreement. Variables predicting higher no-show rates included insurance type; smoking-status; higher BMI; and more prior cancellations, time between visit and scheduling date, and between current and previous visit. CONCLUSIONS: The high prevalence of no-shows when seeking care for musculoskeletal conditions from physical therapists highlights an inefficiency that, unaddressed, could limit delivery of guideline-adherent care that advocates for earlier use of non-pharmacological treatments for musculoskeletal conditions and result in missed opportunities for using telehealth to deliver physical therapy.

Assessment of Common Comorbidity Phenotypes Among Older Adults With Knee Osteoarthritis to Inform Integrated Care Models.

OBJECTIVE: To establish the frequency of concordant, discordant, and clinically dominant comorbidities among Medicare beneficiaries with knee osteoarthritis (KOA) and to identify common concordant condition subgroups. PARTICIPANTS AND METHODS: We used a 5% representative sample of Medicare claims data to identify beneficiaries who received a diagnosis of KOA between January 1, 2012, and September 30, 2015, and matched control group without an osteoarthritis (OA) diagnosis. Frequency of 34 comorbid conditions was categorized as concordant, discordant, or clinically dominant among those with KOA and a matched sample without OA. Comorbid condition phenotypes were characterized by concordant conditions and derived using latent class analysis among those with KOA. RESULTS: The study sample included 203,361 beneficiaries with KOA and 203,361 non-OA controls. The largest difference in frequency between the two cohorts was for co-occurring musculoskeletal conditions (23.7% absolute difference), chronic pain syndromes (6.5%), and rheumatic diseases (4.5%), all with a higher frequency among those with knee OA. Phenotypes were identified as low comorbidity (53% of cohort with classification), hypothyroid/osteoporosis (27%), vascular disease (10%), and high medical and psychological comorbidity (10%). CONCLUSIONS: Approximately 47% of Medicare beneficiaries with KOA in this sample had a phenotype characterized by one or more concordant conditions, suggesting that existing clinical pathways that rely on single or dominant providers might be insufficient for a large proportion of older adults with KOA. These findings could guide development of integrated KOA-comorbidity care pathways that are responsive to emerging priorities for personalized, value-based health care.

Predicting Recurrent Care Seeking of Physical Therapy for Musculoskeletal Pain Conditions.

OBJECTIVE: Musculoskeletal pain conditions are a leading cause of pain and disability internationally and a common reason to seek health care. Accurate prediction of recurrence of health care seeking due to musculoskeletal conditions could allow for better tailoring of treatment. The aim of this project was to characterize patterns of recurrent physical therapy seeking for musculoskeletal pain conditions and to develop a preliminary prediction model to identify those at increased risk of recurrent care seeking. DESIGN: Retrospective cohort. SETTING: Ambulatory care. SUBJECTS: Patients (n = 578,461) seeking outpatient physical therapy (United States). METHODS: Potential predictor variables were extracted from the electronic medical record, and patients were placed into three different recurrent care categories. Logistic regression models were used to identify individual predictors of recurrent care seeking, and the least absolute shrinkage and selection operator (LASSO) was used to develop multivariate prediction models. RESULTS: The accuracy of models for different definitions of recurrent care ranged from 0.59 to 0.64 (c-statistic), and individual predictors were identified from multivariate models. Predictors of increased risk of recurrent care included receiving workers' compensation and Medicare insurance, having comorbid arthritis, being postoperative at the time of the first episode, age range of 44-64 years, and reporting night sweats or night pain. Predictors of decreased risk of recurrent care included lumbar pain, chronic injury, neck pain, pregnancy, age range of 25-44 years, and smoking. CONCLUSION: This analysis identified a preliminary predictive model for recurrence of care seeking of physical therapy, but model accuracy needs to improve to better guide clinical decision-making.

Active surveillance of metastatic renal cell carcinoma: Results from a prospective observational study (MaRCC).

BACKGROUND: Systemic therapy (ST) can be deferred in patients who have metastatic renal cell carcinoma (mRCC) and slow-growing metastases. Currently, this subset of patients managed with active surveillance (AS) is not well described in the literature. METHODS: This was a prospective observational study of patients with mRCC across 46 US community and academic centers. The objective was to describe baseline characteristics and demographics of patients with mRCC initially managed by AS, reasons for AS, and patient outcomes. Descriptive statistics were used to characterize demographics, baseline characteristics, and patient-related outcomes. Wilcoxon 2-sample rank-sum tests and χ2 tests were used to assess differences between ST and AS cohorts in continuous and categorical variables, respectively. Kaplan-Meier survival curves were used to assess survival. RESULTS: Of 504 patients, mRCC was initially managed by AS (n = 143) or ST (n = 305); 56 patients were excluded from the analysis. Disease was present in 69% of patients who received AS, whereas the remaining 31% had no evidence of disease. At data cutoff, 72 of 143 patients (50%) in the AS cohort had not received ST. The median overall survival was not reached (95% CI, 122 months to not estimable) in patients who received AS versus 30 months (95% CI, 25-44 months) in those who received ST. Quality of life at baseline was significantly better in patients who were managed with AS versus ST. CONCLUSIONS: AS occurs frequently (32%) in real-world clinical practice and appears to be a safe and appropriate alternative to immediate ST in selected patients.